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Table of Contents
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 125-130

Deviated nasal septum in children: Our experience at a tertiary care teaching hospital of eastern India

Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission13-Jan-2022
Date of Decision26-Jan-2022
Date of Acceptance29-Jan-2022
Date of Web Publication08-Jun-2022

Correspondence Address:
Santosh Kumar Swain
Professor, Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar 751 003, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcsr.jcsr_7_22

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Background: Nasal obstruction is a common symptom among children with numerous causes. Congenital or acquired nasal septal deviation may cause nasal obstruction in children. Deviated nasal septum (DNS) may also result in sinusitis, headache, epistaxis and hyposmia which increase the morbidity of the child and hamper the quality of life.
Objective: The purpose of this study is to investigate the clinical details of the DNS among children at a tertiary care teaching hospital.
Methods: This is a retrospective study conducted at a tertiary care teaching hospital between November 2016 and December 2021. History of nasal obstruction, mouth breathing, nasal bleeding and sinusitis among children with DNS was noted. Physical examination such as anterior rhinoscopy, fiberoptic endoscopic examinations of both nostrils and imaging such as computed tomography scan were done in all participating children with DNS.
Results: Out of 652 children who attended the outpatient department of otorhinolaryngology, 128 (19.63%) were diagnosed with DNS. Out of 128 children with DNS, 72 (56.25%) were male and 56 (43.75%) were female with a male-to-female ratio of 1.28: 1. Out of 128 children, 54 (42.18%) children showed C-shaped DNS, 27 (21.09%) showed anterior dislocation, 21 (16.40%) showed S-shaped DNS, 15 (11.78%) showed spur and 11 (8.59%) showed nasal septal thickening.
Conclusions: DNS and its impact on nasal breathing impairment in children are often underestimated by clinicians. Clinicians often have little knowledge on the impact of DNS and its clinical manifestations in children and its appropriate management. Early intervention for DNS in children is helpful to prevent morbid symptoms and their complications.

Keywords: Children, deviated nasal septum, rhinogenic contact point headache, septoplasty

How to cite this article:
Swain SK, Pani SR. Deviated nasal septum in children: Our experience at a tertiary care teaching hospital of eastern India. J Clin Sci Res 2022;11:125-30

How to cite this URL:
Swain SK, Pani SR. Deviated nasal septum in children: Our experience at a tertiary care teaching hospital of eastern India. J Clin Sci Res [serial online] 2022 [cited 2022 Aug 12];11:125-30. Available from: https://www.jcsr.co.in/text.asp?2022/11/3/125/347045

  Introduction Top

Deviated nasal septum (DNS) is a common nasal disorder in human beings.[1] It plays an important role in nasal patency, the aesthetic appearance of the nose, the resistance of nasal airflow and sometimes snoring.[1] A significant proportion of the population has DNS with varying degrees. There are several causes for the occurrence of DNS such as racial factors, birth moulding of nasal septum during parturition, trauma and developmental deformities.[2] This nasal septal deformity may result in and aggravate sinusitis, upper airway infection and different middle ear infections.[3] DNS produces several clinical manifestations such as nasal obstruction, postnasal drip, mouth breathing, crusting, epistaxis and recurrent sinusitis due to mechanical obstruction of the drainage of the paranasal sinuses.[4] DNS even causes Eustachian tubal catarrh and/or middle ear infection and leads to hearing impairment in children.[5] This spectrum of clinical problems in children poses a challenge to otolaryngologists and paediatricians. The role of early diagnosis and intervention is helpful for long-term relief of this morbidity clinical entity in a paediatric patient. There is very lesser number of literature and lack of standard description of nasal septal deviation in paediatric age group. This study is an attempt for evaluating the deviated nasal obstruction in children and its associated factors.

