Deviated nasal septum in the newborn - A 1-year study

Abstract

A prospective study of 200 newborn babies was done at Silchar Medical College Hospital from September 2002 to August 2003. The babies aged from 0 to 4 days were taken in the study. They were examined for any signs of nasal obstruction, birth trauma, prolonged labour, mode of delivery (forceps/vaginal/caeserian section), intrauterine malposition, postmaturity, birthweight, cephalopelvic disproportion, parity of the mother and gestational period. The diagnosis was done by clinical examination, rhinometry, struts and applying cotton wool. In the study, the incidence was found to be 14.5% (29 cases). It was found that high-birth weight babies, delivered by vaginal route (55%), to a primi mother are more likely to have DNS after birth. Moreover, intrauterine malposition particularly breech (45%) and prolonged labour seemed to play a role in newborn DNS. More importantly, the present study seems to indicate that since a good percentage of such deformity originate at the gestational period, early detection at the neonatal age is vital to manage and also to prevent complications and sequelae in adult life. Therefore, a policy of routine screening in view of early correction is advocated to decrease the morbidity associated with nasal septal deviation in newborns.

Full text

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Main Article
DEVIATED NASAL SEPTUM IN THE NEWBORN – A 1-YEAR STUDY
Abhinandan Bhattacharjee1, S. Uddin2, P. Purkaystha3
ABSTRACT: A prospective study of 200 newborn babies was done at Silchar Medical College Hospital
from September 2002 to August 2003. The babies aged from 0 to 4 days were taken in the study. They
were examined for any signs of nasal obstruction, birth trauma, prolonged labour, mode of delivery
(forceps/vaginal/caeserian section), intrauterine malposition, postmaturity, birthweight, cephalopelvic
disproportion, parity of the mother and gestational period. The diagnosis was done by clinical
examination, rhinometry, struts and applying cotton wool. In the study, the incidence was found to be
14.5% (29 cases). It was found that high-birth weight babies, delivered by vaginal route (55%), to a
primi mother are more likely to have DNS after birth. Moreover, intrauterine malposition particularly
breech (45%) and prolonged labour seemed to play a role in newborn DNS. More importantly, the present
study seems to indicate that since a good percentage of such deformity originate at the gestational
period, early detection at the neonatal age is vital to manage and also to prevent complications and
sequelae in adult life. Therefore, a policy of routine screening in view of early correction is advocated to
decrease the morbidity associated with nasal septal deviation in newborns.
Key Words: Deviated nasal septum; newborn
In day-to-day practice, the deviation of nasal septum has been
a regularity in its spectra of presentation in our country as
well as world over. Infact, 58% of newborn babies have some
sort of septal deviation, 4% of which have associated external
nasal deformity. There are two basic types of septal deformity
seen, namely anterior nasal deformity and combined septal
deformity. They may occur independently or both together in
a neonate and are considered to acquire from different types
of pressures on the foetus during pregnancy or parturition.[1]
In addition to race, genes and trauma, gestation and parturition,
also determine the ultimate architecture of the nose.[2–4] The
two basic mechanisms as suggested by Gray in his works are
differential rate of growth of septum as compared to other
midfacial structures and trauma to nose as a result of prolonged
contact with the uterine wall or during parturition.[5–8] Such
nasal injury should not be surprising considering the
compressional and rotational forces thrust upon the fetal head
during passage through birth canal. So, the nose being the
most prominent structure by 2–3 cm is subjected to
extraordinary forces during birth process. This, influence both
quantitative and qualitative development of the premaxilla,
maxilla and other nasal elements. Investigators have also found
that temporary flattening of nose results from dislocation of
septum at birth and is related to the size of the pelvis to the
size of baby’s head (head pelvic outlet ratio).[9]
Septal dislocations in most cases return to normal within few
days, but gross deviation gives rise to physiological,
anatomical, psychological, cosmetic as well as some systemic
dysfunction. It results in nasal obstruction leading to slow or
difficult feeding with colic due to aerophagy, infected nose,
snuffle and if severe mimics choanal atresia and other
subsequent sequeale. It also causes sinusitis, epistaxis,
eustachian tube dysfunction, CSOM, facial asymmetry,
sagittal and dental malalignments and malocclusions, as well
as change in thoracic architecture and poor general health.
