Medical Management First, Then Consider Septoplasty
You should pursue a minimum 4-week trial of comprehensive medical therapy before considering septoplasty, including intranasal corticosteroids, regular saline irrigations, and mechanical nasal dilators—this is an absolute requirement per current guidelines. 1, 2
Why Medical Management is Mandatory First
The American Academy of Allergy, Asthma, and Immunology explicitly requires documented failure of at least 4 weeks of appropriate medical therapy before septoplasty can be considered medically necessary. 1, 2 This is not optional—it is a prerequisite for surgical intervention.
Key point: While 80% of people have some septal asymmetry, only 26% have clinically significant deviation requiring surgery. 1, 2 Your 7-8 year history of deviation that only recently became symptomatic suggests a functional or inflammatory component that may respond to medical therapy.
Required Medical Management Protocol
Before any surgical consideration, you must complete and document:
Intranasal corticosteroid spray (e.g., fluticasone, mometasone) used consistently for at least 4 weeks, with specific documentation of medication name, dosage, frequency, and compliance 1, 2
Regular saline irrigations (nasal rinses) with documented technique and frequency—this addresses mucosal inflammation and clear mucous production 1, 2
Mechanical nasal dilators or strips trial with documentation of compliance and response 1
Objective documentation of persistent symptoms despite compliant use of all above therapies, specifically noting nasal congestion, mouth breathing, and cognitive symptoms 1
Why This Approach Makes Clinical Sense
Your intermittent symptoms with clear rhinorrhea over 6 months suggest a mucosal/inflammatory component rather than pure structural obstruction. 3 The fact that symptoms fluctuate ("some days clear") indicates that medical management targeting mucosal inflammation may provide significant relief. 3
The cognitive impairment and lightheadedness you describe could be related to chronic mouth breathing and sleep disruption from nasal obstruction, which can improve with medical therapy alone. 4
When to Consider Septoplasty
Septoplasty becomes appropriate only after documented failure of the 4-week medical management trial, with: 1, 2
- Persistent symptoms of nasal congestion and mouth breathing despite compliant medical therapy
- Physical examination documenting significant septal deviation causing obstruction
- Symptoms significantly affecting quality of life
- CT imaging or nasal endoscopy showing degree of septal deviation and its impact on nasal airway 1
If medical therapy fails: Combined septoplasty with inferior turbinate reduction provides better long-term outcomes than septoplasty alone (77-89% success rate), as compensatory turbinate hypertrophy commonly accompanies septal deviation. 1, 2, 5
Common Pitfalls to Avoid
Do not skip medical management—proceeding directly to surgery without documented medical therapy failure will result in denial of medical necessity 1, 2
Intermittent Afrin use is not appropriate medical management and does not count toward the required 4-week trial 2
Not all septal deviations require surgery—anterior deviations affecting the nasal valve area are more clinically significant than posterior deviations 2, 4
Document everything—specific medications, doses, duration, compliance, and persistent symptoms must be objectively recorded 1