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Prevalence of deviated nasal septum and its association with birth moulding among neonates-a hospital based study.

INTRODUCTION: Deviation of nasal septum is very common in adults. Morrel Mc Kenzie (1) studied over 2000 skulls and found that 75% of adults had deviated septum. Gray (2) reported that septal deformities are very common in the neonate, occurring in 48 to 60%. He stated that most cases are due to the effect of skull compression as a result of moulding pressure during pregnancy and parturition. Many authors have been unable to confirm the high incidence found by Gray. Many studies (Jeppensen and Windfield, (3) Jazbi, (4) Alpini (5) etc.) showed less than 4% incidence of deviated nasal septum.

Birth trauma was first reported by Metzenbaum (6) in 1936 as being a causative factor in nasal septal deformities. It has been reported by other authors since then.

Aim of the study was to find the prevalence of DNS among new born, which varies in different studies from <4%-60%, and to find whether there is any statistically significant association between deviated nasal septum & birth moulding. If a good percentage of nasal septal deformity originate at the gestational period, early detection in the neonatal period is vital. It helps in management and prevents sequelae in adult life.

MATERIALS AND METHODS: This study was conducted at the Labour Room and Post natal wards of SAT Hospital (Government Medical College), Thiruvananthapuram, over a period of 6 months from February 2013.

STUDY POPULATION: A total of 400 full term newborn babies aged less than or equal to 3 days were included in the study; of which 247 were vaginal deliveries and 153 caesarian sections. Twin/multiple pregnancy, premature babies, neonates with congenital anomalies and those who were not willing to participate in the study were excluded.

METHODS: A written informed consent was taken from parents for the planned examination in proforma approved by our institutional ethical committee. A detailed prenatal and natal history was taken. Details about duration of labour, cephalo pelvic disproportion (CPD) and birth weight were obtained from hospital records. Babies were examined under strict aseptic precautions which included cold spatula test and anterior rhinoscopy using a bright light (Otoscope).

STATISTICAL ANALYSIS: A standardized set of data was abstracted for each case and statistical analysis done according to the data collected. Descriptive statistics including frequency distribution, diagrams and proportions were constructed for the prevalence of DNS. 95 percent confidence limits computed. To study the association, Chi-square test and Odd's Ratio computed.

RESULTS AND OBSERVATION: In this study, 400 new born babies aged less than or equal to 3 days were examined for Deviated nasal septum (DNS). 177 cases were found to have DNS. Association of DNS with mode of delivery, intra uterine position, parity & duration of second stage of labour were studied.

Prevalence of DNS in new born was found to be 44.3% [Fig 1]. Out of the 247 normal deliveries 177 had DNS (47.4%); out of the 153 caesarean section, 60 had DNS (39.2%). DNS was found to be more common in normal labour even though the association was not statistically significant. DNS was slightly more common in female babies (45.1%) than male babies (43.6%). Left sided deviations were found to be more prevalent (62.7%) [Fig. 2].

Out of 377 vertex presentation, 164 had DNS (43.5%) and out of 23 breech presentation, 13 had DNS (56.5%) [Table 1].

Prevalence of DNS was found to be more in first born babies and the association was statistically significant [Table 2].

Among the 4 vacuum deliveries 3 had DNS and the single case of forceps delivery also had DNS. Out of the 23 breech presentation 13 had DNS(56.5%) & out of 377 vertex presentation 164 had DNS(43.5%).Deviated nasal septum was found to be more common in vaginal deliveries with cephalo pelvic disproportion and in prolonged second stage of labour. Deviated nasal septum was more common in low birth weight babies but the association was not statistically significant.

TYPE OF DNS: Anterior deviation was found to be more frequent [Fig 3]. Anterior deviations were more common in normal labour (73.5%) than in caesarean section (56.7%) [Table 3, Fig 4]. External nasal deviation was found in 6 new born babies (1.5%). Septal dislocation was present in 36 newborn babies (9%), and found to be more in normal vaginal delivery (12.6%) than in caesarian section (3.3%). In normal vaginal deliveries septal dislocation was more common in first born babies (14.8%) when compared to the other group (9.5%).

DISCUSSION: In the present series, the prevalence of DNS in new born was found to be 44.3%. In the extensive study of neonatal septal deviation by Gray, (2) the incidence of DNS was found to be 48%60%. But Jeppesen and Windfield (3), Jazbi (4) and Alpini et al (5) found an incidence of less than 4%. Incidence from other studies: by Gray L (1965) (7) 21%; by Jazbi (1977)(4) 1.25%; by Sookhnundan 25%;(8) by Saim & Said 21.8%. (9)

In the present series, it is observed that prevalence of DNS is high in vaginal delivery (47.4%) & low in caesarean section (39.2%). This finding is supported by Gray 1965(7), Metzenbaum (1936)(6) and many other authors. DNS was found to be more common in vaginal deliveries with prolonged second stage of labour (66.7%). Jeppensen and Windfield (3) observed the same. Similar findings were observed in most of the studies; however Asterios et al (10) have found no statistically significant relation between DNS and prolonged duration of labour. In our study DNS was significantly high in vaginal delivery with cephalo pelvic disproportion (62.5%).

