Deviated Nasal Septum in Saudi Newborns
From the ENT Department, Security Forces Hospital, Riyadh.
OA Hamid, Deviated Nasal Septum in Saudi Newborns. 1990; 10(3): 293-295
Abstract
Of 500 Saudi infants born at the Security Forces Hospital in Riyadh, 7.2% were found to have deviated nasal septum. Different fetal and maternal variables were tested for their influence on the incidence of congenital deviated septum, and duration of the second stage of labor was the only variable found to be significantly associated with septal deviation. Results showed that factors other than labor trauma could produce congenital deviated nasal septum (i.e., pregnancy factors).
Deviated nasal septum could be due to traumatic or developmental causes. Since Metzenbaum1 first described deviated nasal septum in the newborn, trauma during labor has been recognized as a possible cause. The reported incidence of congenital deviated nasal septum varies. Metzenbaum1 reported 1%, Cottle et al,2 10%, and Alpini et al,3 6.3%. Gray4 discovered a slight degree of nasal septal deviation in 58% of all newborns studied. This variation could be attributed to different study design, but racial factors could also be involved. Because of this and as no such studies have been conducted in Arabs, we undertook to assess the incidence of deviated nasal septum in Saudi newborn babies, and to correlate it with fetal and maternal variables.
Subjects and Methods
From June 1988 to January 1989, 500 Saudi infants born at Security Forces Hospital were evaluated for septal deviation. They were examined by anterior rhinoscopy using an otoscope and Gray's method.4 In the latter method, a 4-mm-wide and 2-mm-thick Silastic strut is inserted into each nostril after being lubricated. The strut is pushed along the floor of the nose, hugging the septum. Normally, the strut can be introduced for 4 to 5 cm but arrest of the strut at 1.5 to 2 cm indicates obstruction due to septal deviation.
The medical records of all mothers and infants were examined for the following variables: parity, delivery route, instrumentation, fetal position, duration of second stage of labor, infant sex, and birth weight. The significance of these variables in relation to the occurrence of septal deviation was studied by the chi-square test and significance was defined at P ≤ 0.05.
Results
Of the 500 neonates, 36 (7.2%) had septal deviation. Among the mothers, 110 were Primipara and 390 multipara, and septal deviation was found in 10% (N = 11) and 6.4% (N = 25) of their infants, respectively. There was no significant difference between the two groups (P = 0.2; X2 = 1.65). Of 269 male infants, 19 (7.06%) showed septal deviation compared with 17 (7.36%) of 231 female infants. The sex of the infant was not significantly associated with septal deviation (P = 0.09: X2 0.02). To assess the effect of birth weight on the incidence of deviated nasal septum, the infants were divided into three subgroups. Of 52 low-birth-weight babies (< 2.5 kg), four (7.69%) had septal deviation. Of 320 babies whose birth weight fell between 2.5 kg and 3.5 kg, 24 (7.5%) had deviated septums. In the high-birth-weight group (> 3.5 kg), eight (6.25%) of 128 infants had deviated nasal septums. When the three groups were compared, birth weight was not found to be significantly associated with deviated nasal septum (P = 0.9; X2 = 0.02).
Vaginal delivery in 418 mothers yielded 33 babies with deviated septum (7.89%), while three of 82 infants (3.66%) delivered by cesarean section had septal deviation, but this did not achieve statistical significance (P = 0.17; X2 = 1.84). Because of the insufficient number of infants delivered with forceps (six of 418 vaginal deliveries), statistical analysis of this variable could not be done.
The most common fetal presentation was occipitoanterior; of 397 babies, 30 (7.56%) had deviated nasal septum. Other presentations included brow, face, and occipitoposterior. Of 21 such presentations, three infants (14.28%) had deviations. This difference between the two groups was also not statistically significant (P = 0.18; X2 = 3.38). The direction of the occipitoanterior presentations was also evaluated, i.e., left versus right. Of 282 left occipitoanterior deliveries, 19 babies (6.74%) had septal deviation compared with 11 (9.57%) of 115 right occipitoanterior deliveries. There was no statistically significant difference seen with the direction of internal rotation (P = 0.50; X2 = 0.47). The remaining 82 infants were delivered by cesarean section, therefore they were not included in the analysis of this birth variable.
