What is the management plan for a patient with blocked nasal passages, moderate mucosal disease in the anterior ethmoid air cells, mucosal thickening in the maxillary sinuses, and a deviated nasal septum, as shown on a CT scan of the facial bones and sinuses?

Management of Chronic Rhinosinusitis with Nasal Septal Deviation

This patient requires a trial of intranasal corticosteroids combined with saline irrigations for at least 4 weeks before considering surgical intervention, as the CT findings show moderate mucosal disease that typically responds to medical management. 1

Initial Medical Management (First-Line Therapy)

The presence of moderate mucosal disease in the anterior ethmoid air cells and mucosal thickening in the maxillary sinuses indicates chronic rhinosinusitis that warrants medical therapy before any surgical consideration. 1

Required medical interventions include:

• Intranasal corticosteroids (e.g., fluticasone propionate, mometasone furoate) administered daily for a minimum of 4 weeks 1, 2
• Nasal saline irrigations performed twice daily to reduce mucosal inflammation and improve mucociliary clearance 1, 2
• Oral antihistamines if allergic rhinitis is suspected as a contributing factor 1

The rationale is that CT findings of mucosal thickening can persist for up to 8 weeks even after microbiologic resolution of disease, and significant mucosal changes do not necessarily indicate need for immediate surgical intervention. 1

Evaluation for Underlying Allergic Disease

Allergy testing should be performed to identify IgE sensitization to inhalant allergens, as allergic rhinitis commonly coexists with chronic rhinosinusitis and contributes to mucosal inflammation. 1 Up to 60% of patients with difficult-to-treat upper airway symptoms have perennial allergen sensitivities. 3

If specific IgE antibodies to relevant allergens are identified, environmental control measures and consideration of allergen immunotherapy may be warranted for long-term management. 1

Role of Nasal Septal Deviation

The left-deviated nasal septum identified on CT is a structural finding that requires careful clinical correlation. Septal deviation alone does not mandate surgical correction - approximately 80% of the general population has some degree of septal asymmetry, but only 26% have clinically significant deviation causing symptoms. 1, 4

Key considerations regarding the septal deviation:

• Anterior septal deviation is more clinically significant than posterior deviation because it affects the nasal valve area responsible for more than two-thirds of airflow resistance 4, 5
• The deviation may contribute to compensatory turbinate hypertrophy on the opposite side 1, 4
• Septal deviation can obstruct the ostiomeatal complex, impairing sinus ventilation and drainage, which perpetuates chronic rhinosinusitis 4, 6

However, septoplasty should only be considered after documented failure of at least 4 weeks of appropriate medical therapy including intranasal corticosteroids and saline irrigations. 1, 4

When to Consider Surgical Intervention

Septoplasty becomes medically necessary only when:

1. Septal deviation causes continuous nasal airway obstruction with documented symptoms affecting quality of life 1, 4
2. At least 4 weeks of comprehensive medical management has failed, with clear documentation of medication compliance and treatment failure 1, 4
3. Physical examination confirms significant structural obstruction correlating with symptoms 4

If surgery is ultimately required after failed medical therapy:

• Septoplasty is preferred over submucous resection due to better tissue preservation and higher success rates (77-89% subjective improvement) 1, 4
• Combined septoplasty with turbinate reduction provides better long-term outcomes when compensatory turbinate hypertrophy is present 1, 4
• Functional endoscopic sinus surgery (FESS) may be considered if chronic rhinosinusitis persists despite medical management and there is documented ostiomeatal complex obstruction 1

Critical Pitfalls to Avoid

Do not prescribe antibiotics for this presentation - the CT findings show mucosal disease without air-fluid levels or complete opacification, which does not indicate acute bacterial rhinosinusitis requiring antimicrobial therapy. 1 Antibiotics are ineffective for structural nasal obstruction and chronic mucosal inflammation. 4

Do not proceed directly to surgery without documenting an adequate trial of medical management. The presence of septal deviation on imaging does not automatically justify septoplasty - clinical symptoms must correlate with objective findings, and conservative therapy must be attempted first. 1, 4

Do not repeat CT imaging in the near term, as additional scans expose the patient to unnecessary radiation without diagnostic benefit when the initial imaging already demonstrates the extent of disease. 3 CT is not recommended for routine management but rather for surgical planning if medical therapy fails. 1

Expected Timeline and Follow-Up

Patients typically show improvement within 1-2 weeks of initiating intranasal corticosteroid therapy, though full resolution may take 4-8 weeks. 3

Reassessment should occur after 4 weeks of medical therapy to determine:

• Symptom improvement using validated scoring systems
• Need for continued medical management versus surgical consultation
• Presence of persistent ostiomeatal complex obstruction on examination

Most patients benefit from continued individualized medical therapy even after any potential surgical intervention, particularly if allergic rhinitis is identified as a contributing factor. 1