DEVIATED NASAL SEPTUM IN THE NEWBORN A 1-YEAR STUDY

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1 34 Main Article DEVIATED NASAL SEPTUM IN THE NEWBORN A 1-YEAR STUDY Abhinandan Bhattacharjee 1, S. Uddin 2, P. Purkaystha 3 ABSTRACT: A prospective study of newborn babies was done at Silchar Medical College Hospital from September 2 to August 3. The babies aged from 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 [] ; Metzenbaum 1936; Selinger 1941; Sercer 194; Steiner [6] ; Lederer 1952; Scotbrown 1952; Klaff 1956; Pease [11] ; Gray [12] ; Olsen [13] ;Thomsen and Negus 1955). 1 Postgraduate trainee, 2 Associate Professor, 3 Professor and Head, Department of ENT, Silchar Medical College and Hospital, Assam, India 34 CMYK

Deviated nasal septum in the newborn 35 Metzenbaum (1936) stated that head, face, nose of a child delivered by caeserian section is perfect in contour than a child born naturally.

2 Deviated nasal septum in the newborn 35 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 [] 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 neonates found the incidence of septal deviation more in babies with increased birth weight. He also found septal deviation significantly high (5%) 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 (197) noted intrauterine trauma during birth affecting male and female alike. 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 2 to August 3. 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 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 ( 12 cm 2 ) which was divided into squares of 1x 1 mm 2, 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 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. Figure 1: Polyphonic standard grade struts are used 35 CMYK

3 36 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, newborn babies aged from 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 occipitoanterior 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 P G 1, and seven babies to P G 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) BREECH 45% LOA 17% ROA 38% Table 2: Incidence (%) of DNS in relation to parity of mother PG1 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 36 CMYK

4 Deviated nasal septum in the newborn 37 Table 3: Comparison of incidence of DNS in newborn in various studies Table 4: Incidence of DNS as reported in various studies in relation to intrauterine position of fetus BREECH OCCIPITO ANTERIOR OCCIPITO POSTERIOR 5 JAZBI'77 PRESENT BHATIA'82 PERTH'63 SAIM'92 SOKNUNDAN'84 STUDY'3 PRESENT JAPPESSON GOYAL'87 GRAY'77 STUDY'3 AND MINDFEILD'72 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 5% in breech presentation and 3% 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 newborn babies, 29 of which were found to have DNS; the incidence being 14.5%. 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. 37 CMYK

5 38 Deviated nasal septum in the newborn REFERENCES 1. Gray LP. Prevention and treatment of septal deformity in infancy and childhood. Rhinology 1977;15: Jappessen, Mindfield. Dislocation of nasal septal cartilage in newborn. Acta Obstet Gynaecol Scandinavia 1972;51: Gray LP. The deviated nasal septum. I. aetiology. J Laryngol Otol 1965;79: Gray LP. Neonatal nasal septal deformity. J Laryngol Otol 1969;83: Gray LP. Septal manipulation in the neonate: method and results. Int J Paediatr Otolaryngol 1985;8: Steiner A. Certain aspects of nasal trauma in the prenatal-natal period. Md State Med J 1959;8: Danforth DN. Obstetrics and Gynaecology 4th edn. Harper and Row Pub Inc: Phildelphia; Gray LP. Septal and associated cranial birth deformities, types and incidence and treatment. Med J Aust 1974;1: Podoshin L, Gertner R, Fradis M, Berger. Incidence and treatment of deviation of nasal septum in newborn. Ear Nose Throat J 1991;7: Kirchner JA. Traumatic nasal deformity in the newborn. Arch Otolaryngol 1955;62: Pease WS. Neonatal nasal septal deformities. J Laryngol Otol 1969;83: Gray LP. Deviated nasal septum. Incidence and etiology. Ann Otol Rhinol Layngol 1978;87: Olsen K. Nasal septal injury in children. Arch Otolaryngol 198;6: Jazbi B. Diagnosis and treatment of nasal birth deformities. Clin Paediatr 1974;13: Sooknundan M, Deka RC, Kacker SK, Verma IC. Indian J Paediatr 1986;53: Gray LP. J Laryngol Otol 1965;79: Saim L, Said H. Birth trauma and nasal septal deformity in neonates. J Sing Paediatr Soc 1992;34: Kawalski H, Spiewak PM. How septum deformations in newborns occur. Int J Pediatr Otorhinolaryngol 1998;44: Kent SE, Reid AP, Nairn ER, Brain DJ. Neonatal septal deviations. J Roy Soc Med 1988;81: Bhatia R, Deka RC, Kaker. Indian J Otolaryngol 1987;39: Jazbi B. Otolaryngol Clin North Am 1977;1: Hinderer KH. Nasal problem in children. J Paediatr Otolaryngol 1976; Bhatia R, Kaker SK, Sood VP, Verma IC, Deka RC. Correlation of birth weight and head circumference with deviated nasal septum in newborns a preliminary report. Indian J Paediar 1984;51: Address for Correspondance Dr. A. Bhattacharjee House no: 23/23, Green Park Meherpur, Silchar 78815, Assam, India dr_abhinandan1@rediffmail.com 38 CMYK

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