Prevalence and clinical features of deviated nasal septum in the pediatric age group in Najran Region, Saudi Arabia

Alshehri; Ali Abdullah

doi:10.4103/sjoh.sjoh_37_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 24 | Issue : 1 | Page : 1-5

Prevalence and clinical features of deviated nasal septum in the pediatric age group in Najran Region, Saudi Arabia

Alshehri, Ali Abdullah
Department of Otorhinolaryngolgy, Head and Neck Surgery, College of Medicine, Najran University, Najran, Saudi Arabia

Date of Submission	14-Aug-2021
Date of Decision	17-Oct-2021
Date of Acceptance	17-Nov-2021
Date of Web Publication	02-Mar-2022

Correspondence Address:
Dr. Ali Abdullah
College of Medicine, Najran University, Najran
Saudi Arabia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_37_21

Abstract

Background: The aim of this study is to evaluate the prevalence and clinical features of deviated nasal septum (DNS) among children under 14 years of age from the Najran region of Saudi Arabia. Materials and Methods: One thousand six hundred and eighty-one patients under 14 years of age were evaluated for DNS. They were divided into five age subgroups of <28 days, 29 days-3 years, 3–6 years, 6–12 years, and 12–14 years. The type of DNS according to Guyuron's classification and associated clinical features were recorded for each patient. Results: Nine hundred and ninety-one (59%) pediatric patients had DNS. Most DNS was found in the 12–14 years group (41%) and least in the <28 days group (9%). Class 1 DNS was maximum in the overall sample, <28 days and 29 days-3 years group. Class 2 DNS was maximum in 3–6 years and 6–12 years group. Class 6 DNS was maximum in the 12–14 years group. Statistically significant difference (P < 0.05) was found between <28 days and 6–12 years, <28 days to 12–14 years, 29 days-3 years to 12–14 years, and 3–6 years to 12–14 years age groups. Clinically in the overall sample, 66.3% had nasal obstruction, 35.6% had nasal discharge, 30.4% had external deformity, 15.5% had rhinitis, 12.6% had pain or headache, 12.34% had sore throat, and 11.6% had snoring. Conclusion: We found that 59% of the pediatric Najran population has DNS. Class I is the most common deformity and the incidence of DNS increases with age. Nasal obstruction and nasal discharge are the most common clinical features associated with DNS.

Keywords: Children, deviated nasal septum, Najran, prevalence

How to cite this article:
Alshehri, Abdullah A. Prevalence and clinical features of deviated nasal septum in the pediatric age group in Najran Region, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:1-5

How to cite this URL:
Alshehri, Abdullah A. Prevalence and clinical features of deviated nasal septum in the pediatric age group in Najran Region, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2023 Mar 27];24:1-5. Available from: https://www.sjohns.org/text.asp?2022/24/1/1/338982

Introduction

Nasal septum is an osseocartilaginous anatomical structure which separates the nasal cavity into two equal right and left halves. Located in the midline, the nasal septum supports the external nose, helps in breathing, and contributes to the esthetics of the person. Deviations in the nasal septum are a common finding in the general population. Rarely, the nasal septum divides the two halves symmetrically, and some amount of deviation is always present and acceptable.^[1] This deviation in the nasal septum can be the etiologic reason behind many nasal patency disorders such as obstruction of the nasal cavity, snoring, obstructive sleep apnea, and chronic paranasal sinus inflammation.^[2] This may also contribute to conditions such as upper airway infection, middle-ear infection, nasal discharge, facial pain, epistaxis, or anosmia.^[3] Nevertheless, a deviated nasal septum (DNS) can remain asymptomatic and only affect the esthetic appearance of the nose.^[4]

A DNS can occur during prenatal, natal, and postnatal impacts on the nose. During the prenatal period, prolonged contact with the uterine wall or during birth when the head of the child is subjected to extraordinary forces can lead to nasal deviation.^[5],[6] In the postnatal developmental process, differential growth rate of nasomaxillary complex structures or any physical trauma can affect the quantitative and qualitative elements of the nose.^[7]

In pediatric age group, the role of nasal septum deviation has a great importance which can affect the growth and development of the maxillofacial structures, especially in the first decade of life.^[8] Hence, it is clinically important to identify and diagnose such cases to prevent functional and esthetic problems in the future. Many studies have been done in the past to identify the incidence and prevalence of nasal septum deviation on various populations, adults, and children. To the best of my knowledge, no such study has been performed on the population of Saudi Arabia. The aim of this study is to identify the prevalence and describe the clinical features of nasal septum deviation in different pediatric age groups of the Najran population of Saudi Arabia.

