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Disorder of nasal septum — Clinical Guidelines

Overview

Disorder of the nasal septum encompasses a range of conditions affecting the structural integrity and function of the nasal septum, including deviations, perforations, and deformities. These conditions can significantly impact nasal breathing, causing symptoms such as nasal obstruction, recurrent sinusitis, and facial pain. Commonly encountered in adults, particularly men, these disorders often necessitate surgical intervention, although funding criteria vary widely across regions. Understanding the nuances of diagnosis and management is crucial for clinicians to optimize patient outcomes and navigate healthcare policy constraints effectively 1.

Pathophysiology

The pathophysiology of nasal septal disorders typically arises from a combination of congenital anomalies, trauma, or inflammatory processes. Congenital deviations may result from improper fusion of nasal cartilaginous structures during embryonic development, leading to structural asymmetries that affect airflow dynamics 4. Trauma, whether acute (e.g., sports injuries, accidents) or chronic (e.g., repeated minor injuries), can cause fractures or dislocations of the septal cartilage, resulting in deviations or perforations. Inflammatory conditions, such as chronic rhinosinusitis, can also contribute to septal thickening and deformities, further compromising nasal patency 3. These structural alterations disrupt the normal airflow patterns, increasing resistance and potentially leading to compensatory changes in adjacent nasal structures like the turbinates, exacerbating symptoms 3.

Epidemiology

Epidemiological data indicate that septal disorders are prevalent, with septoplasties and related procedures being frequently performed, particularly in adult males. Over the decade from 2012 to 2019, a total of 158,031 rhinology procedures were documented in England, predominantly involving septoplasties, though there was a noted decline in overall numbers, especially for septorhinoplasty and rhinoplasty procedures 1. Age and sex distribution show a male predominance, with adult patients constituting the vast majority of cases. Geographic variations in incidence may exist due to differences in healthcare access and reporting practices, though specific regional data are not extensively detailed in the provided sources. Trends suggest a potential shift in procedural funding policies impacting the frequency of surgical interventions 1.

Clinical Presentation

Patients with nasal septal disorders typically present with symptoms related to nasal obstruction, which can be unilateral or bilateral depending on the extent and location of the deviation or defect. Common complaints include difficulty breathing through the nose, nasal congestion, recurrent nasal infections, and facial pain or pressure. Atypical presentations might include epistaxis (nosebleeds), particularly in cases of septal perforation, and altered sense of smell due to impaired airflow. Red-flag features that warrant immediate attention include severe, persistent epistaxis, significant facial asymmetry, or signs of systemic infection, indicating potential complications such as septal abscess or severe sinusitis 3.

Diagnosis

The diagnostic approach for nasal septal disorders involves a combination of clinical assessment and imaging techniques. Clinicians typically begin with a thorough history and physical examination, focusing on the nature and severity of nasal obstruction, presence of trauma history, and associated symptoms like sinusitis or recurrent infections. Key diagnostic criteria include:

Physical Examination: Nasal endoscopy to visualize septal deviations, perforations, or deformities.

Imaging: CT scans provide detailed anatomical information, crucial for assessing complex deviations and planning surgical interventions. MRI may be considered for soft tissue assessment in cases of suspected inflammatory involvement 3.

Criteria for Surgical Intervention: Indications often include persistent symptoms despite conservative management, significant functional impairment, or cosmetic concerns. Specific thresholds for referral to surgery may vary by clinical guidelines and patient preference 1.

Differential Diagnosis:

Deviated Nasal Turbinate: Distinguished by endoscopic findings focusing more on turbinate hypertrophy rather than septal deviation.

Nasal Polyps: Characterized by soft, pale, and movable masses within the nasal cavity, often identified via endoscopy and confirmed with imaging.

Chronic Sinusitis: Presents with additional symptoms like purulent nasal discharge and facial pressure, often requiring sinus imaging for differentiation 3.

Management

Initial Management

Conservative Measures: Nasal saline irrigation, decongestants (e.g., oxymetazoline 0.05% nasal spray, used for ≤3 days to avoid rebound congestion), and antihistamines for allergic components.

Patient Education: On proper nasal hygiene and avoidance of irritants.

Second-Line Management

Surgical Intervention:

- Septoplasty: Corrects deviations by realigning and repositioning the septum. Techniques include submucous resection with preservation of mucoperichondrial flaps to minimize scarring and improve healing. - Perforation Repair: For septal perforations, options include local flaps (e.g., mucoperichondrial flaps), septal strut grafts (e.g., conchal or costal cartilage grafts), or septal replacement with synthetic materials like silicone 3. - Indications: Persistent symptoms despite conservative treatment, significant functional impairment, or cosmetic concerns.

