Aetiology of Deviated Nasal Septum in the Newborn RAJESH BHATIA, R. C. DEKA El" S, K. KACKER

The frequency of deviated nasal septum in the 201 newborns studied has been found to be 15.4 per cent, Various aetiological factors have been studied. Preterm or low birth weight babies have been found to be having higher frequency of septal deformities. Prolonged and obstructed labour is also associated with higher frequency, Birth pressures operating during intra-uterine life and during delivery have been highlighted to explain the occurrence of septal deformity in the newborn.

I n t r o d u c t i o n and R e v i e w of L i t e r a t u r e

The entity of deviated nasal septum in the newborns was first described in 1936 by Metzenbaum. After that many authors (Kirchner, 1955; Gray, 1965; Pease, 1969; Jeppesen and Windfeld, 1972; Jazbi, 1977 and others) have re- ported this condit ion.

The septal deviation in the newborn occurs due to various pressures impinged upon the foetus during intrauterine life or during birth. Foetal nose is well develop- ed by the fourth month of intra- uterine life (Jazbi, 1977). A uter- ine fibroid by pressure on the soft and pliable nose of the foetus can cause septal deviation (Kirchner, 1955). Also the foetal nose can get hit against the pelvic walls resulting in dislocation of the cartilagenous septum from the maxillary groove (Kirchner, 1955). Similarly during the passage of the foetal skull through the birth canal the foetal nose can get com- pressed and septal cartilage may get dislocated from the maxillary

Rajesh Bhatia, R. C. Deka, S. K. Kacker, The Department of Otorhinolaryngology. All-India Institute of Medical Sciences, New Delhi-110 029.

Reprint request : Dr. R. C. Deka, Assistant Professor, Department of Otorhinolaryngology, All-India Institute of Medical Sciences, New Delhi-110 029.

Acknowledgements : Thanks are due to Dr. I. C. Verma,

Assoc. Prof, Peadiatrics for his kind help and permission to use the nursery material.

crest resulting in septal deviation and external nasal deformity (Jeep- pesen and Windfeld, 1972). Infact two types of septal deviations have been described in the newborn (a) anterior cartilagenous disloca- t ion (b) combined septal deformity (Gray, 1965). Anterior cartilage- nous deformity involves the dislocation of the septal cartilage from the maxillary crest wi th asso- ciated external nasal deformity. This type of deformity occurs due to direct trauma over nose at any age and has been described in the newborns (Gray, 1965). Com- bined septal deformity on the other hand involves all the septal com- ponents namely the vomer, the ethmoid and the septal cartilage. It is a typical deformity in the newborns and is due to transmit- ted pressures.

The incidence of septal deviation in the newborns is reported to be from 1.25 per cent (Jazbi, 1977) to 23 per cent (Pease, 1969). This study was undertaken to find out the frequency of deviated nasal septum in the newborns in our condit ions and to find out the aetiological factors that might be responsible for this condit ion.

M a t e r i a l s and M e t h o d s

The prospective study on new- borns was conducted at the depart- ments of Paediatrics and Otolaryn- gology of AIIMS, New Delhi, from January 1980 to December 1981. Two hundred and one new- borns during this period were picked up at random for the study. All the newborns selected were between 1-4 days of neonatal life. A detailed history of the mother

was taken. The parity of the mother, gestational period of the present pregnancy, durations of Ist and l ind stage of labour, type of delivery and cephalopelvic dis- proportion, if any, were recorded. All the newborns were then exa- mined by the etolaryngologist. Any diff iculty in breathing, or feeding, external injury of the newborn were noted. The external nose of the newborns was exami- ned to look for deviation of the dorsum of the nose, leaning of collumella, flattening or asym- metry of the nares. A celtton wool test on the sleeping or resting newborn, whenever possible, was carried out. A thin wisp was fashioned from cotton wool and placed in front of the nostril and its movements were observed with breathing. If the cotton wisp moved freely it was presumed that the passage of the air current across the nostrils was normal. Any restriction in its movement indicated a block in the passage of the air current. Deviated nasal septum was diagnosed wi th the help of a strut modified from that described by Gray (1965). The- strut was made from soft poly thene of 2 mm thickness. It was 6 mm wide and 12 cm long. It was calibrated to know the exact depth of deviation from the ex- ternal naris. This strut was passed along the floor of the nose parallel to the inferior turbinate down to the choana. If the strut passed normally, it was taken as normal. If any obstruction was to its passage particularly at 1.5-2.0 cm level from external naris septal deviation was dia- gnosed. Septal deviation was dia- gnosed as mild if the strut could

14 Indian Journal of Otolaryngology, Volume 39, No. 1, March, 1987

AETIOLOGY OF DEVIATED NASAL SEPTUM IN THE NEWBORN--BHATIA et al

be negotiated beyond the obstruc- TABLE I t ion wi th the use of gentle force. If it could not be negotiated Correlation of type of delivery and frequency of deviated septum at birth beyond the obstruction, it was labelled as severe. Whenever Type of delivery Total No. of No. of newborns % affected sepcal deviation was associated newborns with deviated wi th external nasal deformity it septum was labelled as anterior cartila- genous dislocation. Combined Vaginal 100 16 16.00 septal deformity was diagnosed whenever strut testing revealed Forceps 25 2 8.00 septal deviation in absence of external nasal deformity. Emergency caesarean section 55 12 21.82

