Clinical Case Discussion: Deviated Nasal Septum (DNS)

👃🏻 Clinical Case Discussion: Deviated Nasal Septum (DNS)

Today we will discuss a very common ENT OPD presentation - Deviated Nasal Septum (DNS).

TThis case discussion format will be helpful for both undergraduates and postgraduates.

We'll go through the patient's history, discuss how history guides us to a provisional diagnosis, cover the clinical examination findings and their significance, summarize the case, arrive at a provisional diagnosis, and outline the management plan.

Let's begin!

📋 Patient Profile

• Age: 30 years
• Sex: Female
• Residence: Hyderabad

Chief Complaint

• Nasal obstruction on both sides since 6 years

History of Present Illness

Patient was apparently asymptomatic 6 years back

• Developed nasal obstruction on both sides

• Insidious onset

• More on right side

• Constant and present all the time

• Partial obstruction on both sides

• Aggravated during common cold

• Partially relieved with nasal decongestant drops

• Associated with reduced sensation of smell on right side

Negative History (Rule-outs):

(Though not a formal heading, these points are crucial to ask and document within the History of present illness)

• No history of recurrent episodes of runny or itchy nose, watering of eyes, sneezing

• No history of bleeding from the nose

• No history of double vision

• No history of chronic irritation in throat, throat clearing

• No history of headache

• No reduced or altered sense of smell

• No history of trauma

• No history of loosening of teeth

• No history of significant weight loss, change in voice

• No history of ear complaints

Past History:

• No history of similar complaints in the past.

• No history of Diabetes Mellitus, Hypertension, Bronchial Asthma, or TB.

• No history of surgeries in the past.

• No history of known drug allergies.

What is the relevance of taking Past history in this patient?

Family History:

No significant family history.

Treatment History:

History of usage of nasal decongestant drops (with no relief).

Personal History:

Sleep - Reduced

Appetite - Normal

Diet - Non-vegetarian

Bladder/Bowel - Normal

No addiction history

🗣️ Significance of History Points

What are the causes of Bilateral Nasal Obstruction?

What are the causes of Unilateral Nasal Obstruction?

What are the causes of Unilateral Nasal Obstruction + Bleeding?

• Constant obstruction → Suggests structural cause

• Obstruction is partial on both sides → indicates no side is completely blocked

What would partial obstruction progressing to complete obstruction suggest?

• Partial relief with decongestant → Suggests mucosal component
  → Mixed structural + mucosal obstruction

What is Rhinitis medicamentosa?

• Reduced smell on one side → Suggests reduced airflow to olfactory cleft

❌ Relevant Negative History (with Significance)

What is Sluder's Neuralgia?

What is Vacuum headache?

What are the causes of Unilateral nasal discharge?

What are the causes of Bilateral nasal discharge?

What is the most common cause of Unilateral foul smelling discharge in a child?

✨ Clinical Examination Findings

General & External Nose

Facial symmetry, skin, osteocartilaginous framework, ala, columella, vestibule: All normal

Anterior Rhinoscopy Findings

• Septum deviated to right (C shaped DNS)
• Left inferior turbinate hypertrophy
• Nasal mucosa pinkish
• Nasal cavity narrowed on both sides
• Middle turbinate not visualized

What is Anterior Rhinoscopy?

How to use Thudicum’s Nasal speculum?

What are the Structures seen on Anterior Rhinoscopy? What are all the things you look for under each heading?

What is a Wide Nasal cavity? Name some causes of wide nasal cavity.

What are the causes of Septal Perforation?

Which part of septum is perforated in these conditions - Tuberculosis, Leprosy & Syphilis?

How to differentiate between Polyp & Hypertrophied inferior turbinate?

Why do we see compensatory turbinate hypertrophy on the opposite side?

Posterior Rhinoscopy

• Normal

What is Posterior Rhinoscopy?

What is the size of the Posterior Rhinoscopy mirror? What is the name of the instrument?

How to prevent fogging of mirror on introducing it into the oral cavity?

What are the differences between Indirect Laryngoscopy mirror & Posterior Rhinoscopy mirror?

How will you perform Posterior Rhinoscopy?

What are the structures seen on Posterior Rhinoscopy?

Paranasal Sinus Tenderness

• All sinuses non-tender

What are the different sites for checking sinus tenderness?

What are the Boundaries of Canine Fossa? What is it's clinical importance?

Functional Tests of Nose

• Cottle’s test – Negative
• Cold spatula test – Reduced misting both sides
• Cotton wool test – Reduced movement both sides
• Smell – Absent on right side

What is Cottle’s Test? How will you perform Cottle’s Test?

What are the Boundaries of Internal Nasal Valve?

📝 Case Summary

A 30 year old female came with the chief complaint of both sided nasal obstruction for 6 years.

Nasal obstruction is insidious in onset, more on the right side than the left side, constant and present all the time, obstruction is partial on both sides, aggravated by common cold, partially relieved on using decongestant nasal drops. a/w reduced sensation of smell on right side

On Examination, septum is deviated to the right with hypertrophied inferior turbinate on the left side. Nasal mucosa on the both sides is pinkish. Nasal cavity is narrow on both sides.

Cottleʼs Test shows no improvement on both sides. Cotton wool test shows reduced movement on both sides. Cold spatula test show reduced misting. Smell is absent on right side.

🩺 Provisional Diagnosis

Deviated Nasal Septum to Right with Left Compensatory Inferior Turbinate Hypertrophy

What are the points in favour of your diagnosis?

What are the different types of DNS (Deviated Nasal Septum)?

What is Caudal Dislocation?

What is Septal Spur?

What is Cottle’s Classification of DNS?

What is Cottle’s line? What is it's clinical importance?

What are Cottle’s Areas?

What is the instrument named Cottle which is related to ENT?

What are the different Parts of Nasal septum?

What is the Blood supply of Nasal Septum?

What is Little’s Area? What are the arteries contributing to this anastomosis? What is it's clinical importance?

🏥 Management Plan

Management ALWAYS involves two key aspects: Investigations and Treatment.

🔬 Investigations

To confirm the diagnosis and plan treatment:

1- Routine Blood Investigations:

• CBC
• BT / CT
• RBS
• HBsAg / HIV
• Urea / Creatinine

2- Diagnostic Nasal Endoscopy:

• Assess deviation extent
• Evaluate turbinate hypertrophy
• Rule out polyps / masses

3- CT Scan of Nose & Paranasal Sinuses (Coronal, Sagittal, Axial views):

Indications:

• Facial pain
• Sinus disease suspicion
• Surgical planning

🏥 Treatment Plan

Septoplasty + Left Inferior turbinate reduction

What is Septoplasty?

What are the Indications of Septoplasty?

What are the Contraindications of Septoplasty?

What are the different types of Septoplasty incisions? What is Freer's incision & Killian's incision?

What are the Steps of Septoplasty?

What are the packing materials using post Septoplasty?

What is the Postoperative Care in Septoplasty?

What are the Complications of Septoplasty?

What are the causes of Saddle Nose Deformity?

Classify the surgeries for enlarged turbinates.

What is Empty Nose syndrome?

Septoplasty vs SMR

📚 To know the complete list of differences between SMR and Septoplasty, please purchase my notes.