Deviated Nasal

Septum
Nandini V
3rd year
BGS GIMS
Patient Particulars
• Name: Gopal Das
• Gender: male
• Age: 23years
• Education: 7th standard
• Occupation: Chef in hospital canteen
• Address: Kengeri
• SES: lower middle class (modified kuppuswamy scale)
• Date of admission: 23/10/2021
• Date of examination:24/10/2021
Chief Complaints
• Patient complains of bilateral nasal obstruction since 5 years
• Patient complains of facial pain since 1 year
History of Presenting Illness
• Patient was apparently normal 5 years ago after which he
developed bilateral partial nasal obstruction. Obstruction was
initially unilateral(left side) and then progressed to become
bilateral.
• It was insidious in onset and is present all the time.
• Obstruction is aggravated during work, nasal discharge and
slightly relieved with medications
• Obstruction increased on lying down on the left side and while
bending down.
• Not associated with smell disturbances
• No history of mouth breathing or snoring.
• Not associated with dryness of nose
• Patient also complains of facial pain since 1 year which is more
towards the left side and present throughout the day.
• Character: dull aching
• Diurnal variation is present, pain is aggravated in the evenings
after work.
• Pain is aggravated during nasal discharge and relieved with
medications
• Bilateral nasal discharge is seen during winter months which is
sudden is onset, intermittent in nature, mucopurulent in
consistency and non-foul smelling. Relieved on medications.
• Not associated with throat clearing.
• No history of fever
• No history of sneezing, itching or watering of eyes.
• No history of ear pain or decreased hearing
• No history of bleeding from nose
• No history of sore throat
• No history of change in voice
• PAST HISTORY:
• No h/o DM, TB, HTN, Syphilis, Asthma
• No h/o nasal/dental surgeries
• No history of any drug allergies
• History of trauma to nose at 10 years of age
• Allergic to egg
• FAMILY HISTORY:
• Nothing significant
• PERSONAL HISTORY:
• Diet: mixed
• Appetite: normal
• Sleep: disturbed
• Bowel and bladder movements: normal
• Addictive habits: Has been chewing gutka for the past 2years. Consumes 2
packets per day everyday after work.
• No pets at home
• No dusty environment at home or work
Summary
• Here is a 23year old male patient who came with complaints of
bilateral partial nasal obstruction that was initially only on the
left side and soon progressed to involve both sides. The
obstruction is associated with facial pain and nasal discharge
during cold weathers.
General Physical Examination
• Patient’s consent was taken.
• Patient was examined in a well lit room.
• Patient was well oriented to time, place and person.
• Height:165cm
• Weight:5Okg
• BMI:18.38
• VITALS:
• Temp: afebrile
• BP: 131/90 mmhg (right arm, sitting position)
• Pulse: 87 bpm, regular rhythm, normal in volume and character, no
radio-radial delay. Other pulses were felt and found to be normal.
• RR: 17 breaths per minute
• Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema: not
seen
Local examination
• NOSE:
• External nasal pyramid:
• Inspection: Dorsum of the nose is deviated to the left, the tip is in the
midline. Small scar(traumatic) is present on the tip of the nose.
• Proptosis absent
• Eye movements: no pain during movementa
• Palpation: Tenderness over the dorsum present on palpation.
• No increase in temperature, thickening of sift tissues or crepitations
present.
• Tip raising test:
• ALA: normal
• Columella: normal
• Vestibule: normal
• Anterior rhinoscopy:
• Nasal passage: narrow on both sides
• Floor of the nose: normal
• Roof: not appreciated
• Medial wall/septum: deviated to the left side with bony spur
indenting on left inferior turbinate, caudal dislocation to the
right
• Lateral wall:
• Mucosa: congested
• Turbinates: Hypertrophied right inferior turbinate
• Discharge: purulent discharge in the middle meatus
Anterior Rhinoscopy Picture
• FUNCTIONAL EXAMINATION OF NOSE:
• Cold spatula test: fogging markedly reduced on left side.
• Cottle’s test: positive on left side.
• Cotton wisp test: reduction of movements on both sides more
marked reduction on left side.
• Smell test: not done
• EXAMINATION OF PARANASAL SINUSES:
• Maxillary tenderness: mild tenderness present on left side
• Frontal tenderness: absent
• Ethmoidal tenderness: absent
• POSTERIOR RHINOSCOPY: not done.
• ORAL CAVITY:
• Mouth opening: adequate
• Lip and commissures: normal
• Tongue: normal in size, surface not coated; no fissures or ulcers
• Floor of mouth: normal; no ulcers or fissures; opening of
submandibular duct was normal
• Gingivo-Buccal mucosa: stained due to gutka chewing; normal
surfaces
• Dentition: normal
• Teeth were stained due to gutka chewing
• Retromolar trigone: normal
• Hard palate: normal
• OROPHARYNX:
• Halitosis: absent
• Uvula: normal
• Soft palate: normal
• B/L Anterior pillars: normal
• Tonsils: normal
• B/L: posterior pillars: normal
• Posterior pharyngeal wall: normal
• Indirect laryngoscopy: not done
• Irwin Moore sign: not elicited
• EXAMINATION OF EAR:

Right ear Left ear

Pinna normal normal
Pre-auricular area normal normal
Post-auricular area normal normal
Tragal tenderness absent absent
Mastoid tenderness absent absent
External auditory normal normal
canal
Tympanic Normal Normal
membrane Cone of light seen Cone of light seen
clearly with handle clearly with handle
of malleus of malleus
 Right ear Left ear
Rinne’s test positive Positive
Weber’s test Equally heard on both Equally heard on both
sides sides
Absolute bone conduction Not reduced Not reduced

facial nerve test:

Able to close eyes tightly Yes Yes
Able to blow cheeks Yes Yes
Able to raise eyebrows Yes Yes
Able to stretch neck yes yes
Fistula test Negative Negative
• NECK EXAMINATION:
• Inspection: skin is normal
• Trachea appears to be centrally placed
• No swellings seen
• No scars, visible dilation or pulsations
• Palpation:
• Trachea is centrally placed
• No palpable lymphnodes
• Larygeal crepitus: positive
Systemic Examination
• CVS: S1 and S2 heard, no murmurs.
• RS: normal vesicular breath sounds, no added sounds.
• PA: soft, non-tender, no organomegaly
• CNS: no focal neurological deficits
Diagnosis
• Case of deviated nasal septum towards left side with bony spur
indenting on left inferior turbinate causing compensatory
hypertrophy of right inferior turbinate with mild left maxillary
sinusitis.