As a good percentage of such deviation originate at the
gestational period, detection of any deviation of septum at
the neonatal period is very important. We can manage it easily
and can prevent many complications and squeale in adult life.
Therefore, screening of neonates for early diagnosis and
management is important to decrease the morbidity associated
with this deformity.
REVIEW OF LITERATURE
As early as 1939, Metzenbaum addressed the general subject
of birth trauma to nose. Since then many others have contributed
to our knowledge of this subject (Erner 1944; Heinberg 1958;
Kirchner[10]; Metzenbaum 1936; Selinger 1941; Sercer 1940;
Steiner[6]; Lederer 1952; Scotbrown 1952; Klaff 1956; Pease[11];
Gray[12]; Olsen[13];Thomsen and Negus 1955).
1Postgraduate trainee, 2Associate Professor, 3Professor and Head, Department of ENT, Silchar Medical College and Hospital, Assam, India
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Deviated nasal septum in the newborn
Metzenbaum (1936) stated that head, face, nose of a child
delivered by caeserian section is perfect in contour than a
child born naturally.
Perth (1963, 1964) examined newborn infants and found nasal
obstruction in 21% cases out of which 41% was right sided
and 59% left.
Jappensen and Mindfield[2] found incidence higher in neonates
born to primipara as compared to multipara.
Kirchner[10] stated that lateral nasal displacement in the
newborn is a consequence of trauma that is either due to forces
applied to the nose during the late months of intrauterine life
or during birth. He felt that the latter variety of injury usually
consists of dislocation of septal cartilage from vomer.
Bhatia (1982) in his study found incidence of septal deviation
in newborn to be 15.4%. Reports from other studies ranged
from 1.25 to 25%.[14,15]
Klaff (1963) reported 12 cases of septal dislocation in
newborns and went on to describe the causative factors and
methods of treatment.
Goyal (1987) while studying 100 neonates found the incidence
of septal deviation more in babies with increased birth weight.
He also found septal deviation significantly high (50%) in
neonates born with breech presentation as compared to
occipito-anterior position.
Hinderer (1972) stated that injury during the periods of growth
caused long-term deformities.
Sinha and Maheshwari (1970) noted intrauterine trauma
during birth affecting male and female alike.
Fischer (1957) stated that forceful and prolonged stress during
birth process may lead to dislocation of septum.
Gray (1972) suggested that abnormal intrauterine posture may
result in compression over the nose.
Jappensen and Windfield[2] in their study showed that septal
dislocation in new born (3.19%) were common in primipara
and when the second stage of labour lasted for more than
15 min.
Cottle (1951) made a distinction between temporary flattening
of nose from delayed and permanent damage occurring in
utero.
Steiner[6] stated that nasal trauma may occur at any time after
fourth month of gestation and discussed the continuous
pressure on nose from intrauterine growth of fetal limbs among
other causative factors.
METHODS AND MATERIALS
This was a prospective study done in the departments of
Otolaryngology, Obstetrics and Paediatrics at Silchar Medical
College Hospital from September 2002 to August 2003.
Two hundred new born babies who were delivered in
Obstetrics (Neonatal ward) or admitted in ENT or paediatrics
department for management were examined for DNS. The
age of the babies ranged from 0 to 4 days.
The cases were examined for any signs of nasal obstruction,
external deformity, nasal discharge, mouth breathing,
difficulty in suckling, sneezing, history of birth trauma,
prolonged/difficult labour, forceps/vaginal delivery, caeserian
section delivery, intrauterine malposition, postmaturity, birth
weight, cephalo pelvic disproportion, parity of the mother
and gestational period. Clinical examination was done by
inspection of nose, palpation and by using small auroscope.
