Is there an association between nasal septal fracture and the development of chronic rhinitis or sinusitis?

Association Between Nasal Septal Fracture and Chronic Rhinitis/Sinusitis

While nasal septal deviation (whether from fracture or other causes) is commonly found in patients with chronic rhinosinusitis, the evidence does not establish a definitive causal relationship—only severe deviations affecting the ostiomeatal complex appear to contribute to chronic sinus disease, and the majority of septal deviations do not lead to chronic rhinitis or sinusitis. 1, 2, 3

Understanding the Prevalence and Clinical Significance

The relationship between septal deviation and chronic rhinosinusitis is more complex than commonly assumed:

• Approximately 80% of the general population has some degree of septal asymmetry, but only about 26% have clinically significant deviation causing symptoms 4
• Studies show no significant difference in the prevalence of septal deviation between patients with chronic rhinosinusitis and the general population 1, 3
• In a study of 500 patients, researchers found no correlation between the severity of septal deformity at the ostiomeatal complex and the severity of sinus disease 3

Evidence Supporting a Limited Association

Some studies do suggest a relationship, but only under specific circumstances:

• Only extremely severe septal deviations appear to contribute to chronic rhinosinusitis, particularly when they cause mechanical obstruction of the ostiomeatal complex 2
• An increased angle of septal deviation in the ostiomeatal complex area correlates with increased incidence and severity of sinus disease in some studies 1
• Among patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis, 81.7% had nasal septal deviation, suggesting an association in severe cases requiring surgery 5
• One study found 84% of patients with deviated nasal septum had coexistent rhinosinusitis, with a statistically significant correlation (p ≤ 0.05) 6

Proposed Mechanisms (When Association Exists)

When severe septal deviation does contribute to chronic rhinosinusitis, the mechanisms include:

• Mechanical obstruction of the ostiomeatal complex, preventing normal sinus drainage and ventilation 1, 4
• Alteration of ciliary activity secondary to modified airflow patterns 1
• Impaired sinus ventilation demonstrated in studies of septal deviation and antral ventilation 1
• Nasal obstruction and inflammation that interrupts normal mucociliary clearance, leading to retention of secretions within sinus cavities 7

Clinical Implications for Management

The weak association has important treatment implications:

• Septoplasty alone aims primarily at relieving nasal obstruction or improving surgical access, not treating chronic sinusitis 1
• No relationship has been demonstrated between septal surgery combined with sinus surgery and postoperative prognosis or subjective patient comfort 1
• Patients with chronic rhinosinusitis and septal deviation should be evaluated for other contributing factors including allergy, asthma, immunodeficiency, and mucociliary disorders 2
• The American Academy of Allergy and Clinical Immunology recommends that patients with recurrent or chronic sinusitis should be evaluated for underlying allergy, as allergic rhinitis commonly precedes chronic sinusitis development 7

Common Pitfalls to Avoid

• Do not assume all septal deviations (including those from fracture) cause chronic rhinosinusitis—the literature cannot establish a definite causal role 1, 3
• Avoid performing septoplasty solely to treat chronic sinusitis without addressing other contributing factors and ensuring adequate medical management has failed 4, 1
• Do not overlook that chronic rhinosinusitis has multiple etiologies including allergy (found in 40-84% of adult patients with chronic sinusitis), viral infections, and other anatomical abnormalities 7
• Remember that secondary atrophic rhinitis can develop as a direct result of trauma to the nose, which is a separate consideration from the septal deviation itself 7

When to Consider Surgical Intervention

If a patient with nasal septal fracture develops chronic rhinosinusitis:

• Document failure of at least 4 weeks of appropriate medical therapy including intranasal corticosteroids, saline irrigations, and treatment of underlying allergic components 4
• Obtain CT imaging to confirm both the severity of septal deviation and the presence of sinus disease 4, 8
• Consider combined septoplasty and functional endoscopic sinus surgery only when both conditions are documented: significant septal deviation causing obstruction AND chronic rhinosinusitis requiring surgical intervention 4, 6
• Recognize that in cases where both procedures are indicated, combined surgery may provide better outcomes than addressing either condition alone 6