Second stage of labor, commencing from the time of full cervical dilation until delivery, ranged from 2 to 100 minutes. Subjects were divided into three subgroups based on the following durations: less than 15, 15 to 30, and more than 30 minutes. The incidence of deviated nasal septum increased with prolongation of the second stage of labor and was 5.76%, 11.49%, and 16.6% in the three groups, respectively. This difference among the groups was statistically significant at P = 0.03 (X2 = 7.2).
Discussion
The frequency of deviated nasal septum in Saudi newborns in this study (7.2%) is comparable to that observed in different Western populations, thus eliminating racial factor as a likely influence. Because different pregnancy and labor mechanisms that may cause trauma to the infant's nose are essentially similar among different races, this further rules out race as a significant variable.
Duration of the second stage of labor was the only factor that was significantly associated with the frequency of deviated nasal septum in newborns. During this time of labor, maximum parturition pressures are exerted to expel the fetal head and the soft cartilaginous nose is subjected to trauma. Because the second stage of labor is generally more prolonged in primiparas than in multiparas, an increased incidence of deviated nasal septum would be expected in the offspring of the former; however, this was not seen in our series. One study did show an increased incidence of deviated septum among primiparas, but in their population, multiparas had a longer second stage.3 Most studies conclude that the length of the second stage of labor is an important variable.
If labor contractions were a main causative factor, fetal presentation would have proved to be a significant variable. During face and brow deliveries, the infant's nose is subjected to more direct trauma and this would be expected to lead to a higher incidence of septal deviation. A higher incidence would also be expected following right occipitoanterior presentation because the arch of internal rotation is longer than that with left occipitoanterior presentations. In neither event was an increased incidence of deviated nasal septum seen in our study. The fact that congenital septal deviation occurred in babies delivered by cesarean section also disproves labor contraction as a cause of nasal trauma. This suggests that deviation could happen during pregnancy.7 Long sustained pressure against the nose caused by the fetus's hand or a uterine fibromyoma can produce nasal deviation.8
Developmental rather than traumatic factors could also be involved. Abnormal development of the palatal folds may cause elevation of the soft palate, thus decreasing the vertical dimension of the nasal cavity and compressing or kinking the septum.9 Differences in the rate of growth of the septum compared to other midfacial structures could result in a septum that is too large for the space it has to occupy, and consequently it deviates.
Of all the variables investigated, the length of the second stage of labor was the only one that was significantly associated with the incidence of deviated nasal septum in newborns. The possibility of prenatal (pregnancy) causes should also be considered.
Acknowledgment
The author thanks Dr. Edward B. DeVol from King Faisal Specialist Hospital and Research Centre for his help in the statistical analysis.
References
1. Metzenbaum M. Dislocation of the lower end of the nasal septum cartilage. Arch Otolaryngol 1936;24:78-81.
2. Cottle MH, Fischer GG, Loring RM, et al. Early nasal injuries. Presented at the Meeting of the American Medical Association (June, 1956). (Cited in: Jazbi B. Subluxation of the nasal septum in the newborn: etiology, diagnosis, treatment. Otolaryngol Clin North Am 1977;10:125-36).
3. Alpini D, Corti A, Brusa E, et al. Septal deviation in newborn infants. Int J Pediatr Otorhinolaryngol 1986;11:103-7.
4. Gray LP. Septal manipulation in the neonate: method and results. Int J Pediatr Otorhinolaryngol 1985;8:195-209.
5. Jeppesen F, Windfeld I. Dislocation of the nasal septal cartilage in the newborn. Acta Obstet Gynecol Scand 1972;51:5-15.
6. Jazbi B. Subluxation of the nasal septum in the newborn : etiology, diagnosis and treatment. Otolaryngol Clin North Am 1977;10:127-36.
7. Harkaway KL, Scanlan JW. Dislocation of the triangular cartilage after cesarean section for breech presentation without labor. J Pediatir 1978;92:162-6.
8. Steiner A. Certain aspects of nasal trauma in the prenatal-natal period. Maryland Med J 1959;24:78-82.
9. Gray LP. The development and significance of septal and dental deformities from birth to eight years. Int J Pediatr Otorhinolaryngol 1983;6:265-77.
Print version 
Plain text 