  Material and Methods Top

This retrospective study was conducted at a tertiary care teaching hospital between November 2016 and December 2021. This study was approved by the Institutional Ethical Committee (IEC) with reference number IEC/IMS/SOA/28/12.08.2021. The study population comprised 128 children with DNS [Figure 1] and [Figure 2] aged between 3 and 18 years. The study participants were classified into three groups such as Group 1 aged between 3 and 7 years, Group 2 aged between 8 and 13 years and Group 3 aged between 14 and 18 years. History of nasal allergy, nasal injury, kind of labour by mother, present clinical symptoms of the child and previous otorhinolaryngological treatment was taken. This study excluded the children of DNS with a lack of written consent from parents on examination, children above the age of 18 years and children of DNS with acute upper respiratory tract infection. The children with allergic rhinitis, sinusitis and adenoids were also excluded from this study. The history of trauma/injury to the nose of the children was documented. The trauma may be minor or major. The minor trauma includes trauma to the nose resulting in minor aesthetic deformities, minimal septal and vault alterations with absence of airway compromise. The major trauma includes the trauma to the dorsum, tip or pyramid of the nose resulting in deformation and aesthetic impairment, swelling of the septal cartilage, functional vault deformity and even septal perforation. The detail examinations include anterior rhinoscopy without using the vasoconstrictive drugs. Otoscope was employed for visualising the septal deviation in some young children. Fiberoptic endoscopic examination of the nasal cavity and computed tomography (CT) scan of the nose and paranasal sinuses were done to confirm the DNS and other associated pathology. The type of DNS such as C-shaped, S-shaped, anterior dislocation, spur and thickening was documented from the participating children. Cotton wool test and cold spatula tests were performed to confirm the nasal obstruction.{Figure 1}{Figure 2}

Statistical Package for the Social Science (SPSS) Statistics for Windows, version 20, was used for all statistical analyses (IBM-SPSS Inc., Chicago, IL, USA).

  Results Top

A total of 652 paediatric patients were examined at the outpatient department of otorhinolaryngology. Out of 652 children, 128 (19.63%) showed DNS. Out of 128 children with DNS, 72 (56.25%) were male and 56 (43.75%) were female with a male-to-female ratio of 1.28:1. The first group (3–7 years) consisted of 32 (25%) children, the second group (8–13 years) had 38 (29.68%) children and the third group (14–18 years) had 58 (45.31%) children [Table 1]. Out of 128 children, 54 (42.18%) children presented C-shaped DNS, 27 (21.09%) showed anterior dislocation, 21 (16.40%) showed S-shaped DNS, 15 (11.78%) showed spur and 11 (8.59%) showed nasal septal thickening [Table 2]. The left-sided nasal septal deviation was slightly more prevalent than right side septal deviation (46.09% and 37.50%, respectively) [Table 3]. There were 21 (16.40%) children showed S-shaped DNS with a bilateral deviation of the septum. Out of 128 children with DNS, there was a history physical trauma on the nose in 32 (25%) children. Out of 32 children with history of trauma to the nose, minor trauma to the nose was in 28 (21.87%) children and major trauma in 4 (3.12%) children. There was history of birth trauma (obstructed delivery) during delivery of 5 (3.9%) children those participated in this study. The most common symptom among participant children was nasal obstruction, followed by nasal discharge, postnasal, headache, epistaxis, snoring and hyposmia/anosmia [Table 4]. Out of 128 children with DNS, 120 (93.75%) were symptomatic and 8 (6.25%) were asymptomatic. In this study participants, 120 children with symptomatic DNS were suggested for treatment. Out of the 120 symptomatic children, 22 (17.18%) children presented with alternate nasal obstruction managed by conservative treatment with saline nasal drop and anti-cold measures for children with allergy and the common cold. There were 98 (76.56%) children of DNS with symptoms suggested for septoplasty. In this study, 88 (68.75%) children underwent septoplasty and all of them improved symptomatically, whereas 10 children avoided surgery.{Table 1}{Table 2}{Table 3}{Table 4}

