What is the appropriate workup for a possible deviated septum?

Workup for Possible Deviated Septum

The workup for possible deviated septum requires clinical examination with anterior rhinoscopy and nasal endoscopy—imaging is NOT indicated solely to confirm septal deviation or nasal obstruction.

Clinical Assessment is the Gold Standard

The diagnosis of deviated nasal septum is fundamentally clinical. Anterior rhinoscopy and endoscopic examination serve as the reference standard for evaluating nasal septal deviation 1. Physical examination allows direct visualization of the septum and assessment of how deviation affects the nasal airway.

Key Elements of Clinical Examination

Perform systematic analysis by dividing the nose into horizontal thirds 2:

• Upper third: Bony pyramid position
• Middle third: Dorsal septum and upper lateral cartilages
• Lower third: Alar cartilages, caudal septum, and alar base

Categorize each third as midline, deviated right, or deviated left. This framework is critical because surgical treatment differs for each third 2.

Distinguish between deviation and asymmetry—asymmetries involve left/right differences in shape, width, and length of nasal components, while deviation refers to displacement from midline 2. This distinction is key to successful management.

When Imaging Should NOT Be Ordered

CT should not be performed solely for evaluation of septal deviation 1. Multiple lines of evidence demonstrate that:

• CT has limited correlation with physical examination findings 1
• CT may underestimate the degree of nasal obstruction at the internal nasal valve 1
• CT morphology and the angle of nasal septal deviation cannot predict severity of nasal obstruction 3
• No causal relationship exists between CT findings and symptom severity scores 3

Requesting CT examination just to objectively confirm nasal obstruction is not justified 3. This is particularly important given that third-party payers sometimes inappropriately request CT confirmation before authorizing septoplasty 3.

When Imaging IS Appropriate

CT maxillofacial without IV contrast is indicated for:

• Presurgical planning when septoplasty is already decided based on clinical grounds 1
• Evaluation of concurrent chronic rhinosinusitis 1
• Identification of anatomic variants that increase surgical risk (cribriform plates, lamina papyracea, anterior ethmoidal artery canal) 1

CT provides excellent bony detail for surgical planning but adds nothing to the diagnostic workup itself 1.

Common Pitfalls to Avoid

1. Do not order CT to "confirm" clinical findings—this wastes resources and exposes patients to unnecessary radiation
2. Do not rely on imaging to determine obstruction severity—patient symptoms and clinical examination are what matter
3. Recognize that asymptomatic minor septal deviation is a normal developmental variation found in the majority of the population 4

Clinical Decision-Making Algorithm

1. Perform anterior rhinoscopy and nasal endoscopy
2. Assess symptom severity using validated tools (NOSE scale, SNOT-22)
3. If symptomatic deviation confirmed clinically → consider septoplasty
4. Order CT only if proceeding to surgery for presurgical planning
5. Do not order CT to justify the surgical decision—that decision is made clinically

The evidence consistently shows that septoplasty significantly improves nasal obstruction symptoms and quality of life compared to non-surgical management at 6 and 12 months 5, 6, but this decision should be based on clinical assessment, not imaging findings.