Materials and Methods

This was a prospective study performed at Najran University Hospital, Najran Region, Saudi Arabia, from October 2015 to December 2019. The study protocol was approved by the Institutional Review Board. A total of 1681 patients under 14 years of age were evaluated for DNS. Written consent was obtained from all the patients, their parents and legal guardians in this study. Non-Najran origin patients and those with a history of nasal surgery or trauma were excluded from the study. General baseline data and demographic details were recorded for each patient. All the patients were physically examined in detail. Fiberoptic nasal pharyngoscope with topical nasal anesthetic spray was used to observe the internal nasal cavity and computed tomography (CT) as advised when deemed necessary. The shapes of the nasal septum deviation were then classified according to Guyuron's classification which comprises six types of deviation: Class 1-septal tilt, Class 2-C-shaped anteroposterior, Class 3-C-shaped cephalocaudal, Class 4-S-shaped anteroposterior, Class 5-S-shaped cephalocaudal, and Class 6-localized deviation.^[9] Clinical features including nasal obstruction, external deformity, rhinitis, snoring, sneezing, itching, epistaxis, sore throat, postnasal drip, and headache were recorded for each patient.

The entire data were collected, and the study pediatric population was divided into six subage groups: <28 days newborns, 29 days-3 years, 3–6 years, 6–12 years, and 12–14 years based on four categories; gross motor development, common etiologies of DNS at the pediatric age subgroups, school age, and types of physical sport activities at specific ages. The statistical analysis was performed using IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. The prevalence was described in percentage, and the Chi-square test was used to analyze the data in different groups. A P < 0.05 was considered statistically significant.

Results

In this study, a total of 1681 patients were evaluated for DNS. A 991 (59%) of them were found to have DNS and 690 (41%) were without DNS. In the total sample size, around 602 (36%) males and 389 (23%) females were found to have DNS as shown in [Table 1]. The pediatric study population was divided into five subage groups as shown in [Table 2]. In the <28 days age group, 53 (59%) males and 37 (41%) females had DNS. In the 29 days-3 years age group, 67 (61%) males and 42 (39%) females had DNS. In the 3–6 years age group, 118 (66%) males and 60 (34%) females had DNS. In the 6–12 years age group, 117 (56%) males and 91 (44%) females had DNS. In the 12-14 years age group, 240 (59%) males and 166 (41%) females had DNS. Considering the overall sample of 991 patients with DNS, 602 (60%) males and 389 (40%) females were found to have DNS.

Table 1: Total number (percentage) of patients with and without deviated nasal septum in the studied pediatric population under the age of 14 years

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Table 2: Total number (percentage) of patients according to gender in different pediatric age groups

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Patients with DNS were classified according to Guyuron's classification in different pediatric age groups as shown in [Table 3]. In the <28 days age group, 66.6% had Class 1, 17.7% had Class 2, and 10% had Class 6 DNS. In the 29 days-3 years age group, 53.2% had Class 1, 21.1% had Class 2, and 12% had Class 6 DNS. In the 3–6 years age group, 39.88% had Class 2, 24.8% had Class 6, and 20.2% had Class 1. In the 6–12 years age group, 43.26% had Class 2, 27.88% had Class 6, and 17.7% had Class 1 DNS. In the 12–14 years age group, 44.33% had Class 6, 30% had Class 2, and 14.77% had Class 1 DNS. In the overall sample of patients with DNS under the age of 14 years, 25.32% had Class 1, 32.49% had Class 2, and 30.68% had Class 6. On comparing the various pediatric age groups with each other, statistically significant difference (P < 0.05) was found between <28 days and 6–12 years, <28 days to 12–14 years, 29 days-3 years and 12–14 years, 3–6 years and 12–14 years age groups. In the other age groups, the comparison was found to be statistically insignificant as shown in [Table 4].

