393

Mhairi G. MacDonald

Relocation of a Dislocated

Nasal Septum

56

A. Indications

To avoid future surgery, breathing and feeding problems,

epistaxis, malocclusion, and sinusitis.

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. 56.1). In some instances, intrauterine forces or

pressure applied during delivery cause a true septal dislocation (Fig. 56.2). The incidence of true septal dislocation

ranges from 1% to 4% of births (1–8). The otolaryngology literature indicates that septal dislocation should be relocated

within a few days of birth for the best outcome (2,4,9,10). 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.

B. Contraindications

1. Presence of other nasal or midline congenital anomalies requiring more extensive treatment

2. Posterior septal dislocation

3. Nasal orifice too small to easily admit smallest septal

forceps

C. Equipment

1. Septal forceps—modified Walsham or other appropriately sized septal forceps (Fig. 56.3).

D. Precautions

1. Reduction should be performed within the first 3 to

4 days after birth.

2. Otolaryngology evaluation for refractory dislocations or

associated facial abnormalities

3. Adequate restraint of infant, especially the head

4. 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.

E. Technique

1. 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 cm. Do not advance past the inferior aspect of the

middle turbinate; do not force (Fig. 56.4A).

2. Gently close the forceps onto the septum.

3. 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.

56.4B,C).

4. Re-examine to ensure adequate reduction.

F. Complications

1. Hemorrhage

2. Damage to nasal structures (e.g., the turbinates, septum)

3. Damage to skull base—resulting in cerebrospinal fluid

leak (if speculum inserted too far)

4. Persistent dislocation

394 Section IX ■ Miscellaneous Procedures

A

B

C

Fig. 56.4. A: Landmarks of nasal anatomy. (From Fletcher MA.

Physical Diagnosis in Neonatology. Philadelphia: LippincottRaven; 1998:210.) B: The cartilaginous 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

Fig. 56.3. Walsham septal forceps. pull. C: The septum postreplacement.

A B

Fig. 56.1. 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.)

A B

Fig. 56.2. 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.)