When is septoplasty indicated and what pre‑operative evaluation and post‑operative care are recommended for a patient with a deviated nasal septum causing persistent obstruction despite optimal medical therapy?

Septoplasty: Indications, Pre-operative Evaluation, and Post-operative Care

Indications for Septoplasty

Septoplasty is medically necessary when septal deviation causes continuous nasal airway obstruction that has failed at least 4 weeks of appropriate medical therapy, including intranasal corticosteroids, saline irrigations, and mechanical treatments. 1

Medical Management Requirements Before Surgery

• A minimum 4-week trial of intranasal corticosteroids must be documented, with specific medication, dose, frequency, and patient compliance recorded 1
• Regular saline irrigations with documentation of technique and frequency are required 1
• Mechanical treatments (nasal dilators or strips) should be trialed with documentation of compliance and response 1
• Objective documentation of treatment failure must show persistent symptoms despite compliance with all above therapies 1
• Intermittent Afrin use does not constitute appropriate medical therapy and should not be considered adequate medical management 1

Clinical Significance of Septal Deviation

• Approximately 80% of the general population has some degree of septal asymmetry, but only 26% have clinically significant deviation causing symptoms requiring surgical intervention 1
• 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
• The presence of septal deviation on imaging alone does not justify surgery without corresponding symptoms and failed medical management 1

Combined Procedures

• Combined septoplasty with turbinate reduction provides better long-term outcomes than septoplasty alone when compensatory turbinate hypertrophy accompanies septal deviation 1
• 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 1
• Combined septoplasty with endoscopic sinus surgery may be warranted when septal deviation obstructs the ostiomeatal complex in patients with documented chronic rhinosinusitis (symptoms >8 weeks) that has failed medical therapy 1

Pre-operative Evaluation

Clinical Assessment

• Objective physical examination findings must document specific description of septal deviation location and degree of obstruction 2
• Nasal valve function should be fully evaluated before performing septoplasty, as 51% of revision septoplasty patients have nasal valve collapse that was not addressed during primary surgery 3
• Symptoms must include nasal obstruction affecting quality of life, with documentation that symptoms persist despite medical management 1

Imaging Considerations

• CT imaging with fine-cut protocol should be obtained for surgical planning when indicated 1
• CT scanning should not be used as the primary criterion for septoplasty candidacy because imaging may not reflect the functional impact of the septal deviation 1
• Photographic documentation of the septum is not required before performing septoplasty 1

Important Clinical Pitfalls

• Do not assume all septal deviations require surgical correction—only 26% are clinically significant 1
• Do not proceed with surgery without objective evidence correlating symptoms with physical findings 1
• Avoid rigid, predetermined medical protocols that delay surgery, as these are not patient-centered and lack evidence-based support 1
• A trial of medical therapy longer than 4 weeks is unnecessary to determine eligibility for septoplasty 1

Surgical Technique Considerations

Tissue Preservation Approach

• Modern septoplasty emphasizes preservation of cartilaginous tissue through realignment, suture fixation, and reconstruction rather than aggressive resection 1
• Septoplasty is preferred over submucous resection due to better tissue preservation, lower complication rates, and higher success rates (77-89% of patients achieve subjective improvement) 1

Endoscopic Versus Conventional Approach

• Endoscopic septoplasty is increasingly replacing traditional septoplasty with better visualization, allowing improved assessment and treatment of posterior aspects of the septum 1
• Endoscopic septoplasty shows significantly better results than conventional septoplasty in terms of operative time, blood loss, post-operative complications, and quality of life scores 4

Addressing Caudal Septal Deviation

• Severe deformities or deviations of the dorsal and caudal septum require extensive septal manipulation facilitated by individualized exposure, potentially including hemitransfixion or open transcolumellar approach 5
• Caudal or dorsal deflections may be more difficult to correct and are the most common sites of persistent deviation requiring revision surgery 6
• Anterior septal reconstruction has been shown to be safe and effective for addressing severe caudal septal deviation with long-term symptom reduction 7

Post-operative Care

Follow-up Requirements

• Routine follow-up between 3-12 months post-operatively is required to assess symptom relief, quality of life, complications, and need for ongoing care through history and nasal endoscopy 1
• Patients should be re-evaluated 3-6 months post-operatively to determine if persistent sinusitis symptoms warrant functional endoscopic sinus surgery 1

Antibiotic Use

• Routine prophylactic antibiotics are unnecessary during septoplasty unless nasal packing or a splint is placed intra-operatively 1

Continued Medical Management

• Continued medical management of underlying rhinitis may be necessary even after septoplasty, as some patients still require ongoing treatment 1
• Many patients require less medication to treat symptoms of nasal congestion postoperatively, but this should be assessed during follow-up 6

Expected Outcomes

• Up to 77% of patients achieve subjective improvement with septoplasty when appropriate patient selection criteria are met 1
• Revision septoplasty significantly improves disease-specific quality of life in patients with persistent nasal obstruction and residual septal deviation, with mean NOSE scores decreasing from 75.9 preoperatively to 14.9 at 3 months 6
• Long-term complications following septoplasty with submucous resection of inferior turbinate are infrequent, with revision septoplasty being the most common 1