Atlas of Procedures in Neonatology, 4th Edition

Miscellaneous Procedures

53

Relocation of a Dislocated Nasal Septum

Smitha Warrier

Mhairi G. MacDonald

  1. Indications

To avoid future surgery, breathing and feeding problems, epistaxis, malocclusion, and sinusitis (1)

Fetal compression sufficient to cause some degree of nasal deformation is a frequent physical finding on early newborn examination and normally resolves within 48 hours of birth (Fig. 53.1). In some instances, intrauterine forces or pressure applied during delivery cause a true septal dislocation (Fig. 53.2)Fig. 53.2). The incidence of true septal dislocation ranges from 1% to 4% of births (1,2,3,4,5,6 and 7). The otolaryngology literature indicates that septal dislocation should be relocated within a few days of birth for the best outcome (1,3,8). To differentiate compression deformity from true septal dislocation, apply gentle pressure to the tip of the nose; a dislocated septum will move farther from the midline at the base, a compressed septum will not move from the midline at the base. A compressed nose can be restored to normal anatomy with gentle pressure; a nose with septal dislocation cannot.

  1. Contraindications
  2. Presence of other nasal or midline congenital anomalies requiring more extensive treatment
  3. Posterior septal dislocation
  4. Nasal orifice too small to easily admit smallest septal forceps
  5. Equipment
  6. Septal forceps—modified Walsham or other appropriately sized septal forceps (Fig. 53.3).
  7. Precautions
  8. Reduction should be performed within the first 3 to 4 days after birth.
  9. Otolaryngology evaluation for refractory dislocations or associated facial abnormalities
  10. Adequate restraint of infant, especially the head
  11. Remember that many newborns are obligate nasal breathers; insertion of a large-bore nasogastric tube into the stomach or an oral airway, prior to the procedure, will serve to separate the tongue from the palate and to promote oral respiration.
  12. Technique
  13. Place septal forceps into the nares on the anterior aspect of the cartilaginous septum, posterior to columella. Advance blades gently, approximately 0.5 to 1.0 cm. Do not advance past the inferior aspect of the middle turbinate; do not force(Fig. 53.4).
  14. Gently close the forceps onto the septum.
  15. Direct the pressure of the lower edges of the forceps blades toward the midline, to move the septum into alignment with the nasal groove on the vomer (spine)—a slight upward motion may be required to lift the inferior border of the septum over the side of the vomer into the spinal groove (can be compared to replacing a sliding door into the slider) (Fig. 53.4B, C).
  16. Re-examine to ensure adequate reduction.
  17. Complications
  18. Hemorrhage
  19. Damage to nasal structures, e.g., the turbinates, septum
  20. Damage to skull base—resulting in cerebrospinal fluid (CSF) leak (if speculum inserted too far)
  21. Persistent dislocation

P.391

 

FIG. 53.1. Nasal compression without septal deviation. A: Shortly after birth, the nose is asymmetrical from simple compression with an angled septum at rest. B: The septum assumes its normal angle. (From 

Fletcher MA. Physical Diagnosis in Neonatology. Philadelphia: Lippincott-Raven; 1998:211

.)

 

FIG. 53.2. A: At rest it is difficult to distinguish a true deviation. B: Attempts to restore normal anatomy are unsuccessful as the septum remains deviated at the base. (From 

Fletcher MA. Physical Diagnosis in Neonatology. Philadelphia: Lippincott-Raven; 1998:211

.)

 

FIG. 53.3. Walsham septal forceps.

 

FIG. 53.4. A: Landmarks of nasal anatomy. (From)Fletcher MA. Physical Diagnosis in Neonatology. Philadelphia: Lippincott-Raven; 1998:210.) B: Shows the cartilagenous nasal septum displaced to the left from the ridge on the vomer. Large arrows indicate the direction of turn of the forceps blades needed to replace the septum into the groove; small arrows indicate the concurrent upward pull.C: Shows the septum postreplacement.

P.392

 

References

  1. Tasca I, Compradretti GC.Immediate correction of nasal septum dislocation in newborns. Am J Rhinol. 2004;18(1):47.
  2. Podoshin L, Gertner R, Fradis M, Berger A.Incidence and treatment of deviation of the nasal septum in newborns. Ear Nose Throat J. 1991;70:485.
  3. Silverman SH, Leibow SG.Dislocation of the triangular cartilage of the nasal septum. J Pediatr. 1975;87:456.
  4. Jeppesen F, Windfield J.Dislocation of nasal septal cartilage in the newborn. Acta Obstet Gynecol Scand. 1972;51:5.
  5. Bhattacharjee A, Uddin S, Purkaystha P.Deviated nasal septum in the newborn—a 1 year study. Indian J Otolaryngol Head Neck Surg. 2005;57:304.
  6. Gray LP.Septal and associated cranial birth deformities: types, incidence, and treatment. Med J Aust. 1974;1:557.
  7. Kent SE, Reid AP, Brain DJ, Nairn ER.Neonatal septal deviations. J R Soc Med. 1988;81:132.
  8. Pentz S, Pirsig W, Linders H.Longterm results of neonates with nasal deviation: a prospective study over 12 years. Int J Pediatr Otorhinolaryngol. 1994;28:183.