Diagnosing a Deviated Septum After Trauma
The diagnosis of a deviated septum after trauma requires a systematic nasal examination using a nasal speculum with appropriate lighting, otoscope with nasal adapter, or rigid/flexible nasopharyngoscope to visualize septal deviation and associated nasal pathology. 1
Physical Examination Techniques
External Nasal Assessment
- Observe for external nasal deformity or asymmetry
- Divide the nose into horizontal thirds (upper, middle, and lower) to systematically analyze deviation 1
- Upper third: bony pyramid
- Middle third: dorsal septum and upper lateral cartilages
- Lower third: alar cartilages, caudal septum, and alar base
- Check for saddle nose deformity which may indicate previous trauma 1
- Assess nasal valve patency using the Cottle maneuver (pulling the patient's cheek laterally) - improvement in breathing suggests nasal valve pathology 1
Internal Nasal Examination
- Anterior rhinoscopy using a nasal speculum with proper lighting to visualize:
- Caudal septal deformity
- Inferior turbinate hypertrophy (often enlarged on the side opposite to septal deviation) 1
- Apply topical decongestant to differentiate between mucosal edema and bony hypertrophy
- Nasopharyngoscopy for better visualization of:
- Middle meatus
- Posterior septum
- Sinus ostia
- Posterior choanae
- Nasopharynx
- Presence of nasal polyps 1
Key Diagnostic Findings
- Septal deviation: Displacement of the septum from midline
- Asymmetry: Left/right differences in shape, width, and length of nasal components 1
- Nasal obstruction: Typically worse on one side
- Mucosal changes: Pallor, edema, or hyperemia (not specific to septal deviation) 1
- Associated findings: Check for mucopurulent discharge suggesting sinusitis 1
Advanced Assessment
Evaluate for complications of septal hematoma (requires immediate intervention):
- Fluctuant swelling of the septum
- Bilateral nasal obstruction
- Risk of cartilage necrosis and saddle nose deformity 2
Consider radiological imaging for complex cases:
- CT scan can classify and assess the severity of the deviated septum 3
- Particularly useful for evaluating associated sinus pathology or complex trauma
Special Considerations
- Pediatric patients: Complete intranasal examination is essential as septal trauma in children can lead to significant functional and cosmetic abnormalities if untreated 2
- Adolescents: Higher incidence of re-deviation after septoplasty (21.2%) compared to adults (7.1%) 4
- Associated conditions: Assess for eustachian tube dysfunction, sinusitis, and other complications 1
Common Pitfalls to Avoid
- Incomplete examination: Failure to perform a thorough nasal examination may miss septal hematomas requiring urgent intervention
- Overlooking associated injuries: Nasal trauma often involves multiple structures beyond the septum
- Misdiagnosis: Distinguishing between deviation (positional) and asymmetry (structural differences) is key to successful treatment 1
- Delayed diagnosis: Untreated septal injuries can lead to considerable functional and cosmetic abnormalities 2
Remember that while clinical assessment is sufficient for diagnosis, imaging techniques may be required for treatment planning in complex cases 3. The severity of deviation may affect nasal airflow, causing obstruction or impairing olfactory function, and can be associated with headache, rhinosinusitis, and breathing difficulties 3.