How to Approach Nasal Septal Deviations

Gordon H. Sun, MD, MS

December 21, 2015

The Role of Imaging

The AAO-HNSF clinical consensus statement panel on septoplasty agreed that using CT to routinely document septal deviation before septoplasty is unnecessary, but also agreed on the value of CT in identifying other sinonasal pathology in patients whose symptoms cannot be solely explained by the presence of a nasal septal deviation.[3] For example, CT is considered by many clinicians to be the reference standard for obtaining objective evidence of sinonasal inflammation in patients with chronic rhinosinusitis, and CT displays many sinonasal anatomic structures and abnormalities more effectively than such techniques as anterior rhinoscopy and nasal endoscopy.[17,18,19,20,21] However, the panel also agreed that CT, despite its strengths, may not accurately demonstrate the degree of septal deviation and therefore should not be the main determinant for septoplasty candidacy.[3] Physical examination remains the ideal approach for primary assessment of septal deviation.[22]

The AAO-HNSF septoplasty panel agreed that plain radiographs do not provide useful information to guide surgical decision-making for septoplasty and are not indicated in the workup of nasal septal deviation, because plain radiographs "cannot distinguish the variable changes of the nasal valve and miss most of the adjunctive diagnoses identified by multiview CT scan."[3] The 2013 American College of Radiology (ACR) Appropriateness Criteria for sinonasal disease gave X-rays of the paranasal sinuses a rating of 1 out of 9, the lowest possible score reserved for cases in which the imaging modality is "usually not appropriate," for all 6 clinical scenarios listed.[23] Multiple studies have reported substantial inaccuracy in interpretation of plain radiographs of the paranasal sinuses compared with CT scans ordered for patients with suspected acute sinusitis.[24,25,26]

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