What is the recommended treatment for a patient with a deviated nasal septum and significant mechanical nasal obstruction, who has shown partial response to Flonase (fluticasone) and improvement with Breath Rite (nasal adhesive strips)?

Recommended Treatment for Deviated Nasal Septum with Nasal Valve Collapse

The proposed surgical plan of septoplasty with spreader grafts for nasal valve collapse and bilateral turbinate reduction is the appropriate treatment for this patient who has failed conservative medical management with Flonase and demonstrates improvement with nasal dilator strips. 1

Medical Necessity Criteria Met

This patient satisfies all requirements for surgical intervention:

• Failed medical management: The patient has trialed intranasal corticosteroids (Flonase) with only partial response, meeting the minimum 4-week medical therapy requirement before surgical consideration 1, 2

• Significant mechanical obstruction: The presence of internal nasal valve collapse confirmed by positive response to Breath Rite strips (mechanical nasal dilators) indicates structural pathology that cannot be adequately addressed with medical therapy alone 1

• Multifactorial anatomical pathology: The combination of septal deviation, nasal valve collapse, and turbinate hypertrophy represents complex structural obstruction requiring comprehensive surgical correction 1

Appropriate Surgical Approach

Septoplasty alone would be insufficient for this patient - the presence of nasal valve collapse necessitates additional structural grafting procedures 1:

• Spreader grafts are specifically indicated when nasal valve collapse accompanies septal deviation, providing both functional improvement in airflow and structural support to prevent recurrent collapse 3, 1

• Combined septoplasty with turbinate reduction provides superior long-term outcomes compared to septoplasty alone when both conditions are present, as compensatory turbinate hypertrophy commonly accompanies septal deviation 1, 2

• The American Academy of Otolaryngology recognizes that anterior septal deviation with nasal valve collapse and anterior inferior turbinate hypertrophy are major structural components requiring comprehensive surgical correction 1

Critical Importance of Addressing Nasal Valve Collapse

Failure to address nasal valve pathology is a common cause of persistent obstruction after septoplasty 4:

• A significant proportion (51%) of patients requiring revision septoplasty have unaddressed nasal valve collapse from their primary surgery 4

• Only 4% of patients undergoing revision septoplasty had nasal valve surgery during their initial procedure, compared to 19% of successful primary cases 4

• This patient's positive response to Breath Rite strips is diagnostic evidence of nasal valve collapse that must be addressed surgically with structural grafting (spreaders and/or batten grafts) 1

Surgical Technique Considerations

The proposed approach aligns with current best practices:

• Tissue preservation approach: Modern septoplasty emphasizes preservation of cartilaginous tissue through realignment, suture fixation, and reconstruction rather than aggressive resection 1, 2

• Spreader grafts: Positioned between the septum and upper lateral cartilages to widen the internal nasal valve area and provide midvault support 3, 1

• Turbinate preservation: Submucous resection with outfracture is the most effective surgical therapy for turbinate hypertrophy with the fewest complications, while preserving as much turbinate tissue as possible to avoid nasal dryness 1, 2

Expected Outcomes

• Up to 77% of patients achieve subjective improvement with septoplasty when appropriately selected 1, 2

• Combined procedures provide better long-term outcomes than addressing septal deviation alone when multiple anatomical factors contribute to obstruction 1

• Clinical assessment at initial presentation is highly accurate (sensitivity 86.9%, specificity 91.8%) in predicting which patients will ultimately need septoplasty after failed medical management 5

Common Pitfalls to Avoid

• Do not proceed with septoplasty alone when clinical examination or positive Cottle maneuver/nasal dilator response indicates valve collapse - this leads to persistent symptoms and need for revision surgery 1, 4

• Approximately 80% of the general population has some septal deviation, but only 26% have clinically significant deviation causing symptoms - however, this patient clearly meets criteria with documented symptoms and failed medical management 1, 2

• Ensure adequate medical management trial is documented - while this patient has trialed Flonase, documentation should confirm at least 4 weeks of consistent use, along with saline irrigations if attempted 1, 2