Diagnosis and Management of Nasal Septum Deviation
Diagnostic Approach
Anterior rhinoscopy using a nasal speculum with appropriate lighting or an otoscope with nasal adapter is the gold standard initial diagnostic approach for nasal septal deviation. 1
Physical Examination Essentials
Inspect the external nose for deviation or deformity suggesting previous trauma, as external deviation often correlates with internal septal deviation 1
Perform anterior rhinoscopy to identify the location and degree of septal deviation, focusing particularly on caudal (anterior) deformities which affect the nasal valve area responsible for more than 2/3 of airflow resistance 1
Document inferior turbinate hypertrophy, especially on the side opposite the deviation, as compensatory turbinate enlargement commonly accompanies significant septal deflection 1
Apply topical decongestant (such as phenylephrine) and re-examine after 5-10 minutes to distinguish mucosal edema from structural obstruction—structural obstruction will persist despite mucosal shrinkage 1
Perform the Cottle maneuver by pulling the patient's cheek laterally to open the nasal valve angle—improvement in breathing suggests nasal valve pathology that may coexist with septal deviation 1
Critical Clinical Context
Approximately 80% of the general population has some degree of septal asymmetry, but only 26% have clinically significant deviation causing symptoms requiring intervention 1
Physical findings must correlate with symptoms such as continuous nasal airway obstruction, mouth breathing, or sleep disturbance to determine clinical significance 1
Role of Imaging
CT scanning should be reserved for presurgical planning when septoplasty is being considered, to evaluate the extent of deviation and identify anatomic variants 1
CT is necessary if concurrent chronic rhinosinusitis is suspected (symptoms >8 weeks including facial pain/pressure, purulent drainage, or reduced sense of smell) to assess sinus disease and guide combined surgical approach 1
Clinical decisions should be based on physical examination and patient complaints, not CT findings alone, as the degree of septal deviation on CT is significantly different from physical examination findings and doesn't correlate with symptom severity 2
Nasal Endoscopy Indications
The American Academy of Otolaryngology-Head and Neck Surgery recommends nasal endoscopy for patients with recurrent nasal bleeding despite prior treatment, or with recurrent unilateral nasal bleeding 3
Nasal endoscopy is necessary in pediatric persistent allergic rhinitis patients to understand disease severity and plan specific surgical treatment, as bilateral and anterior septal deformities are strongly associated with poor response to medical treatment 4
Management Algorithm
Step 1: Medical Management (Mandatory First-Line)
A minimum of 4 weeks of documented medical therapy is required before considering surgical intervention. 5
Intranasal corticosteroids (specific medication, dose, frequency, and patient compliance must be documented) 5
Saline irrigations (documentation of technique and frequency required) 5
Mechanical treatments including nasal dilators or strips (documentation of compliance and response required) 5
For patients with allergic rhinitis component, add antihistamines and treat underlying allergic conditions appropriately 5
Step 2: Surgical Intervention Criteria
Septoplasty is medically necessary when septal deviation causes continuous nasal airway obstruction that has not responded to at least 4 weeks of appropriate medical therapy. 5
Required Documentation for Surgery:
Objective physical examination findings with specific description of septal deviation location and degree of obstruction 5
Documented failure of medical management including duration of treatment and evidence of treatment failure 5
Symptoms affecting quality of life (nasal congestion, difficulty breathing, mouth breathing, sleep disturbance) 5
Step 3: Surgical Approach Selection
Septoplasty is preferred over submucosal resection due to better tissue preservation, lower complication rates, and higher success rates (77% of patients achieve subjective improvement). 5
Combined septoplasty with turbinate reduction is appropriate when compensatory turbinate hypertrophy accompanies septal deviation, as the combined approach provides better long-term outcomes than septoplasty alone 5
Turbinate reduction should only be offered after inadequate response to medical management including intranasal steroids and antihistamines, with preservation of as much turbinate tissue as possible to avoid complications like nasal dryness 5
Endoscopic septoplasty is increasingly replacing traditional septoplasty with better visualization, allowing for better assessment and treatment of posterior aspects of the septum 5
Step 4: Special Considerations
For Chronic Rhinosinusitis:
The presence of chronic sinusitis alone does not justify septoplasty without documented failure of medical management 5
Combined septoplasty with endoscopic sinus surgery may be warranted for patients with both septal deviation AND chronic rhinosinusitis requiring surgical intervention 5
Septal deviation can contribute to chronic sinusitis by obstructing the ostiomeatal complex, impairing sinus ventilation and drainage 5
For External Nasal Deformity:
Pre-operative photographs showing standard 4-way view (anterior-posterior, right and left lateral views, and base of nose) are required to confirm external nasal deformity when rhinoplasty is performed as part of septoplasty 6
Functional septorhinoplasty (not septoplasty alone) is necessary when J-shaped deformity with bony and cartilaginous deviation exists, as the external framework deviation will persist and continue to cause obstruction 6
Common Pitfalls and Caveats
Do not assume all septal deviations require surgical correction—only 26% are clinically significant 5
Do not proceed with surgery without objective evidence correlating symptoms with physical findings 5
Avoid attributing all nasal obstruction to septal deviation in patients with rhinitis medicamentosa, as mucosal inflammation is often the primary contributor 1
Do not overlook compensatory turbinate hypertrophy on the side opposite the deviation, as this contributes significantly to obstruction and affects treatment planning 1
Intermittent Afrin use is inappropriate chronic management and does not constitute medical therapy 5
Continue medical management of underlying rhinitis even after septoplasty, as some patients may still require ongoing treatment 5
Anterior septal deviation (types 1,2,4, and 6 in Mladina's classification) is more clinically significant than posterior deviation, particularly bilateral deviations which are strongly associated with poor response to medical treatment and greater rhinitis severity 4