  Discussion Top

The nasal septum is a mucosa-covered structure and consists of bony and cartilaginous parts separating the nasal cavity into right and left both anatomically and physiologically.[6] DNS is not an uncommon clinical entity in the paediatric age group.[7] The DNS is situated in a sagittal plane extending from the skull base superiorly to the hard palate inferiorly and nasal tip anteriorly to the sphenoid sinus and nasopharynx posteriorly.[6] DNS is a common cause for unilateral nasal obstruction and may follow midfacial and nasal trauma.[8] High birth weight babies, normal vaginal delivery of the baby and prime mother are prone to DNS of the baby after birth.[9] Moreover, breech presentation and prolonged labour seem to play an important role for the newborn with DNS.[10] The risk of occurrence of DNS increases after nasal trauma. These traumas are more commonly found in boys. The true incidence of DNS in children is not known clearly. In a study of 2380 infants, 58% had shown septal deviations.[11] Conventionally, it was thought that DNS resolves spontaneously. Gray disputed this thought by studying 2000 skulls and suggested early intervention in nasal septal deformities for avoiding serious craniofacial abnormalities.[11] The prevalence of DNS in newborns ranges from 0.93% to 22%.[12],[13] In older children, the prevalence of DNS is 12.4% in the age of 2.5–6 years and 13.6% in the age of 6–9 years old.[12],[14] In this study, a total of 652 paediatric patients were examined at the outpatient department of otorhinolaryngology. Out of 652 children, 128 (19.63%) showed DNS. In this study, the first group (3–7 years) consisted of 32 (25%) children, the second group (8–13 years) had 38 (29.68%) children and the third group (14–18 years) had 58 (45.31%) children. This result suggests that chance of DNS increases as the age of the child increases.

DNS is classified in different ways. One classification of DNS is based on their vertical and/or horizontal orientation.[15] Cottle et al. classified DNS into four types such as subluxation, large spur, caudal deflection and tension septum.[16] Guyuron et al. classified DNS into six types such as septal tilt, anteroposterior C-shaped, cephalocaudal C-shaped, anteroposterior S-shaped, cephalocaudal S-shaped and wide spur.[17] In this study, out of 128 children, 54 (42.18%) children presented C-shaped DNS, 27 (21.09%) showed anterior dislocation, 21 (16.40%) showed S-shaped DNS, 15 (11.78%) showed spur and 11 (8.59%) showed nasal septal thickening. Buyukertan et al. classified DNS by separating the nasal septum into ten segments for better localisation of the deformity.[18] There is a common occurrence of anterior nasal septal deviations in children by normal vaginal delivery in comparison to those born by a caesarean section which is the importance of birth injury on the facial area.[19] Minor trauma sustained in early life can be easily overlooked and often results in microfractures of the septal cartilage. Healing of these microfractures results in bending the cartilage away from the side of the trauma. If it occurs in the early part of life, it may cause asymmetric growth of the entire nasal structure because of the interruption of the chondrocyte growth. Nasal septal thickening is an uncommon type of DNS. Nasal septal hematoma and abscess may result in thickening of the septum which are not adequately treated.[20] Hence, nasal septal hematoma or abscess needs immediate surgical drainage of the collection followed by antibiotic coverage. Drainage in children is best performed under general anaesthesia. Although preoperatively needle aspiration has been suggested, however, it is neither cost-effective nor practical to use this technique for the management of nasal septal hematoma or abscess. In this study, there was a history of physical trauma on the nose in 25% children with DNS. There was minor trauma to the nose in 21.87% of children and major trauma in 3.12% of children with DNS. There was a history of birth trauma (obstructed delivery) during delivery of 5 (3.9%) children who participated in this study.

