Diagnosis of Septal Deformities in Newborns RAJESH BHATIA, R. C. DEKA 8- S. K. KACKER

The discrepancies in the incidences of septai deformities in the newborns reported in literature have been analysed and discussed. A protocol for the detection of septal deformities in the newborns has been presented.

Septal deformities are known to occur in the newborns (Gray, 1965; Jeppesen and Windfeld, 1972; Jazbi, 1977; Bhatia, 1982). The incidence of septal deformity in newborns has been reported to be varying from 1.25 per cent (Jazbi, 1977) to 25.0 per cent (Sookhnundan, 1984). Two types of septal deviations have been described in the newborns (Gray, 1965): (i) Anterior cartilagenous dislocation involves the cartila- genous septum. It is due to trau- matic pressures operating within the birth canal which result in slipping up of the septal cartilage from the maxillary groove. It is associated with external nasal de- formity. (ii) Combined septal deformity on the other hand is due to transmitted pressures on the foetal skull explained by birth moulding theory (Gray, 1965, 1978). It may or may not be associated with external nasal de- formity. The methods of diagnosis of septal deformities in the new- born have varied from author to author. Gray (1965) utilised strut method to diagnose septal de- formities in the newborns (g.v.) and reported an incidence of 21 per cent. Pease (1969) also utili- sed strut method and reported an

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

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.

incidence of 23 per cent of septal deformities in the newborns. Jep- posen and Windfeld (1972) on the other hand diagnosed septal de- formities on the basis of external nasal deformity and reported an incidence of 1.45 per cent. Jazbi (1977) diagnosed septal deformi- ties with basis of external na~al deformity and reported an inci- dence of 1.25 per cent. Jazbi (1977) in another experiment exa- mined all newborns with the help of small sized otoscope and specia- lly designed elevator for palpation of the nasal cavity and reported an incidence of 1.9 per cent. Bhatia (1982) examined all newborns with strut and reported a frequency rate of 15.4 per cent and Sook- hnandan et al (1986) in a similar study reported the frequency to be 25.0 per cent. The present paper analyses the causes of discre- pancies in the incidence reported by various authors and set out a protocol for the diagnosis of septal deformities in the new- brons.

Reasons f o r d iscrepancy in t h e incidences

Based on a study on the new- borns (Bhatia, 1982) we have made observations on the reasons for discrepancy in the incidences.

(i) The studies based no diagnosis of septal deformities by external nasal examination alone have reported low incidence. This is essentially because all septal deformities are not associated with external nasal deformity. In fact, of the two types of septal defor- mities described by Gray (1965) only anterior cartilagenous dislocation is associated with ex- ternal nasal deformity. Combined septal deformity on the other hand

can exist without association with the deformity of the external nose. In fact, external nasal deformity in the newborn is relatively a rare occurrence. Gray (1978) describ- ed external nasal deformities only as four per cent of the newborns. Bhatia (1982) described this to be present only in 2.5 per cent. Hence series which are based on external nasal examination are bound to report lower incidence. It is imperative thus that estimation of the incidence of septal deformi- ties should be based on intranasal examination.

(ii) Jazbi (1977) has examined all newborns rhinologically with the help of small sized otoscope and specially devised elevator and has reported incidence to be 1.9 per cent. Incidences based on strut examination have varied from 15.4 per cent (Bhatia, 1982) to 25.0 per cent (Sookhnundan, 1984). The examination with the strut appears to be a logical one. The thickness of the strut (2 mm) corresponds with the width of the nasal cavity in the newborns (Gray, 1978). Any deviation of the septum would impede the passage of the strut in the nasal cavities, Minor deviations of the septum can be missed by examination with the help of a small otoscope or by palpation with elevator as describ- ed by Jazbi (1977). Hence it is essential that newborns should be strut tested to detect the septal deformities with a strut.

We recommend the following tests for the accurate diagnosis of septal deformities in the newborns:

1. External nasal e x a m i n a t i o n The newborns to be tested for

nasal septal deformity should un- dergo external nasal examination.

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

DIAGNOSIS OF SEPTAL DEFORMITIES IN NEWBORNS--BHATIA et al

Following points should be looked for intthe examination :

a. Deviation of the dorsum of the nose.

b. Leaning of collumella. c. Flattening of the ala. d. Asymmetry of the external

nares. e. Asymmetry of the movement

of ala.

2. Test fo r t i p i ns tab i l i t y The index finger of the right hand

should be placed on the tip of the nose and slight compression ap- plied. In a newborn with anterior cartilagenous dislocation the tip sinks due to the lack of support of the rigid cartilage. 3. Co t ton Woo l t es t (Fig. 1)

A thin wisp of cotton should be placed in front of the nostril of the newborn and its movements obser- ved with breathing. Any restriction in the movement on either side should indicate the possibility of aseptal deviation. However, this- is not a confirmatory test and should not be carried out if the baby struggling or crying. 4. M e t a l p late t es t (Fig. 1)

Anterior hygrometry as described in adults with a metallic tongue depressor blade can be carried out in newborns as well. Any asym- metry in the condensation should point to the possibility of septal deviation to be confirmed by other tests described below. 5. Examinat ion by small auris-

cope (Fig. 1) An auriscope with a small spe-

culum can be inserted into the nasal cavities to look for any asymmetry in the nares. Though not reliable, it gives a visual impres- sion and aids in the further exami- nation with the strut. 6. Examinat ion w i t h strut

(Fig. 1 ) A lubricated polythene strut

(2 mm thick, 6 mm wide, 12 cm long) can be inserted into the nasal cavities along the floor of the nose parallel to the inferior turbinate. In normal noses the struts can be passed equally and smoothly on either side of the nasal cavities. Any obstruction to its passage, however, indicates a septal devia- tion and to date it is the mostl reliable test of detection of septal deformities in the newborns.

Fig. 1. Showing different tests for detection of septal deformity in newborns. Top (left to right) : Cotton Wool test ; Metal plate test ; testing with auriscope ; Bottom (left to right) Polythene strut : Strut test in a normal baby ; strut test in a ibaby with left sided nasal septal deviation.

Examination carried out with the above protocol should detect majority of the septal deviations in the newborns. However, some septal deformities may still be missed since the examination with

the strut is palpatory and a crude one. This has been demonstrated aptly by Gray (1978) who com- pared septal deformities in the newborns and dried adult skulls.

References 1. Bhatia, R. (1982) : Deviated nasal

septum in the newborn, its fre- quency, aetiology and treatment. Thesis submitted to the Faculty of ALMS, New Delhi.

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

3. Gray, L.P. (1978) : Deviated nasal septum : Incidence and aetiology. Annals of Otology, Rhinology and Laryngology. Suppl. 50 :Vol. 87, No. 3, part 3.

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

5. Jeppesen, F. and Windfeld, II (1972): Dislocation of the nasal septal cartilage in the newborn. Acta Obstet. Gynaecol. Scand. 5 1 : 5 .

6. Pease, W.S. (1969) : Neonatal septal deformities. Journal of LarynEology andOtology. 83 : 271.

7. Sookhnandan, M. et. al. (1986) : Nasal septal deviation at birth and its diagnosis. Indian Journal of Paediatrics, 53 : 105.

8. Sookhnandan, M. (1984) : Effects of septal correction at birth and during childhood. Thesis submitted to the Faculty of AIIMS, New Delhi.

Indian Journal of Otolaryngology, Volume 39, No. 1, March, 1987 19