What is the recommended management for chronic nasal congestion caused by a deviated nasal septum, including optimal medical therapy and criteria for septoplasty?

Management of Chronic Nasal Congestion with Nasal Septum Deviation

For chronic nasal congestion caused by deviated nasal septum, initiate a minimum 4-week trial of intranasal corticosteroids combined with saline irrigations before considering septoplasty, which is indicated when documented anatomic obstruction persists despite medical therapy and significantly impacts quality of life. 1, 2, 3

Initial Medical Management

Required Medical Therapy Components

• Intranasal corticosteroids (e.g., fluticasone, mometasone) used daily for at least 4 consecutive weeks to reduce turbinate hypertrophy and improve nasal patency 1, 2
• Saline nasal irrigations performed regularly (typically twice daily) for the same 4-week minimum period 1, 2
• Mechanical nasal dilators or strips may be trialed to assess whether external valve support provides relief 3

Important Caveats About Medical Management Duration

• The American Academy of Otolaryngology explicitly states that medical therapy trials exceeding 4 weeks are unnecessary to establish surgical candidacy for septoplasty 4, 3
• Avoid rigid, predetermined "boilerplate" medical protocols that delay appropriate surgical intervention, as these are not patient-centered and lack evidence-based support 4
• Document the specific medications used, duration of therapy, patient compliance, and treatment failure—but recognize that patients reporting chronic over-the-counter medication use "for as long as they can remember" have adequately demonstrated failed medical management 3

What NOT to Require

• Antibiotics alone are insufficient for structural nasal obstruction from septal deviation, as they only address infection, not anatomic blockage 2
• CT scanning should not be the primary determinant for septoplasty candidacy, as it may not accurately demonstrate the functional degree of septal deviation 4, 1
• Photodocumentation is unnecessary to document septal deviation prior to septoplasty 4

Criteria for Septoplasty

Clinical Requirements

• Documented septal deviation on physical examination causing continuous nasal airway obstruction, with specific description of deviation location (anterior vs. posterior) and degree of obstruction 1, 2
• 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 1, 2
• Symptoms affecting quality of life including chronic nasal congestion, difficulty breathing through the nose, mouth breathing (especially at night), and sleep disturbance 1, 3
• Failed medical management as documented above, with persistent symptoms despite compliant use of appropriate therapy 1, 2

Objective Examination Findings

• Nasal endoscopy demonstrating septal deviation contacting the lateral nasal wall or turbinates, creating fixed obstruction 1
• Only approximately 26% of septal deviations are clinically significant enough to cause symptoms requiring surgical intervention—the majority of the population has some degree of septal asymmetry that is asymptomatic 2, 3, 5
• Compensatory turbinate hypertrophy commonly accompanies septal deviation, typically on the side opposite the deviation 2

Surgical Approach

Septoplasty Technique

• Septoplasty is preferred over submucous resection due to better tissue preservation, lower complication rates (21% for submucous resection vs. lower rates for septoplasty), and higher success rates of 77-89% 2, 6, 7
• Modern tissue preservation approaches emphasize realignment, suture fixation, and reconstruction rather than aggressive resection 2
• Endoscopic septoplasty provides better visualization of posterior septal aspects and helps prevent complications 2

Combined Procedures

• Combined septoplasty with inferior turbinate reduction is appropriate when compensatory turbinate hypertrophy accompanies septal deviation, as this combined approach provides better long-term outcomes than septoplasty alone 2, 3
• Turbinate reduction should preserve as much turbinate tissue as possible to avoid complications like nasal dryness and reduced sense of well-being 2
• Submucous resection with outfracture is the most effective surgical therapy for turbinate hypertrophy with the fewest complications compared to turbinectomy, laser cautery, or electrocautery 2

When to Add Endoscopic Sinus Surgery

• Septoplasty can be combined with functional endoscopic sinus surgery (FESS) when the septum is contacting the middle turbinate and obstructing drainage of the ostiomeatal complex in patients with documented chronic rhinosinusitis 4, 2
• FESS should only be added when there is documented chronic rhinosinusitis (symptoms >8 weeks including facial pain/pressure, purulent drainage, nasal obstruction, and reduced sense of smell) that has failed medical management 4, 2
• Septal deviation can contribute to chronic sinusitis by obstructing the ostiomeatal complex and impairing sinus ventilation and drainage 2, 8, 9

Relationship Between Septal Deviation and Chronic Rhinosinusitis

Evidence of Association

• Studies demonstrate that 84% of patients with deviated nasal septum have coexistent rhinosinusitis, with statistically significant correlation between the two conditions 9
• Only extremely severe septal deviation appears to contribute to the etiology of chronic rhinosinusitis—not all subtypes of deviation result in CRS development 8
• The side of septal deviation correlates with the side of rhinosinusitis predisposition 9

Clinical Implications

• In patients with both septal deviation and chronic rhinosinusitis, combined septoplasty and FESS is advisable, as septoplasty alone may never relieve symptoms in chronic patients 9
• Surgical correction of septal deviation improves outcomes for patients with chronic sinusitis by enhancing sinus drainage and ventilation, and facilitating better delivery of intranasal medications 2

Common Pitfalls to Avoid

Documentation Errors

• Do not deny surgery based solely on lack of precise start/stop dates for over-the-counter medications used chronically—this is clinically unrealistic and not supported by guidelines 3
• Requiring predetermined medical protocols (e.g., "must use X medication for exactly Y weeks") is not patient-centered and carries potential for added cost, harm from adverse events, or delays of effective treatment 4

Inappropriate Surgical Indications

• Do not perform septoplasty for asymptomatic septal deviation identified incidentally on imaging—80% of the population has some degree of septal asymmetry 2, 5
• Intermittent congestion that responds to medical therapy typically indicates a functional or inflammatory component rather than fixed anatomic obstruction, and septoplasty is not indicated 1
• When CT imaging shows a midline septum, this contradicts the fundamental requirement of documented septal deviation and eliminates the anatomical basis for septoplasty 1

Perioperative Considerations

• Routine perioperative antibiotics are unnecessary during septoplasty unless nasal packing or a splint is placed during the procedure 4
• Intranasal splints should be used to reduce the incidence of adhesions (7% complication rate when splints not used) 6

Expected Outcomes

Objective Improvements

• Mean unilateral nasal resistance decreases from preoperative 1.19 Pa/cm³/s to postoperative 0.39 Pa/cm³/s 7
• Mean minimum cross-sectional area increases from preoperative 0.45 cm² to postoperative 0.61 cm² 7
• 77-89% of patients achieve subjective improvement with septoplasty 2, 7

Postoperative Management

• Routine follow-up between 3-12 months postoperatively is required to assess symptom relief, quality of life, complications, and need for ongoing care through history and nasal endoscopy 2
• Continue medical management of underlying rhinitis even after septoplasty, as some patients may still require ongoing treatment 2