DNS may be asymptomatic in some children or may manifest a few symptoms like nasal obstruction and symptoms of rhinosinusitis such as nasal discharge, facial pain, smell disturbances and nasal bleeding.[21] DNS plays a critical role in symptoms of nasal obstruction, increased nasal resistance, the aesthetic appearance of the nose and sometimes snoring in children.[1] The stuffed nose is a common complaint of the child with DNS.[22] In this study, 76.56% of children with DNS presented with persistent nasal obstruction, 17.18% presented with alternate nasal obstruction, 28.12% presented with nasal discharge, 19.53% presented with headache, 21.87% presented with postnasal drip, 13.28% presented with nasal bleeding and 10.93% presented with hyposmia/anosmia. There were 6.25% of children with DNS asymptomatic. C-shaped DNS cause unilateral nasal obstruction, whereas S-shaped cause bilateral nasal obstruction. Nasal septal deviation in the newborn can result in nasal obstruction, snoring and hypoxia.[23] Children with unilateral nasal septal deviation may complain of nasal obstruction on the contralateral side, because of turbinate hypertrophy, called paradoxical nasal obstruction.[24] Despite the presence of nasal septal deviations, many children do not present significant nasal obstruction in the absence of the mucosal inflammation or oedema, or a history of nasal trauma. There may be high nasal septal deviation which will not cause nasal airway obstruction, particularly at the lower part of the nasal cavity or floor of the nasal cavity. In this study, majority of the children with DNS presented with unilateral nasal obstruction and only 16.40% of children with DNS presented with bilateral nasal obstruction. There were 42.18% of children presented with C-shaped DNS and16.40% presented S-shaped DNS. The DNS and septal spur cause more severe headaches by intranasal mucosal contact point in the nasal cavity. DNS can cause rhinogenic contact point headache and often present with intermittent pain localised in the periorbital and medial canthal or temporozygomatic areas. In this study, 19.53% of children with DNS presented with headaches. DNS in the paediatric age causes inadequate nasal airway which causes obligate mouth-breathing habits. Chronic mouth-breathing habits in children result in malocclusion and disharmonious development of the facial skeleton of the growing children.[25] In this study, there were 11.71% of children with DNS presented with snoring and mouth breathing during sleep.

The symptomatic DNS requires treatment of septoplasty in the paediatric age group in comparison to submucosal resection. Careful history taking and complete otorhinolaryngological examination, flexible endoscopy, tympanometry and rhinomanometry are performed in paediatric patients to determine the nasal flow resistance in children with DNS.[26] Clinical diagnosis of the DNS is straightforward. Clinical presentation and examinations often give a diagnosis of DNS. Diagnostic nasal endoscopy along with a CT scan of the nose and paranasal sinuses is ideal for diagnosis of the anatomical variations of the nasal cavity such as DNS.[27] Diagnostic endoscopy and CT scan of the nose and paranasal sinus are useful to rule out inflammatory pathologies such as sinusitis and mass lesions in the nose and sinuses. A DNS can be found easily via coronal and axial CT scans of the nose and paranasal sinuses. A 3D image of the midline structure is helpful for direct evaluation of the DNS. The nasal septum is usually displaced to one side of the nasal cavity. The main target of the treatment of the DNS in children is to restore the patency of the nasal cavity. Septoplasty is the choice of surgery for DNS in children.[28] Septoplasty, although safe, sometimes may be associated with nasal and facial growth problems. This creates some controversy among otolaryngologists while managing the paediatric DNS. However, septoplasty is a safe surgical procedure for children. One of the common indications for septoplasty is nasal obstruction. Hyposmia, epistaxis and septal abscess are important indications for septoplasty. The septoplasty may be approached by a standard incision, called hemitransfixation along the caudal edge of the caudal septum or Killian's incision in case posterior DNS. Only spur is removed by spurectomy. Optimum care must be undertaken for preserving a 1–1.5 cm L-shaped dorsal and caudal strut of the cartilage anteriorly for preserving nasal tip support. The mucoperichondrial flap is elevated after incision, followed by incision of the quadrangular cartilage and elevation of opposite side mucoperichondrial flaps. Then, the cartilage may be removed. Dissection superiorly should be avoided as it may cause injury to the skull base and lead to cerebrospinal fluid leak.[29]

DNS is a common clinical entity in children, although it is found in any age group. C-shaped nasal septal deviation is a common type and nasal obstruction is a very frequent symptom in paediatric patients of DNS. DNS is an important cause of nasal obstruction. Other than nasal symptoms, it may result in headache, nasal bleeding, nasal discharge, postnasal drip and hyposmia or anosmia. Diagnostic fibreoptic nasal endoscopy and imaging like CT scan of the nose and paranasal sinuses are important investigations for assessing the DNS in children. Symptomatic DNS in children require septoplasty. Awareness of DNS in children by paediatricians or clinicians is essential for early interventional management of this condition with otorhinolaryngologists.

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