What are the treatment options for a deviated nasal septum, including medical therapy (e.g., isotonic saline irrigation, intranasal corticosteroid spray, oral antihistamines, short‑course decongestants) and surgical options such as septoplasty and balloon septoplasty?

Treatment Options for Deviated Nasal Septum

Medical Management Should Be Attempted First, But Has Limited Efficacy for Structural Obstruction

For patients with nasal obstruction due to deviated nasal septum, medical therapy with intranasal corticosteroids and saline irrigation provides minimal to no benefit when the obstruction is primarily structural, and septoplasty is the definitive treatment that provides sustained symptom improvement. 1

Initial Medical Therapy (Limited Role)

Medical management can be trialed but should not delay surgical referral when structural obstruction is clearly present:

• Isotonic saline irrigation may provide modest symptomatic relief through mechanical clearance of mucus and inflammatory mediators, though evidence for benefit in structural nasal obstruction is inconsistent 2

  • High-volume nasal douching (250ml twice daily) shows better distribution to sinuses than sprays or nebulization 2
  • Duration of at least 3-7 months may be needed to see any benefit 2

• Intranasal corticosteroid sprays do not significantly improve nasal obstruction when the primary cause is septal deviation 1

  • A rigorous double-blind RCT found no difference between intranasal steroids and saline placebo for DNS-related obstruction (mean NOSE score change: -5.8 vs -3.9, p=0.60) 1
  • May have adjunctive benefit only if concurrent mucosal inflammation or turbinate hypertrophy is present 2

• Topical decongestants have extremely limited evidence and carry significant risks 2

  • Short-term use (≤5-7 days) can help differentiate mucosal swelling from fixed structural obstruction 3, 4
  • If symptoms do not improve with decongestant trial, this predicts that septoplasty will be beneficial 4
  • Should NOT be used long-term due to risk of rebound congestion (rhinitis medicamentosa) 2
  • The EPOS 2020 guideline explicitly recommends against routine use of nasal decongestants in chronic nasal obstruction 2

• Oral antihistamines are not indicated unless concurrent allergic rhinitis is present 3

Surgical Management: Septoplasty Is the Definitive Treatment

Indications for Septoplasty

Septoplasty should be offered when: 4

• Persistent nasal obstruction interfering with daily activities, work, or school despite medical therapy trial
• Recurrent sinus infections (≥3 episodes per year) despite optimal medical management
• Failed medical management with topical nasal steroids and decongestants for adequate duration

Patient Selection Is Critical

Not all septal deviations require surgery: 3, 4

• Approximately 80% of the general population has an off-center septum, but only 26% of patients with nasal obstruction have clinically significant deviation 3, 4
• Anterior septal deviations are more clinically significant than posterior deviations because they contribute the majority of nasal airflow resistance 4
• Compensatory turbinate hypertrophy commonly occurs on the side opposite the deviation (or bilaterally with S-shaped deviations) and should be evaluated pre-operatively 3, 4
• Use topical decongestant trial to differentiate mucosal from structural obstruction—lack of improvement suggests septoplasty will be beneficial 4

Surgical Technique

Septoplasty (not submucosal resection) is the preferred surgical approach: 3, 4

• Septoplasty reshapes, repositions, or recontours cartilage rather than extensively resecting tissue 3, 4
• This tissue-sparing approach has lower complication rates, particularly lower risk of septal perforation compared to submucosal resection 3, 4
• Endoscopic septoplasty is increasingly favored over traditional techniques due to superior visualization, reduced hemorrhage, lower rates of mucosal adhesions and persistent deviation, and shorter operative time 4

Role of Concurrent Turbinate Reduction

The evidence for adding turbinate reduction to septoplasty is mixed: 4, 5, 6

• Inferior turbinate reduction is frequently performed together with septoplasty, though current evidence does not conclusively demonstrate long-term added benefit 4
• A systematic review found that 8 out of 9 studies on subjective measures and 5 out of 7 studies on objective measures found no additional benefit of turbinate surgery when added to septoplasty 5
• The decision should be individualized based on the degree of turbinate hypertrophy present 6

Expected Outcomes

Septoplasty provides substantial and sustained benefit: 7, 1, 8, 9

• Approximately 77% of patients report subjective improvement after septoplasty 3, 4
• The largest and most recent RCT (NAIROS trial, 378 patients) showed septoplasty resulted in 20-point greater improvement in SNOT-22 scores compared to medical management at 6 months (19.9 vs 39.5, p<0.0001) 7
• Sustained improvement persists at 12 months post-surgery 7, 9
• A 2022 RCT demonstrated significant improvements in VAS (6.28→2.9 vs 6.0→5.26), SNOT-22 (19.5→10 vs 15→12), and NOSE scores (14→8 vs 12→10) at 6 months, all p=0.001 8
• Meta-analysis of 721 patients confirmed significant improvements in NOSE and SNOT-22 scores at 6 and 12 months 9
• Surgery in the NAIROS trial showed mean NOSE score improvement of -50 points across all postoperative timepoints 1

Complications and Limitations

Septoplasty is generally safe but has recognized limitations: 7, 9

• Complication rates are low: bleeding (4.12%), infection (4.12%), septal perforation (rare), revision rate (0.31%) 9
• Recurrence of septal deviation may occur after surgery, highlighting the importance of thorough pre-operative planning 3, 4
• Some patients may continue to experience a disturbed nasal cycle despite successful correction 4
• Comprehensive evaluation of all contributors to nasal obstruction (turbinate hypertrophy, mucosal disease, nasal valve collapse) is essential, as addressing the septum alone may not resolve symptoms 4

Pediatric Considerations

Septoplasty is generally avoided in children because it can adversely affect nasal growth, particularly of the nasal dorsum 4

Cost-Effectiveness

Septoplasty has favorable long-term cost-effectiveness: 7

• At 12 months, septoplasty had only 15% probability of being cost-effective at £20,000 willingness-to-pay threshold
• However, this probability increased to 99% at 24 months and 100% at 36 months 7
• The initial higher cost is offset by sustained symptom improvement and reduced need for ongoing medical therapy

Referral Criteria to Otolaryngology

Refer patients when: 4

• Anatomic defects obstruct the ostiomeatal complex
• Recurrent sinusitis occurring 2-3 times per year despite appropriate treatment
• Complications threatening intracranial or ocular structures (meningitis, brain abscess, vision loss)
• Persistent nasal polyps despite optimal medical therapy
• Failed medical management with intranasal steroids and saline for adequate duration (typically 3-6 months)

Alternative/Adjunctive Devices

Nasal dilators and custom nasal devices have minimal evidence and are not recommended as primary treatment 10, 11

• External nasal dilators are not recommended for improving sleep-disordered breathing or nasal obstruction 10
• Custom nasal dilators with nasopharyngeal tubes may serve as temporary adjuncts while awaiting definitive surgery, but are not substitutes for septoplasty 11