How to Approach Nasal Septal Deviations

Gordon H. Sun, MD, MS

December 21, 2015

Case: A History of Nasal Trauma

A 44-year-old salesman presented to his family physician with chronic difficulty breathing through the right nostril. He stated that, perhaps 10 years ago, he collided hard with a friend while playing football in his backyard, resulting in a brisk nosebleed and bruising over his nose. After the nosebleed stopped, the patient noted that he had some trouble with getting enough air through his right nostril. He thought that the nasal obstruction would recover spontaneously, but the symptom has persisted. He denied anosmia, recurrent epistaxis, nasal pain or sensitivity, otalgia, vision problems, or fevers. The patient had no surgical history. He was a nonsmoker and nondrinker and denied illicit drug use. He was not actively taking any medications.

On examination, the patient's vital signs were all within normal limits. The patient appeared comfortable, with a clear voice and no stridor. Eye and ear examinations were unremarkable. Anterior rhinoscopy demonstrated a substantial deviation of the nasal septum to the right, obstructing view of the rest of the nasal vault. No septal perforation was seen. There was no tenderness to palpation of the external nose, and no obvious bony step-off of the nasal bones was appreciated. The remainder of the head and neck examination was unremarkable.

The patient was interested in having surgery to improve his nasal airway, if it wouldn't be too risky. He began to ask questions about how often nasal septal deviations occur and how often complications occur after surgery for a deviated septum.

General Considerations

Nasal obstruction is a very common symptom, and a deviated nasal septum is considered the most common cause of nasal obstruction.[1] The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) reported that approximately 80% of all nasal septa are deviated.[2]

In general, patients who do not have symptoms related to an identified septal deviation do not need septoplasty; candidacy for septoplasty is based on both symptoms and physical examination.[3] An estimated one fourth of patients with nasal obstruction ultimately pursue surgical treatment.[4] In the United States, more than 340,000 septoplasties and turbinate surgeries are performed in ambulatory surgical centers, based on data from the 2006 National Survey of Ambulatory Surgery.[5] In this particular study, no cases of cardiac arrest, malignant hyperthermia, or blood transfusion were reported, and only 0.1% of all patients with septoplasties made postoperative visits to the emergency department.

For patients who decide to undergo septoplasty, historically the procedure has been done under general anesthesia. However, several reports indicate that septoplasty can be done safely under local anesthesia with sedation, contributing to decreased operative and recovery times, decreased postoperative pain and epistaxis, and lower cost in many instances.[1,3,6-9]

Case: Difficult Nasal Breathing

A 22-year-old college student presented to his primary care provider with a long-standing history of difficulty breathing through the left nostril. The patient stated that this symptom began after he was hit in the face with a baseball during a high school game several years ago. He denied nasal pain or tenderness, epistaxis, rhinorrhea, anosmia, or visual deficits. The patient had no other significant medical history. He smoked cigarettes occasionally when socializing and denied alcohol or illicit drug use. The patient reported no use of any prescribed medications and has no known drug allergies.

On examination, the patient had normal vital signs and appeared comfortable, with no apparent difficulty breathing. Extraocular movements were intact. The nasal dorsum appeared straight and was nontender to palpation. There was no external nasal valve collapse on inspiration. On anterior rhinoscopy, the right nasal passage demonstrated a somewhat enlarged inferior turbinate but no other findings of note. Visualization of the left nasal passage was severely obstructed by a large deviation of the anterior nasal septum, which nearly contacted the left inferior turbinate. There was no septal perforation. No rhinorrhea or epistaxis was present. The external auditory canals were patent and the tympanic membranes were clear and intact. An examination of the oral cavity and oropharynx was unremarkable. The neck was flat and supple, with full range of motion.

The clinician was fairly confident that the patient's symptom was caused by the septal deviation. However, he was uncertain whether his examination alone was sufficient documentation of the patient's nasal obstruction.

Making the Diagnosis

The AAO-HNSF clinical consensus statement on septoplasty and inferior turbinate reduction concluded that anterior rhinoscopy, nasal endoscopy, or both are all sufficient for documenting septal deviation prior to septoplasty.[3] Furthermore, the consensus statement indicates that nasal endoscopy is valuable in identifying other possible causes of nasal obstruction, such as sinonasal polyps or tumors, which may not be readily visible on anterior rhinoscopy. However, there was no agreement among the panel members on whether all patients with septal deviation must regularly undergo nasal endoscopy. Most primary care providers do not receive comprehensive training on endoscopic techniques, and so referral to a specialist such as an otolaryngologist is necessary if nasal endoscopy is to be pursued.