Table 3: Total number of patients according to Guyuron's classification in different pediatric age groups

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Table 4: Statistical comparison among various pediatric age groups for nasal septum deviation

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On analyzing the various clinical features in patients with DNS in different pediatric age groups as shown in [Table 5], it was found that in the <28 days age group, 45.2% had nasal obstruction, 25.6% had nasal discharge, and 21.8% had external deformity. In the 29 days-3 years age group, around 62.3% had nasal obstruction, 33.4% had nasal discharge, 28.6% had external deformity, 10.7% had rhinitis, and 10.6% had sore throat. In the 3–6 years age group, 69.5% had nasal obstruction, 30.4% had external deformity, 14.7% had snoring, 13.3% had snoring, 12.6% had rhinitis, and 10.5% had pain or headache. In the 6–12 years age group, 75.6% had nasal obstruction, 39.5% had nasal discharge, 32.7% had external deformity, 22.5% had rhinitis, 22.3% had pain or headache, 18.4% had snoring, and 15.7% had sore throat. In the 12–14 years age group, 79.3% had nasal obstruction, 42% had nasal discharge, 38.6% had external deformity, 27.6% had pain or headache, 27.4% had rhinitis, 22.1% had snoring, 16.8% had sore throat, and 10% had sneezing and itching both. On evaluating the overall sample of patients with DNS under the age of 14 years, 66.3% had nasal obstruction, 35.6% had nasal discharge, 30.4% had external deformity, 15.5% had rhinitis, 12.6% had pain or headache, 12.34% had sore throat, and 11.6% had snoring.

Table 5: Clinical features of patients with deviated nasal septum in different pediatric age groups

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Discussion

In this study, the prevalence of DNS in the Najran population of Saudi Arabia has been found to be 59% in the pediatric age group (<14 years). Around 60% males and 40% females were found to be affected by DNS in this study. The literature shows that the prevalence of DNS varies greatly in different populations and age groups. In other populations, a prevalence rate of 28.9% was reported in 2–22 years of age from Zagreb, Croatia.^[10] In Finnish and Polish children between the age of 6–15 years, the prevalence rates have been found to be 43% and 35%, respectively.^[11],[12] Similarly, Turkish children reported a prevalence of 35% in the 4–16 years age group and 25% in 0–14 years Kashmiri children.^[13],[14] Low prevalence rates of 13.6% in children between 6 and 9 years have been reported from Korea.^[15] This vast variation in the world pediatric population can be attributed to the vivid genetic, ethnic, physical, and environmental factors which contribute to the development of nasomaxillary process and trauma to the nose during growth.

In this study, subage groups were also evaluated for the prevalence of DNS. It was found to be 9% in <28 days, 11% in 29 days-3 years, 18% in 3–6 years, 21% in 6–12 years, and 41% in 12–14 years. Moreover, statistically significant difference (P < 0.05) was found between lower and higher age groups (<28 days to 6–12 years, <28 days to 12–14 years, 29 days-3 years to 12–14 years, and 3–6 years to 12–14 years). High prevalence rates were seen in the older age groups, indicating that the rates of DNS increase with age. This is in accordance with the findings of Min et al.^[15] and Wojas et al.^[16] who observed that the incidence of DNS increases with age. During the pubertal stage, extensive growth of the nasomaxillary complex can contribute to the septal deviation. This could be the reason for the increase in the occurrence of DNS with age. Furthermore, physical injury to the nose during contact sports, activities, or driving can deform the nasal septum and lead to deviation. This is evident from the fact that, in this study, males (60%) who are much prone to physical injuries were found to be affected more by DNS than females (40%). The Finnish boys^[11] also reported greater prevalence of septal deviation than girls but on the contrary, Croatian^[10] and Turkish children^[13] showed no sex-related difference in the prevalence of DNS.

