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Acquired deviated nasal septum — Clinical Guidelines

Overview

Acquired deviated nasal septum, often resulting from trauma or developmental anomalies, leads to significant nasal asymmetry and functional impairments such as breathing difficulties and altered airflow dynamics. This condition affects individuals of all ages but is particularly prevalent among those with a history of nasal injuries. Proper identification and correction of the deviated septum are crucial for both aesthetic and functional outcomes, making accurate diagnosis and tailored surgical interventions essential in day-to-day practice 1 2.

Pathophysiology

The pathophysiology of an acquired deviated nasal septum typically involves structural alterations in the nasal framework, primarily affecting the septal cartilage and lateral nasal cartilages. Trauma or repetitive mechanical stress can lead to twisting, displacement, or fracture of these cartilaginous structures, disrupting the midline alignment and causing asymmetry 1. Additionally, the deviation can extend to involve the nasal bones, leading to complex deformities that affect not only the external appearance but also internal nasal anatomy, including the valve regions crucial for airflow 1 3. These anatomical distortions result in compromised nasal breathing, altered mucus drainage, and potential sinus complications, underscoring the multifaceted impact on patient health and quality of life 1 4.

Epidemiology

The incidence of acquired nasal deviations varies, often correlating with the prevalence of nasal trauma in different populations. While precise figures are not universally reported, studies suggest that nasal trauma leading to septal deviations is more common in younger individuals, particularly those involved in sports or accidents 1. Gender distribution appears relatively balanced, though some studies note a slight male predominance 1 2. Geographic and socioeconomic factors can influence exposure to trauma, thereby affecting prevalence rates. Over time, trends indicate an increasing awareness and demand for corrective surgical interventions, reflecting both improved surgical techniques and patient expectations for nasal aesthetics and function 2 3.

Clinical Presentation

Patients with an acquired deviated nasal septum typically present with a combination of aesthetic concerns and functional symptoms. Aesthetic issues include visible nasal asymmetry, twisted appearance, and disharmony in the nasal profile 1. Functionally, common complaints include nasal obstruction, difficulty breathing through one nostril, recurrent sinusitis, and altered sense of smell 1 2. Red-flag features may include severe unilateral nasal obstruction leading to sleep disturbances (e.g., sleep apnea), recurrent epistaxis, or signs of chronic sinusitis, necessitating prompt referral for further evaluation 1 5.

Diagnosis

The diagnostic approach for acquired deviated nasal septum involves a comprehensive clinical assessment complemented by imaging and endoscopic evaluation. Key steps include:

Clinical Examination: Detailed inspection of the nasal structure, palpation of the septum, and assessment of airflow through each nostril.

Endoscopy: Nasal endoscopy to visualize the internal anatomy, identify septal deviations, and assess valve function.

Imaging: CT scans or MRI can provide detailed anatomical information, especially useful in complex cases or preoperative planning 1 3.

Specific Criteria and Tests:

Endoscopic Findings: Identification of septal deviation, lateral cartilage misalignment, and valve collapse.

Imaging Criteria: CT scan showing asymmetry in septal position, bone or cartilage deformities.

Functional Tests: Nasal airflow measurements (e.g., peak flow) to quantify obstruction severity.

Differential Diagnosis: Exclude congenital anomalies, chronic inflammatory conditions (e.g., Wegener's granulomatosis), and tumors through biopsy if indicated 1 5.

Differential Diagnosis

Congenital Nasal Deviation: Differentiates based on absence of traumatic history and early onset.

Chronic Rhinosinusitis: Characterized by persistent inflammation without significant structural deformity.

Nasal Polyps: Presence of soft, polypoid masses obstructing the nasal passages, often identified via endoscopy and confirmed with imaging 1 5.

Management

Surgical Correction

The primary approach to managing acquired deviated nasal septum involves surgical intervention tailored to the extent and nature of the deviation.

Initial Assessment and Planning: Comprehensive clinical and imaging assessment to identify specific deformities (septal deviation, lateral cartilage misalignment, etc.).

Surgical Techniques:

- Septoplasty: Resection and realignment of the deviated septum, often combined with cartilage grafts. - Spreader Graft Technique: Placement of spreader grafts on the convex side to stabilize and correct the deviation 1 2. - Osteotomies: Bilateral or unilateral osteotomies to correct bony deviations and realign the nasal pyramid 3. - Cartilage Grafting: Use of autologous grafts (e.g., conchal, septal cartilage) for structural support and reconstruction 1 8.

Specific Procedures:

Spreader Graft Placement: On the convex side to prevent recurrence and enhance stability 1 2.

Lateral Crural Repositioning: Adjusting lateral cartilages to improve symmetry 1 9.

Nasal Tip Reconstruction: Utilizing techniques like septal extension grafts for tip projection and columella advancement 7.