Rhinometry was done using a chromium coated metal plate
(10´12 cm2) which was divided into squares of 1x 1 mm2, for
assessing the airway patency of each nasal cavity separately
by measuring the area of vapour condensed over the plate
during expiration. The difference between the two areas was
noted and compared with normal findings from which we
found out the side of partial or complete nasal obstruction.
Struts made from polyphonic standard grade were also used
[Figure 1]. The normal sheeting size 1/16th in. and 6 mm wide
with squarish ends was passed readily through the normal
nose into the nasal space. In some, a long hard obstruction
was felt about 1.25 to 2 cm from the external nares preventing
the passage of strut. In some we detected sensation of
Figure 1: Polyphonic standard grade struts are used
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306 Deviated nasal septum in the newborn
irregularity of the surface at the passage of struts. The struts
were found in vertical plane in normal nasal cavity but oblique
in gross DNS.
We also applied cotton wool in front of both nasal cavity and
looked for their movement during expiration and inspiration
and on comparing with normal subject partial, complete or
no obstruction was detected. The small sized autoscope was
used to inspect the deformity of septum.
RESULTS AND OBSERVATION
In this prospective study, 200 newborn babies aged from 0 to
4 days were examined for septal deviation. 29 cases were
found to have DNS and were separately studied for
intrauterine position, mode of delivery, birth weight, parity
and gestational period of the mother. The findings are
discussed below:
1. Incidence of DNS: the incidence of DNS in newborn was
found to be 14.5%.
2. Incidence in relation to mode of delivery: it is seen that
out of 29 babies with DNS, 16(55%) were vaginally
delivered, 7(24%) by forceps delivery and 6(21%) were
delivered by caeserian section.
3. Incidence of nasal septal deviation in relation to
intrauterine position of fetus: the incidence of DNS in
breech presentation was seen in 13 cases, right occipito-
anterior in 11 cases and left occipito-anterior in five cases
[Table 1].
4. Incidence in relation to birth weight of newborn: 16 babies
out of 29 born with DNS had birth weight of >7 pounds,
i.e. 55%. Only nine (31.3%) babies with DNS had birth
weight of 5–7 pounds and four (13.7%) with birth weight
below 5 pounds.
5. Incidence of nasal septal deviation in relation to parity of
mother: it is seen that 14 newborn babies having DNS
was born to mothers who were P0G1, and seven babies to
PG mothers. The incidence of DNS decreased as the
1 2
parity increase [Table 2].
DISCUSSION
Incidence of DNS: in the present series, the incidence of DNS
in newborn was found to be 14.5%. Similarly, Bhatia (1982)
found the incidence as 15.4%. DNS in newborn was also
reported by Gray,[16] Jappesen and Windfeild.[2] Incidence as
observed by Perth (1963, 1964) is 21%, by Jazbi (1977) is
1.25% and Sookhnundan[15] is 25% and Saim and Said[17] to
be 21.8% [Table 3].
Incidence in relation to mode of delivery: in the present series,
it is observed that incidence is high in vaginal delivery (55%),
low in forceps and caeserian section (21 and 24%,
respectively). These finding is supported by Metzenbaum
Table 1: Incidence of DNS in relation to intrauterine
position of newborn.(LOA= Left occipito--anterior.
ROA=Right occipito--anterior)
LOA
17%
ROA
38%
BREECH
45%
Table 2: Incidence (%) of DNS in relation to parity of
mother
50
45
40
35
30
25
20
15
10
5
0
14
7
4
2 2
P0G1 P1G2 P2G3 P3G4 P5G6
(1936) and Gibson (1977). Definite correlation between the
type of delivery and the nasal deformity was noted.[9] A much
more frequent occurrence of anterior nasal septal deviation
has been found in children born by spontaneous labour. It
testifies to the importance of birth injury, which leads to
anterior nasal septal deformation.[18] Gray found that pressure
on the external nose during birth was not commonly associated
with bony obstruction but is usually due to bending of cartilage
without dislocation from maxillary crest which corrects itself
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307
Deviated nasal septum in the newborn
Table 3: Comparison of incidence of DNS in newborn in
various studies.
