--- title: "Clinical Case Discussion: Deviated Nasal Septum (DNS)" description: "A step-by-step ENT clinical case discussion on Deviated Nasal Septum (DNS)a, covering history, examination, diagnosis, and management." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/deviated-nasal-septum-dns-case-presentation" categories: ["Clinical Case Presentations"] video: "https://www.youtube.com/watch?v=RTwsimhK9Q8" image: "https://media.theentresident.com/og-images/deviated-nasal-septum-dns-case-presentation.png" --- # Clinical Case Discussion: Deviated Nasal Septum (DNS) A step-by-step ENT clinical case discussion on Deviated Nasal Septum (DNS)a, covering history, examination, diagnosis, and management. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=RTwsimhK9Q8 ## šŸ‘ƒšŸ» 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! --- ### šŸ“‹ 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** --- ### šŸ—£ļø 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** ā†’ Suggests structural cause - Obstruction is **partial on both sides** ā†’ indicates no side is completely blocked > What would partial obstruction progressing to complete obstruction suggest? - **Partial relief with decongestant** ā†’ Suggests mucosal component ā†’ Mixed structural + mucosal obstruction > What is Rhinitis medicamentosa? - **Reduced smell on one side** ā†’ Suggests reduced airflow to olfactory cleft --- ### āŒ Relevant Negative History (with Significance) | Negative History | Significance | | --- | --- | | No mouth breathing / snoring | Rules out severe obstruction / adenoid hypertrophy | | No facial pain / headache | Rules out sinusitis / neuralgia / vacuum headache | | No nasal discharge | Rules out rhinitis / sinusitis / foreign body | | No allergic symptoms | Rules out allergic rhinitis | | No epistaxis | Rules out septal spur trauma / nasal mass | | No post nasal drip | Rules out chronic sinusitis | | No fever | Rules out acute infection | | No trauma history | Trauma-induced DNS | | No ear complaints | No Eustachian tube dysfunction | > 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? --- ### āœØ 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 Thudicumā€™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 diļ¬€erentiate 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 diļ¬€erences 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 - Cottleā€™s test ā€“ Negative - Cold spatula test ā€“ Reduced misting both sides - Cotton wool test ā€“ Reduced movement both sides - Smell ā€“ Absent on right side > What is Cottleā€™s Test? How will you perform Cottleā€™s Test? > What are the Boundaries of Internal Nasal Valve? --- ### šŸ“ 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. CottleŹ¼s 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. --- ### šŸ©ŗ 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 Cottleā€™s Classification of DNS? > What is Cottleā€™s line? What is it's clinical importance? > What are Cottleā€™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 Littleā€™s Area? What are the arteries contributing to this anastomosis? What is it's clinical importance? --- ### šŸ„ Management Plan Management **ALWAYS** involves two key aspects: Investigations and Treatment. ### šŸ”¬ 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 --- ### šŸ„ 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 | Feature | Septoplasty | SMR | | --- | --- | --- | | Nature | Conservative | Radical | | Cartilage removal | Only deviated part | Large portion | | L-strut preservation | Yes | Minimal | | Age | Any age | After 17 years | | Complications | Less | More | > šŸ“š To know the complete list of differences between SMR and Septoplasty, please purchase my notes. --- ## About This Note This free ENT note on Clinical Case Discussion: Deviated Nasal Septum (DNS) was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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