What is the treatment for a deviated septum?

Treatment for Deviated Septum

Septoplasty is the definitive treatment for deviated nasal septum causing nasal obstruction, but only after documented failure of at least 4 weeks of medical management including intranasal corticosteroids, saline irrigations, and mechanical treatments. 1

Medical Management (First-Line Treatment)

Before considering surgery, a comprehensive trial of medical therapy must be attempted and documented as failed:

• Intranasal corticosteroid sprays for minimum 4 weeks with documentation of medication, dose, frequency, and patient compliance 1, 2
• Regular saline irrigations with documentation of technique and frequency 1
• Mechanical treatments including nasal dilators or strips with documentation of compliance and response 1
• Treatment of underlying allergic component if present, including antihistamines 1, 2
• Appropriate antibiotics only if bacterial sinusitis is documented 1

Important caveat: Intermittent Afrin (oxymetazoline) use does not constitute appropriate medical therapy and should not be considered adequate medical management. 1

Surgical Management (After Medical Failure)

Indications for Septoplasty

Surgery becomes medically necessary when all of the following criteria are met:

• Documented septal deviation causing continuous nasal airway obstruction on physical examination or imaging 1, 2
• Failed medical management for minimum 4 weeks as outlined above 1, 2
• Symptoms affecting quality of life including nasal congestion, difficulty breathing, mouth breathing, or sleep disturbance 1
• Objective findings correlating with symptoms - only 26% of septal deviations are clinically significant despite 80% of the population having some asymmetry 1, 2

Surgical Approach

Septoplasty with concurrent turbinate reduction is the preferred approach when both conditions are present:

• Combined septoplasty with turbinate reduction provides better long-term outcomes than septoplasty alone, with less postoperative nasal obstruction and sustained improvement 1
• Tissue preservation approach is emphasized - realignment, suture fixation, and reconstruction rather than aggressive resection 1
• Endoscopic septoplasty is increasingly preferred over traditional approaches due to better visualization, particularly of posterior septal aspects, and improved complication prevention 1, 3
• Submucous resection with outfracture is the most effective technique for turbinate hypertrophy with fewest complications compared to turbinectomy, laser, or electrocautery 1

Expected Outcomes

• 77% of patients achieve subjective improvement with septoplasty 1
• Sustained improvement is demonstrated in randomized controlled trials, with mean Glasgow Health Status Inventory scores improving by 8.3 points at 12 months, favoring septoplasty over non-surgical management 4
• Effectiveness sustained to 24 months of follow-up 4

Anatomical Considerations

Anterior septal deviation is more clinically significant than posterior deviation because it affects the nasal valve area responsible for more than 2/3 of airflow resistance. 1, 2

Compensatory turbinate hypertrophy commonly accompanies septal deviation, typically on the side opposite the deviation, which is why combined procedures are often necessary. 1

Special Populations

Patients with Obstructive Sleep Apnea

• Septoplasty is recommended for reducing high therapeutic CPAP pressure due to nasal obstruction, particularly when septal deviation decreases nasal aperture by greater than 50% 2, 5
• Improves CPAP adherence but does not cure OSA itself - continued CPAP therapy post-operatively is essential 2, 5
• Addresses Upper Airway Resistance Syndrome (UARS) by reducing negative intraluminal pharyngeal pressure caused by increased nasal resistance 5

Patients with Chronic Rhinosinusitis

• Septoplasty alone is insufficient if chronic rhinosinusitis is the primary problem - endoscopic sinus surgery (ESS) would be the appropriate procedure 1
• Combined septoplasty with ESS is warranted only when both significant septal deviation AND chronic rhinosinusitis requiring surgical intervention are documented 1
• Septal deviation can contribute to chronic sinusitis by obstructing the ostiomeatal complex, impairing sinus ventilation and drainage 1

Common Pitfalls to Avoid

• Do not assume all septal deviations require surgery - only 26% are clinically significant despite 80% prevalence of some asymmetry 1, 2
• Do not proceed without objective evidence correlating symptoms with physical findings 1
• Do not perform surgery without documented medical management failure - this is the most common reason for denial of medical necessity 1, 2
• Preserve turbinate tissue - aggressive turbinate resection leads to complications like nasal dryness and reduced sense of well-being 1, 2
• Continue medical management post-operatively for underlying rhinitis, as some patients require ongoing treatment even after successful surgery 1

Postoperative Follow-Up

• Routine follow-up between 3-12 months is required to assess symptom relief, quality of life, complications, and need for ongoing care through history and nasal endoscopy 1
• Re-evaluate for persistent sinusitis symptoms 3-6 months post-operatively to determine if FESS is warranted 1

Complications

Long-term complications are infrequent but include:

• Septal perforation (rare) 4
• Septal abscess (rare) 4
• Revision septoplasty (most common long-term complication) 1
• Dental pain, paresthesia, saddle nose deformity (very rare with endoscopic approach) 3