Elective caesarean section 21 1 4.76

Results Total 201 31 15.42

Of the 201 newborns examined, deviated nasal septum has been detected in 31 indicating a fre- quency of 15.4 per cent. There was no sex predilection and right and left sided deviations, were distributed equally. Twenty-f ive of these deviations were mild and six were severe. External nasal de- dormity was diagnosed in five indicating a frequency of anterior septal dislocation to be 2.5 per cent. Rest 26 cases had combined septal deformity. Other factors st- udied were as f o l l o w s :

Chi square--4.64 (not significant).

TABLE II

Correlation of birth weight wi th frequency of septal deviation at birth

Birth weight (kg) Total No. of No. of newborns % affected newborns with DNS

< 2.8 84 17 20.2

2.8--3.5 105 14 13.3

> 3.5 12 0 0

1. Type o f d e l i v e r y

Highest frequency of septal deviation was seen in newborns delivered by emergency caesarean section (21.8%) whi le lowest fre- quency was seen in the elective caesarean group (4.36%). In the group of newborns delivered by spontaneous vaginal delivery the frequency was 16.0 per cent whi le in forceps delivery it was 8.0 per cent (Table I).

Chi square--0.8O (N.S.)

TABLE III

Frequency of septal deviation in AFD and SFD babies

Birth weight Total No. of No. of babies babies with DNS

% affected

AFD

SFD

172 24 13.9

26 6 23.1

Chi square--0.84 (N.S.)

2. B i r t h w e i g h t Low birth weight babies ( . .2 .8 kg) had higher frequency as compared to normal or high birth weight babies (Table II). Also the fre- quency was high in small-for- dates babies as compared to ap- propriate for date babies (Table III).

3. Ges ta t i ona l pe r iod = Babies born preterm had higher frequency

as compared to term or post-dated babies (Table IV).

4. Pa r i t y Babies born, to mult i- parae mothers had high frequency of septal deviation as compared to primigravidae mothers (Table V.)

5. D u r a t i o n o f f i r s t s tage o f l a b o u r Whenever the duration of first stage of labour was pro-

longed ( . . 24 hr) the frequency of Septal duration tended to be high (28.6%) as compared to when it was short ( . .6hr ) (Table VI).

6. D u r a t i o n o f second stage of l abou r The frequency of septal deviation in newborns was high if the duration of the second stage of labour was short ( . . 15 min) as compared to when it was prolonged ( . . 60 min) (Table VII).

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AETIOLOGY OF DEVIATED NASAL SEPTUM IN THE NEWBORN--BHATIA et al

TABLE IV

Correlation of gestational period wi th frequency of nasal septal deviation at birth

Gestation (wks) No. of newborns No. of newborns % affected with septal deviation

< 37 22 4 18.18 37---40 156 25 16.03

> 40 23 2 8.69

Chi square--0.97 (N.S.)

7. Cephalopelv ic d i sp ropo r t i on In presence of cephaloplvic dis- proportion the freuqency of septal deviation was high (Table VIII).

8. H e a d c i r c u m f e r e n c e o f t h e n e w b o r n Newborns with head circumference smaller than 33.0cm had higher frequency (20%) as compared to newborns with head circumference between 330- 350 cm (13.3%) (Table IX).

TABLE V

Correlation of parity of mother to septal deviation in the newbo=n.

Parity No. of newborns No. of newborns % affected with septal deviation

P 0 75 11 14.66 P 1 to P 3 117 18 15.38 >P 9 2 22.22

Chi square--0.35 (N.S.)

TABLE VI

Correlation of duration of first stage of labour with frequency of septal deviation at birth

Duration (hrs) No. of newborns No. of newborns % affected with septa I deviation

< 6 19 1 5.26

6--24 99 15 15.15

> 24 7 2 28.57

Total 125 18

Chi square--2.47 (N.S.) (Vaginal deliveries -- 100 ; forceps deliveries -- 25). (Vaginal deliveries- 16 ; forceps deliveries- -2).

TABLE VII

Correlation of duration of second stage of labour with frequency of septal deviation at birth.

Duration (rain) No. of newborns No. of newborns % affected with septa I deviation

< 15 4 1 25.00

15 - - 30 72 11 15.27

30 -- 60 30 4 13.33

> 60 19 2 10.53

Total 125 18

Chi square--O.67 (N.S.)