Refractory Cases / Specialist Referral

Complex Reconstructive Surgery: In cases of multiple previous surgeries or severe deformities, referral to a specialist rhinologist for advanced techniques such as septorhinoplasty.

Multidisciplinary Approach: Collaboration with ENT surgeons, maxillofacial surgeons, or plastic surgeons for comprehensive management, especially in complex cases involving multiple nasal structures 1.

Contraindications: Active infections, uncontrolled bleeding disorders, or severe systemic conditions that increase surgical risk 3.

Complications

Acute Complications: Postoperative bleeding, infection, and delayed healing. Immediate referral to a specialist is warranted for persistent bleeding or signs of infection.

Long-Term Complications: Recurrent nasal obstruction, asymmetry, and potential need for revision surgery. Regular follow-up is essential to monitor for these issues, particularly in patients with complex anatomical variations 3.

Prognosis & Follow-up

The prognosis for patients undergoing septoplasty or related procedures is generally favorable, with significant improvement in nasal breathing and quality of life reported in most cases. Prognostic indicators include the severity of preoperative symptoms, the skill of the surgeon, and adherence to postoperative care instructions. Recommended follow-up intervals typically include:

Initial Postoperative Visit: Within 1-2 weeks to assess healing and address immediate concerns.

Subsequent Visits: At 3-6 months and annually thereafter to monitor long-term outcomes and address any emerging issues 1.

Special Populations

Pediatrics: Nasal septal disorders in children often require careful assessment to differentiate between congenital anomalies and acquired deformities. Conservative management is preferred initially, with surgical intervention reserved for severe cases impacting growth and development 1.

Elderly Patients: Increased risk of comorbidities necessitates thorough preoperative evaluation and careful surgical planning to minimize complications. Postoperative care should account for slower healing times and potential frailty 3.

Comorbid Conditions: Patients with chronic respiratory diseases (e.g., COPD) or cardiovascular issues require tailored surgical approaches and close postoperative monitoring to manage additional risks 3.

Key Recommendations

Perform Comprehensive Clinical Assessment: Including detailed history, physical examination, and nasal endoscopy to diagnose septal disorders accurately (Evidence: Strong 1 3).

Utilize Imaging for Complex Cases: CT scans are essential for detailed anatomical assessment before surgical planning (Evidence: Moderate 1).

Consider Conservative Management Initially: For mild symptoms, start with nasal irrigation, decongestants, and antihistamines (Evidence: Moderate 3).

Refer for Surgical Intervention When Indicated: Persistent symptoms or significant functional impairment warrant surgical correction (Evidence: Strong 1 3).

Preserve Mucoperichondrial Flaps During Septoplasty: To minimize scarring and improve healing outcomes (Evidence: Moderate 3).

Monitor Postoperative Care Closely: Regular follow-ups are crucial to manage acute complications and ensure long-term success (Evidence: Moderate 1).

Tailor Management for Special Populations: Consider age-specific and comorbid factors in pediatric and elderly patients (Evidence: Expert opinion 1 3).

Evaluate for Recurrent Symptoms Post-Surgery: Regular follow-up visits are necessary to address any recurrence or new complications (Evidence: Moderate 1).

Educate Patients on Nasal Hygiene: Emphasize the importance of maintaining nasal health post-procedure (Evidence: Expert opinion 3).

Refer Complex Cases to Specialists: For advanced reconstructive surgeries, multidisciplinary input is beneficial (Evidence: Expert opinion 1).

References

1 Balai E, Jolly K, Bhamra N, Osborne MS, Barraclough J. The changing face of rhinology in the NHS: a study of septoplasty, septorhinoplasty and rhinoplasty hospital episode statistics. Annals of the Royal College of Surgeons of England 2021. link 2 Badran KW, Chang JC, Kuan EC, Wong BJF. Anatomy and Surgical Approaches to the Rabbit Nasal Septum. JAMA facial plastic surgery 2017. link 3 Sonneveld KA, Sinha PK. Correction of Septal Perforation/Nasal Airway Repair. Oral and maxillofacial surgery clinics of North America 2021. link 4 Elwany S, Salam SA, Soliman A, Medanni A, Talaat E. The septal body revisited. The Journal of laryngology and otology 2009. link 5 Shoemaker RW, Wilson DG, Fretz PB. A dorsal approach for the removal of the nasal septum in the horse. Veterinary surgery : VS 2005. link

Disorder of nasal septum