Septal deviation in newborns and neonates has been extensively researched and addressed by various investigators worldwide. In this study, 9% of the children under 28 days of age were found with DNS. In other studies, the prevalence of DNS has been reported to be as low as 0.93%^[17] to high as 22%^[18] to 40%–60%.^[1] There is a definite correlation between the type of delivery and nasal deformity. With more cesarean-section deliveries being performed nowadays, trauma to the nose during birth has greatly reduced. This might contribute to the low prevalence of DNS in newborns in this study. Nevertheless, factors such as intrauterine fetal position, genetics, birth weight, and parity of mother can stiffly affect the septal growth and position in the gestational period.^[19]

In this study, we have utilized Guyuron's classification system which comprises 6-types of DNS based on his experience in septoplasty. This classification is more user-friendly, popular and considers the surgical aspect for septoplasty. In comparison to Mladina's classification, Guyuron's classification has better clinical application and reflects more realistic DNS as shown with higher concordance rates with CT findings.^[20] To the best of my knowledge, this is the first study describing the prevalence of DNS using Guyuron's classification in any pediatric population. In other studies, Wee et al.^[20] reported a prevalence of 41.4% Guyuron's Class 2 in the adult population from Korea and Iran, and Hassanpour and Behjoo^[21] reported 33% Class 1 septal tilt in the Iranian population. This variation of different deviations in various age groups could be due to the dynamic nature of nasal growth from gestation to puberty. Mostly, nasal injuries lead to anterior nasal septal deformities, and irregular growth of the nasomaxillary complex causes posterior septal deformities.^[8] Studying the population for long term could provide answers about the transformation of deformities, change of classes, and effect of factors on the growth of the nose.

Nasal septal deformities are often asymptomatic but can also lead to an array of clinical features and symptoms. In this study, nasal obstruction (66.3%) and nasal discharge (35.6%) were the most common clinical features in pediatric patients associated with DNS. This is in accordance with the findings of Sriprakash,^[22] Rehman et al.,^[14] Rao et al.^[23] and Prayaga et al ^[24] where nasal obstruction was the most common finding at 86%, 80%, 41%, and 34.8%, respectively. Rao et al.^[23] reported nasal discharge and headache in 41% and 20% cases, respectively. Shoib and Viswanatha^[25] and Singh^[26] reported headache as the most prominent symptom in 93% and 80% of the cases, respectively. Oliveira et al.^[27] found rhinitis as the most common symptoms, whereas only 15.5% of the cases reported with rhinitis in this study. Trauma to the nose often leads to external deformity which affects the esthetics of the person. In a study conducted by Sriprakash, 8% complained of sore throat and 32% of snoring.^[22] Lower incidence of sneezing (7.5%), epistaxis (6.9%), and itching (5.5%) has been reported in this study.

The prevalence and clinical features reported by various studies including this one, vary widely. This is due to the usage of various classification methods, different age groups, diagnostic methods, and other factors at large. This research has been successful in achieving the aims of the study. Although further studies can be performed by including more sample size, CT or magnetic resonance imaging investigations, long-term follow-up into the progress of DNS in various age groups. Since DNS can affect the growth and development of nasomaxillary component, I recommend the identification and classification of septal deformities by otolaryngologist should be part of regular health examination of children at different age subgroups.

Conclusion

The prevalence of DNS was found to be 59% in the pediatric Najran population of Saudi Arabia. Around 60% of males and 40% of females were affected by DNS. Low incidence of 9% was found in <28 days, age group. The incidence of DNS increased with age and Guyuron's Class I septal tilt (34.5%) was the most common septal deformity in the pediatric population. Nasal obstruction (66.3%) was the most common clinical feature associated with DNS followed by nasal discharge (35.6%) and external deformity (30.4%). I recommend further studies in larger population for a better understanding of the prevalence and clinical features of nasal septal deformities throughout the country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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