A more frequent occurrence of anterior nasal septal deviation has been found in children born by normal vaginal labour (86%) than in caesarean section (56.7%). It testifies the importance of Birth injury, which leads to anterior nasal septal deformity. Gray found that pressure applied on the nose during labour was not commonly associated with bony obstruction, but is usually due to bending of cartilage without its dislocation from maxillary crest which corrects itself in a few days. The deformity is usually a smooth concavity rather than a caudal dislocation of the cartilage. Prevalence of septal dislocation in our case series was 9% which was found to be more common in normal delivery (12.6%) than in caesarean section (3.3%).

In this series, the incidence was high in breech presentation (56.5%) when compared to vertex presentation (43.5%). These findings are supported by Jeppeson and Windfield. (3) Danforth (11) observed that most vertex presentations are positioned in left occipito anterior and with rotation in to the normal position; the nasal septum can be pushed to the left of vomer and external nose to right of vomer. With all these forces being brought to bear on neonatal septum, micro fractures and dislocation of cartilage occur frequently. Jazbi (4) and Gray support the idea that the septal deviation occurs as the baby's head undergoes internal rotation in the pelvis. This theory has been cited to explain the relationship between the presentation of the head and the side to which the deviation occurs.

In this study deviated nasal septum was found to be more common towards left (62.7%), as observed by Mackenzie (1880)(1) & Gray (1965). (7)

Prevalence of DNS was comparable in male (43.6%) and female (45.1%) babies. Grey (1978)(12), Sinha and Maheswari (1970)(13) observed that birth trauma affects male and female equally. Other studies also not found a great gender difference in the prevalence of DNS. However in adults a higher percentage of males are found to have deviated septum than females. This is thought to be due to a higher incidence of trauma to septum during childhood and adolescence in males.

This study didn't show statistically significant correlation between the weight of new born and the nasal septal deviation. DNS was found to be more prevalent in low birth weight babies. It may be due to the immature nasal skeleton of low birth weight babies (Bhatia R et al). (14)

In this series, it was observed that prevalence of DNS is more in primipara delivered by vaginal route (54.4%) when compared to multipara delivered by vaginal route (37.1%). This association was statistically significant. Jeppesen and Windfield (3) and Abhinandan et al (15) found incidence higher in neonates born to primipara when compared to multipara. However Asterois et al (10) found no statistically significant difference in the prevalence in nasal septal deviation in primipara and multipara but observed a higher incidence of septal deviation in instrumental deliveries. In our study also prevalence of DNS was significantly higher in instrumental deliveries (80%).

There is controversy regarding correction of DNS in neonates. Some authors suggest correction of dislocation with Gray's strut. Some believe self-correction in later life. Only gross deviations interfering with breathing or breast feeding necessitate other measures like cut endotracheal tube insertion through nose up to nasopharynx for a period of 2-3months has been mentioned in a case report. (16) Majority of authors suggest elective septoplasty in later life.

CONCLUSION: In the present study, out of 400 new born babies, 177 were found to have DNS; the prevalence being 44.3%. It has been observed that incidence of DNS is more in new born delivered by vaginal route. The prevalence was low in caesarian section. High prevalence was also found in cephalo pelvic disproportion, prolonged labor and in newborns of primipara. Results also suggest an increased incidence of nasal septal deviation in breech presentation and instrumental delivery, but the numbers are too small to be statistically significant.

The nose bears the brunt of injuries in most cases of facial trauma. Since a good percentage of such deformity originate at the gestational period and during delivery, early detection at the neonatal period is important for an early management and to prevent complications in adult life. It is suggested that examination of nasal septum should be made a part of routine screening of new born so that morbidity associated with this deformity can be minimized in newborns and children in later life.

There is lack of literature to assess whether the septal manipulation and septal reduction is effective on long term. At the same time, comprehensive study and research is required to standardize the diagnostic methods and treatment modalities for early detection and management of deviated nasal septum.

DOI: 10.14260/jemds/2015/1534

BIBLIOGRAPHY:

(1.) MacKenzie M. Manual of diseases of the nose and throat. London: Churchill, 1880-1884: vo 2, 4323.

