Is nasal deviation a risk factor for developing sinusitis?

Nasal Septal Deviation and Sinusitis: The Evidence-Based Connection

Nasal septal deviation can contribute to chronic rhinosinusitis by obstructing the ostiomeatal complex and impairing sinus ventilation and drainage, but this relationship is primarily relevant for severe anterior deviations, and septal deviation alone does not justify surgical intervention without documented failure of at least 4 weeks of appropriate medical management. 1, 2

The Anatomical Relationship

Nasal septal deviation may block the flow of nasal secretions and obstruct the ostiomeatal complex, which is the critical drainage pathway for the frontal, anterior ethmoid, and maxillary sinuses. 1 This obstruction can lead to:

• Decreased sinus oxygenation and mucous impaction 1
• Impaired mucociliary clearance from affected sinuses 1
• Creation of an anaerobic environment that facilitates bacterial growth 1

However, the clinical significance of septal deviation is highly variable—approximately 80% of the general population has an off-center septum, but only 26% have clinically significant deviation causing symptoms. 1, 2

Location Matters: Anterior vs. Posterior Deviation

Anterior septal deviation is far more clinically significant than posterior deviation because it affects the nasal valve area, which is responsible for more than two-thirds of nasal airflow resistance. 1, 2 The internal nasal valve in the anterior nose creates the narrowest portion of the nasal airway and is the most critical area for airflow dynamics. 1

A small anterior deviation is therefore much more impactful than a larger posterior deviation. 1

The Research Evidence: Mixed and Controversial

The relationship between septal deviation and sinusitis remains debated in the literature:

Supporting evidence: Recent studies demonstrate that 84% of patients with deviated nasal septum had coexistent rhinosinusitis, with statistically significant correlation (p ≤ 0.05), and rhinosinusitis was more likely to occur on the same side as the deviation. 3 Additionally, extremely severe deviations with increased angles at the ostiomeatal complex show correlation with specific disease patterns. 4

Contradictory evidence: However, a large study of 500 patients found no significant difference in septal deviation between chronic rhinosinusitis patients and controls with normal sinus CT scans, and no correlation between severity of septal deformity and severity of sinus disease. 5 Another systematic review concluded that no definite role for nasal septum in the pathogenesis of chronic sinusitis could be established. 6

The most reasonable interpretation: Only severe septal deviations, particularly those causing mechanical obstruction of the ostiomeatal complex in the anterior nasal cavity, appear to contribute meaningfully to chronic rhinosinusitis development. 4, 6

Clinical Management Algorithm

Step 1: Medical Management First (Mandatory)

Before considering any surgical intervention, patients must undergo at least 4 weeks of documented medical therapy including: 2, 7

• Intranasal corticosteroids (specific medication, dose, frequency documented) 2
• Saline irrigations (technique and frequency documented) 2
• Appropriate antibiotics for bacterial sinusitis if indicated 2
• Treatment of underlying allergic components 2

Step 2: Assess for Surgical Candidacy

Surgery is only considered medically necessary when ALL of the following criteria are met: 2

• Septal deviation causing continuous nasal airway obstruction 2
• Documented failure of at least 4 weeks of appropriate medical therapy 2
• Symptoms significantly affecting quality of life 2
• Objective findings on physical examination confirming significant obstruction 2

Step 3: Surgical Approach if Medical Therapy Fails

If medical management fails, septoplasty combined with endoscopic sinus surgery may be warranted for patients with both septal deviation and chronic sinusitis. 2 Septoplasty alone may never relieve symptoms in patients with coexistent chronic rhinosinusitis, making combined septoplasty and functional endoscopic sinus surgery advisable. 3

Septoplasty is preferred over submucosal resection due to better tissue preservation, lower complication rates, and higher success rates, with up to 77% of patients achieving subjective improvement. 2

Common Pitfalls to Avoid

Do not assume all septal deviations require surgical correction—the vast majority of septal deviations in the general population are asymptomatic and clinically insignificant. 2

Do not proceed with surgery without documented failure of medical management—this is the most common error in surgical decision-making for this condition. 2

Do not rely solely on CT findings—correlation between symptoms and objective measures of disease must be documented. 2

Remember that continued medical management of underlying rhinitis is necessary even after successful septoplasty, as surgery addresses anatomical obstruction but not the underlying inflammatory condition. 2, 7