The AAO-HNSF septoplasty panel concluded that photodocumentation of the septal deviation is unnecessary prior to performing septoplasty.[3] However, it should be noted that photodocumentation is useful, but not necessarily required, in cases in which an external nasal deformity is contributing to nasal valve collapse, another well-known cause of nasal airway obstruction.[10] In this particular case, the patient had no overt signs of external nasal deformity.

Developed in 1989, acoustic rhinometry is the analysis of sound waves reflected from the nasal passages in order to measure cross-sectional area and nasal volume.[11] The technique is considered rapid, noninvasive, and well tolerated by patients, and it does not require nasal airflow.[12] Developed in the 1960s, rhinomanometry assesses nasal patency by measuring the pressure gradient of airflow through the nasal passages, either through normal patient respiration (active technique) or through air driven into the nostrils from an external course (passive technique).[13,14] The AAO-HNSF septoplasty consensus statement panel could not agree on the value of either acoustic rhinometry or rhinomanometry in the diagnosis of septal deviation.[3] The panel cited systematic reviews demonstrating that acoustic rhinometry or rhinomanometry do not have the sensitivity and specificity of anterior rhinoscopy or nasal endoscopy, and that rhinometry or rhinomanometry test results often do not correlate with patient symptoms.[15,16]

Case: Bilateral Nasal Congestion

A 51-year-old nurse presented to her nurse practitioner (NP) with a multiyear history of bilateral nasal congestion, worse on the right side. The nasal congestion occurred year-round, but often worsened with accompanying facial pressure, rhinorrhea, or intermittent right-sided nosebleeds when the weather was cold or if she contracted an upper respiratory infection. She denied constitutional symptoms. The patient reported a history of hypertension treated with hydrochlorothiazide, and no other medical problems. She denied tobacco or alcohol use and reported no known drug or environmental allergies.

On physical examination, the patient's vital signs were within normal limits and the patient was in no respiratory distress. The patient had a hyponasal voice. Anterior rhinoscopy demonstrated a very large septal spur emanating from the right aspect of the nasal septum and significantly enlarged bilateral inferior turbinates. The remainder of the patient's head and neck examination was unremarkable.

The patient's NP recalled hearing from one of her physician colleagues that he never requests imaging for patients with nasal septal deviations because "the surgeons never like what I order."

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.[17-21] 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.[24-26]

Case: Discomfort and Nosebleeds

A 39-year-old paralegal visited her family physician for ongoing left-sided nasal obstruction with occasional soreness of the nose and cheeks and rare, mild nosebleeds. The patient previously attempted a 1-month course of intranasal corticosteroid and isotonic saline sprays, with minimal improvement in symptoms. She was a nonsmoker, rarely drank alcohol, did not use illicit drugs, and had no known drug allergies. She had a previously diagnosed left-sided septal deviation.

At the latest visit, the patient expressed interest in surgical intervention for her symptoms.

Indications for Surgery

The AAO-HNSF clinical consensus statement panel on septoplasty agreed that septoplasty can be an effective adjunctive treatment for several conditions in addition to nasal septal deviation.[3] The panel concurred that septal deviation is a risk factor for the development of epistaxis, owing to traumatization of nasal mucosa from turbulent airflow at the site of septal deviation. Septoplasty has been reported as a treatment for severe recurrent epistaxis in a patient with Glanzmann's thrombasthenia; it was hypothesized that fibrosis in the septal mucosa following septoplasty contributed to a reduction in vascularity of the nasal septum.[27]

Septoplasty can play an important role in the management of chronic rhinosinusitis. Facilitation of access for instrumentation during endoscopic sinus surgery is considered an indication for septoplasty.[3] Septoplasty can also improve intranasal anatomy by relieving any septum-related obstruction of the middle meatus, subsequently improving drainage of the ostiomeatal complex.[3] Moreover, surgically addressing a septal deviation can improve delivery of intranasal medications.[28]

Although septoplasty alone generally is not considered sufficient as a treatment for obstructive sleep apnea, it can be used in conjunction with other treatments to enhance positive outcomes.[29-31] Septoplasty with or without inferior turbinoplasty has been shown to improve continuous positive airway pressure tolerance and compliance in patients with obstructive sleep apnea.[32-34]

The AAO-HNSF septoplasty panel agreed that the effect of septoplasty on olfaction is unpredictable.[3] In a 2004 prospective study using the "Sniffin' Sticks" olfactory test battery, one patient demonstrated improvement in olfaction and five demonstrated a decline 4 months after septoplasty; at 9 months postsurgery, one patient continued to exhibit hyposmia.[35] A 2008 prospective investigation using the same test battery as the 2004 study found that 13% of patients who underwent septoplasty experienced improvement in olfaction 4 months after surgery, whereas in 7%, olfaction declined.[36] Patients should be counseled that anosmia or hyposmia is not an indication for septoplasty, and that the impact of septoplasty on olfaction is variable.

Editor's Recommendations

References

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