D i s c u s s i o n

The frequency of septal devia- tion in the newborns has been found to be 15.4 per cent. This corresponds to the figures reported by Gray (1965) and Pease (1969). Sookhnandan (1984) in a recent study has reported the frequency to be 25 per cent. It is thus obvi- ous that nearly 1/5th to 1/4th of the newborns have septal devia- tion at birth. No sex difference has been noted in the present series and this corresponds with the observations of other authors Gray, 1965) ; Pease, 1969). However, predominance of left sided deviation as reported by Gray (1965) has not been noted in the present series as both right and left sided deviations were distributed equally. The milder forms of septal deviations are commoner and this corresponds to the observations made by Pease (1969). External nasal deformity or anterior cartilagenous disloca- tion has been found to be present in 2.5 per cent. Gray (1978) also reported the incidence cf.external nasal deformity to be four per cent.

The frequency of septal devia- tions has been found to be high in newborns delivered by emergency caesarean section. This is because the delivery is conducted after trial of spontaneous vaginal deli- very has been undertaken. The foetal head in such circumstances underg, oes moulding and that ex- plains the high frequency. The frequency in the group with forceps delivery is low as compared to that of spontaneous unassisted vaginal delivery. Forceps perhaps has shouldering effect and prevents the foetal skull from undergoing

16 Indian Journal of Otolaryngology, Volume 39, No. 1, March, 1987

AETIOLOGYOF DEVIATED NASAL SEPTUM IN THE NEWBORN--BHATIAe t al

TABLE VIii

Correlation of frequency of septal deviation in cases wi th cephalopelvic disproportion in relation to mode of delivery

Mode of delivery No. of newborns No. o f newborns % affected with septa I

deviation

Forceps 1 1 100.00

Emergency caesarean section 5 3 60.00

Elective caesarean section 8 0 --

Total 14 4 28.57

Chi square - - 8.12. P < 0.05.

TABLE IX

Correlation of head circumference with frequency of septal deviation at birth

Head circumference (cm) No. of newborns No. of newborns % affected with DNS

< 33.0 10 2 20.0

33.0 - - 35.0 30 3 13.3

> 35.0 3 0 0

Total 43 6~ 13.95

Chi square-- 0.80 (N.S.)

moulding within the birth canal. The occurrence of septal deviation in the newborns has been explain- ed by birth moulding theory by Gray (1965). However, if only birth pressures are operating the frequency in the elective caesa- rean section cannot be explained. Babies in such cases are delivered prior to spontaneous trial of labour.

This explains that other prenatal pressures are also operating in the production of septal deviation in the newborn as suggested by Kirchner (1955).

Small-for-date babies, low birth weight and preterm babies have been found to be more prone to moulding pressures within the birth

canal (Bhatia et al., 1984). The high frequency of septal deformity in babies born after a prolonged first stage of labour is understand- able. However, frequency is high in multigravidae mothers and when the second stage of labour is short. This is perhaps because moulding pressures occur over a shorter period of time resulting in higher frequency. This has been com- plained by Pease (1969). Nearly two-third of the babies with cep- halopelvic disproportion have been found to be having septal deformi- ties at birth, thus indicating the importance of pressures within the birth canal.

C o n c l u s i o n

Septal deviations in the new- borns are known to occur. Nearly 1/hth of the babies have been found to have septal deformities at birth. The frequency is high in smaller babies and in obstructed and prolonged labour. Birth moulding pressures as propounded by Gray (1965) explain the occur- rence of septal deformity in the newborns. However, doubt has been placed on hereditary aetio- Iogy since Rauno-Gill et al (1980) found septal deformities in two foetuses--one 48 days old and the other 50 days old. Birth pres- sures probably cannot operate at such a young age of the foetus. Also congenital aetiology cannot explain such a high frequency of septal deformities. The evidence in the present stage of knowledge are congenitally acquired due to various traumatic factors operating before or during the birth. How- ever, confirmation of the above study needs to be made in future on a larger sample.

References

1. Bhatia, R., Kacker, S.K., Sood, V.P. Varma, I.C. and Deka, R.C. (1984) : Correlation of birth weight and head circumference with deviated nasal septum in newborns---a preliminary report. Indian Journal of Pediatrics 51 : 649,

2. Gray, L.P. (1965) : Deviated nasal septum Aetiology. Journal of Otology & LaryngoloEy 79 : 567.

3. Jazbi, B. (1977): Subluxation of the nasal septum in the newborn: Aetiology, Diagnosis and Treatment. Otolaryngolical Clinics of North America 1 : 125.

4. Jeppesen, F. and Windfeld, I. (1.972) Dislocation of the nasal septal cartilage in the newborn. Acta Obstet. Gynaecol. Scand., 51 : 5.

5. Kirchner, J.A. (1955) : Traumatic na- sal deformity in the newborn. A.M.A. Archives of Otolaryngology, 62: 139.

6. Metzenbaum, M. (1936) : Disloca- tion of the lower end of the nasal septal cartilage. Archives of Oto- laryngoloEy, 24:78, Quoted by Jeppesen and Windfeld, 1972.

7. Pease, W.S. (1969) : Neonata. septal deformities. Journal of Otology & LaryngoloEy 83 : 271.

8. Ruano-Gil, D. et. al (1980) : Defor- mities of the nasal septum in human foetuses. Rhinology, vol. 18, No. 2 105.

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