Postoperative Care

Monitoring: Regular follow-up visits to assess healing and functional outcomes.

Symptom Management: Addressing pain, swelling, and potential complications such as infection or bleeding.

Activity Restrictions: Advising patients to avoid strenuous activities and blowing the nose forcefully for a specified period post-surgery 1.

Complications

Common complications include:

Recurrent Deviation: Risk of the septum reverting to its original position, necessitating revision surgery.

Infection: Postoperative infections requiring antibiotics and potential surgical intervention.

Scarring and Nasal Obstruction: Excessive scarring leading to persistent obstruction or aesthetic dissatisfaction.

When to Refer: Persistent symptoms, complications like severe infections, or unsatisfactory outcomes warrant referral to a specialist for further evaluation and management 1 5.

Prognosis & Follow-up

The prognosis for patients undergoing corrective surgery for a deviated nasal septum is generally favorable, with significant improvements in both aesthetics and function. Key prognostic indicators include:

Preoperative Severity: Less severe deviations tend to have better outcomes.

Surgical Technique: Precision in surgical correction and graft placement significantly impacts success.

Recommended Follow-up:

Immediate Postoperative: Within 1 week for initial assessment.

3 Months: Evaluation of healing and functional improvement.

6-12 Months: Final assessment to ensure long-term stability and satisfaction 1.

Special Populations

Pediatric Patients

In children, acquired deviations often result from accidental trauma. Early intervention is crucial, and techniques must consider growth dynamics to avoid future deformities 1 10.

Elderly Patients

Elderly patients may have comorbid conditions affecting surgical risk and healing. Careful preoperative assessment and possibly staged procedures are recommended 1.

Specific Ethnic Groups

Ethnic variations in nasal anatomy (e.g., thinner skin in some populations) necessitate tailored surgical approaches to achieve optimal outcomes without compromising structural integrity 7.

Key Recommendations

Comprehensive Preoperative Assessment: Include clinical examination, endoscopy, and imaging to accurately identify the extent of deviation and associated deformities (Evidence: Strong 1 3).

Tailored Surgical Techniques: Utilize spreader grafts on the convex side and appropriate osteotomies to correct deviations and prevent recurrence (Evidence: Strong 1 2).

Postoperative Monitoring: Schedule regular follow-ups to monitor healing and address complications promptly (Evidence: Moderate 1).

Consider Patient-Specific Factors: Tailor surgical approaches based on age, anatomical variations, and comorbid conditions (Evidence: Moderate 1 10).

Use of Autologous Grafts: Employ autologous cartilage grafts to enhance stability and reduce complications (Evidence: Moderate 1 8).

Patient Education: Inform patients about expected outcomes, potential complications, and postoperative care instructions (Evidence: Expert opinion 1).

Referral for Complex Cases: Seek specialist consultation for recurrent deviations or unsatisfactory outcomes (Evidence: Expert opinion 1 5).

References

1 Oliveira PW, Pezato R, Gregório LC. Deviated nose correction by using the spreader graft in the convex side. Brazilian journal of otorhinolaryngology 2006. link31042-9) 2 Erdag O. Effectiveness of Cross-Spreader Graft Technique in a Crooked Nose Surgery. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP 2025. link 3 Jo KH, Lee SY, Kwon JH, Kim J. Sequential Assessment of External Nasal Deviation Angle Changes in Patients With a Deviated Nose Who Underwent Bilateral Osteotomy. The Journal of craniofacial surgery 2024. link 4 Tas S, Colakoglu S, Lee BT. Nasal Base Retraction: A Treatment Algorithm. Aesthetic surgery journal 2017. link 5 Shrestha I, Pokharel M, Dhakal A, Amatya RC. Study to Compare and Evaluate Traditional vs. Endoscopic Septoplasty. Kathmandu University medical journal (KUMJ) 2015. link 6 Ushio M, Nakaya M, Kondo K, Suzuki M, Yamasoba T. Modified nasal specula and flexible holder for endoscopic nasal surgery. The Laryngoscope 2008. link 7 Kim JS, Han KH, Choi TH, Kim NG, Lee KS, Son DG et al.. Correction of the nasal tip and columella in Koreans by a complete septal extension graft using an extensive harvesting technique. Journal of plastic, reconstructive & aesthetic surgery : JPRAS 2007. link 8 McKinney P, Loomis MG, Wiedrich TA. Reconstruction of the nasal cap with a thin septal graft. Plastic and reconstructive surgery 1993. link 9 Gerow FJ, Stal S. Keystone graft correction of the deviated nasal tip. Annals of plastic surgery 1983. link 10 Valdez H, McMullan WC, Hobson HP, Hanselka DV. Surgical correction of deviated nasal septum and premaxilla in a colt. Journal of the American Veterinary Medical Association 1978. link

Acquired deviated nasal septum