25
20
15
10
5
0 JAZBI'77 PRESENT BHATIA'82 P ERTH'63 S AIM'9 2 SOKNUNDAN'8 4
STUDY'0 3
in a few days.[14] The appearance of the deviation is not of a
dislocation of the caudal edge of the cartilage but a smooth
concavity.[19]
Incidence of nasal septal deviation in relation to intrauterine
position of fetus: in this series, the incidence is highest in
breech presentation 45%, followed by right occipito-anterior
(38%) and left occipito-anterior (17%) [Table 1]. These
findings are supported by Jappeson and Mindfield[2] and also
by Goyal (1987) who found 50% in breech presentation and
30% in occipito-anterior position. Such a finding was also
observed by Gray[1] who found the incidence of anterior nasal
deformity to be 4% in cases of spontaneous vaginal delivery,
but 13% in cases of persistent occipito-posterior due to
inceased pressure [Table 4]. As observed by Danforth,[7] most
vertex presentation are positioned in left occipito-anterior and
with rotation into the normal position, the nasal septum can
be pushed to the left of vomer and external nose to right of
vomer.[14] With all these forces being brought to bear on
neonatal septum, its not surprising that microfractures and
dislocation of cartilage occur frequently.
Incidence in relation to birth weight of newborn: in the present
series, it is observed that the incidence of DNS increases with
the increase of birth weight. No statistically significant
correlation was observed between the weight of newborn and
the nasal deformities.[9]
Incidence of nasal septal deviation in relation to parity of
mother: in this series, it is observed that incidence of DNS is
highest in primipara (48%) and decreases as the parity
increases [Table 2]. Jappesen and Mindfield[2] found incidence
higher in neonates born to primipara as compared to multipara.
CONCLUSION
The present study comprized of 200 newborn babies, 29 of
which were found to have DNS; the incidence being 14.5%.
Table 4: Incidence of DNS as reported in various studies
in relation to intrauterine position of fetus.
60
50
40
30 BREECH
OCCIPITO ANTERIOR
20
OCCIPITO POSTERIOR
10
0 PRES ENT JAPPESSON GOYAL' 87 GRAY'7 7
ST UDY' 0 3 AND
MI NDFEI L D' 7 2
It has been observed that incidence of DNS increased with
increase in birth weight, and in newborn delivered by vaginal
route. The incidence is lowest in caeserian section delivery.
High incidence was also found in breech malposition and in
newborns of primipara. Incidence also decreased as parity
increases. It has also been observed that pressure on external
nose during birth was not commonly associated with bony
obstruction but with bending of the cartilage from maxillary
crest.
In this study, the number of cases were few and the follow
up period was short to give a firm comment over the
persistence of deviation in newborn in their later life. The
frequency of extrauterine nasal injury is very high as the
nose being the most exposed and prominent feature of the
face. It naturally bears the burnt of many injuries – trivial
enough to forget. More importantly, since a good percentage
of such deformity originate at the gestational period, early
detection at the neonatal period is important enough to merit
an early management if required and prevent complications
in adult life.
Since, septal deformities can affect growth and development
of maxilla and vice versa, it is suggested that examination of
nasal septum by a rhinologist should be a part of a team
performing the regular systematic health examination of
children.
As rightly suggested by Saim and Said[17] in a study a policy
of routine screening in view of early correction is advocated
so that morbidity associated with this deformity can be
minimized in newborns and children in later life.
ACKNOWLEDGMENTS
I am thankful to all the doctors and staff in the departments of O&G and
Paediatrics for their cooperation and help.
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308 Deviated nasal septum in the newborn
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Address for Correspondance
Dr. A. Bhattacharjee
House no: 23/23, Green Park
Meherpur, Silchar – 788015,
Assam,
India
E-mail: dr_abhinandan1@rediffmail.com
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 4, October-December 2005
308 CMYK