Management of Traumatic Nasal Septal Deviation in a 15-Year-Old
Refer this patient to an otolaryngologist for evaluation and consideration of septoplasty, but only after documenting at least 4 weeks of failed conservative medical management with intranasal corticosteroids and saline irrigations. 1
Immediate Clinical Assessment
The key question is whether this deviated septum is causing clinically significant nasal obstruction or is merely an incidental finding:
- Approximately 80% of the general population has an off-center nasal septum, but only 26% have clinically significant deviation causing symptoms 2
- Trauma is the most common etiology of deviated septum, and the degree of trauma required for clinically significant deviation is inversely related to the patient's age—meaning this 15-year-old is at higher risk for developing a functionally significant deviation 2
- Anterior septal deviations are much more clinically significant than posterior deviations because they affect the internal nasal valve, which creates more than 2/3 of nasal airflow resistance 2
Required Conservative Management Trial
Before any surgical referral is appropriate, this patient must complete at least 4 weeks of medical management: 1
- Intranasal corticosteroid sprays (daily use)
- Regular saline nasal irrigations
- Consider mechanical nasal dilators
- Document the duration of treatment and evidence of persistent symptoms despite compliance
This conservative approach is mandated because septoplasty should only be considered medically necessary when there is septal deviation causing continuous nasal airway obstruction that has not responded to appropriate medical therapy 1
Timing Considerations for Surgical Intervention
If symptoms persist after medical management, surgical correction should not be indefinitely delayed in this adolescent:
- The obstruction becomes more pronounced over time with cartilaginous overgrowth on the dominant side of deviation 2
- Traditional concerns about operating on the pediatric septum have been challenged—severe traumatic septal deviation can and should be corrected to prevent future nasal and systemic complications 3
- Septoplasty is the preferred surgical procedure, with as many as 77% of patients achieving subjective improvement 2
Surgical Approach if Medical Management Fails
The surgical plan should address all anatomic contributors to obstruction:
- Septoplasty alone may be insufficient—a significant number of patients who undergo revision septoplasty have undiagnosed nasal valve collapse 4
- Evaluate for compensatory inferior turbinate hypertrophy on the side opposite the deviation, which commonly accompanies septal deviation and may require concurrent turbinate reduction 2
- Endoscopic septoplasty is replacing traditional septoplasty in many clinical settings with advantages including less operative time, reduced blood loss, and lower complication rates 5, 6
Critical Pitfalls to Avoid
Do not proceed with surgery without:
- Objective documentation that the septal deviation correlates with the patient's symptoms 1
- A complete trial of medical management 1
- Full evaluation of nasal valve function, not just septal position 4
The most common error is operating on an anatomic finding (deviated septum) without establishing that it is the actual cause of functional impairment. Many patients with deviated septa are completely asymptomatic and require no intervention 2, 7