(2.) Gray L P. Deviated nasal septum--incidence and etiology med j aust 1974: 1: 557-63.

(3.) Jeppensen F, Windfield I. Dislocation of the nasal septal cartilage in the new born. Acta Obstet Gynecol Scan 1972; 51: 5-15.

(4.) Jazbi B. Subluxation of the nasal septum in the newborn. Etiology, diagnosis and treatment. Otolaryngol Clin North Am 1977; 10: 125-39.

(5.) Alpini D, Corti A, Brusa E, et al. Septal deviation in new born infant. Int J Pediatr Otorhinolaryngol 1986; 11: 103-8.

(6.) Metzenbaum, M, Arch. Otolaryng (1936)., 24, 78.

(7.) Gray L. The Deviated nasal septum-aetiology (1965a) Journal of Laryngology and Otology, 79,567.

(8.) Sooknundan M, Deka RC, Kacker SK, Verma IC. Indian J Paediatr 1986; 53: 105-8.

(9.) Saim L, Said H. Birth trauma and nasal septal deformity in neonates. J singh Pediatr Soc 1992; 34: 199-204.

(10.) Asterios Korantzis, Emmanouel Cardamakis, Emmanouel, Theofanis Papamihalis. Nasal septum deformity in the new born infant during labour. Eur J Obstet Gyn RB 1992; 44: 41-46.

(11.) Danforth D. N. Obstetrics and Gynaecology 4th edn. Harper and Row Pub Inc: Phildelphia; 1982.

(12.) Gray LP. Deviated nasal septum-incidence and etiology. Ann Oto Rhino Laryngol 1978; 87(Suppl50).

(13.) Sinha S N, Maheshwari V K. Indian J Otolaryngol. 1970; 22(4): 204-209.

(14.) Bhatia R, Kaker S. K, Sood V. P, Verma, Deka R. C, Correlation of Birth weight and head circumference with deviated nasal septum in newborns. A preliminary report. Indian J Pediatr 1984; 51:649-51

(15.) Abhinandan B, Uddin S, Purkaystha P. Deviated nasal septum in the newborn--a 1-year study. Indian J otolaryngol. 2005; 57(4): 304-8.

(16.) Vishal Pooniya, Nisha Pandey. International Journal of Paediatric Otorhinolaryngology, Sept 2012; 3; 147-148.

Satheesh S. [1], Rajina K. [2]

AUTHORS:

[1.] Satheesh S.

[2.] Rajina K.

PARTICULARS OF CONTRIBUTORS:

[1.] Additional Professor, Department of ENT, Medical College, Thiruvananthapuram.

[2.] Senior Resident, Department in ENT, Medical College, Kozhikode.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Satheesh S, Additional Professor, Department of ENT, Medical College, Thiruvananthapuram.

E-mail: shereensatheesh@yahoo.co.in

Date of Submission: 06/07/2015.

Date of Peer Review: 07/07/2015.

Date of Acceptance: 22/07/2015.

Date of Publishing: 28/07/2015.
Table 1: Association of DNS and position of baby

Position   Present           Not Present
of baby    Count   Percen-   Count   Percen-   [chi square]     P
                    tage              tage

Vertex      164     43.5      213     56.5
Breech      13      56.5      10      43.5         1.49       0.222

Table 2: Association of DNS and order of birth of baby in normal
labour

Order of      Present           Not Present
birth of   Count   Percen-   Count   Percen-   [chi square]     P
baby                tage              tage

First       78      54.9      64      45.1
>1          39      37.1      66      62.9        7.66**      0.006

** significant at 0.01 level.

Table 3: Association of type of DNS and type fo delivery

Type of     Normal            Caesarean         [chi square]     P
DNS                           Section
            Count   Percent   Count   Percent

Anterior     86      73.5      34      56.7        5.15 *      0.023
Posterior    31      26.5      26      43.3

* Significant at 0.05 level.

Fig. 1: Prevalance of Deviated nasal septum

Prevalence of DNS

DNS           44.3%
Not Present   55.7%

Note: Table made from pie Chart.

Fig. 2: Distribution according to side of deviation

Percent

Right       31.6%
Left        62.7%
Bilateral   5.7%

Note: Table made from pie Chart.

Fig. 3: Distribution according to type of DNS

Anterior   67.8
Posterir   32.2

Note: Table made from bar Graph.

Fig. 4: Association of type of DNS and type of delivery

           Normal   Caesarean Section

Anterior   73.5     56.7
Posterir   26.5     43.3

Note: Table made from bar Graph.
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Title Annotation:ORIGINAL ARTICLE
Author:Satheesh, S.; Rajina, K.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Jul 30, 2015
Words:2369
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