Diseases of the Nasal Septum

The nasal septum forms the central partition of the nasal cavity and divides it into right and left nasal passages. Structurally, it consists of septal cartilage anteriorly, the perpendicular plate of the ethmoid superiorly, and the vomer inferiorly and posteriorly. Functionally, it maintains laminar airflow, supports the nasal dorsum, and contributes to humidification and filtration of inspired air. Therefore, even minor septal pathology can significantly affect nasal breathing, sinus ventilation, and facial contour. Read more on: 🔗Anatomy of Nasal Septum

Diseases of the nasal septum are commonly present in outpatient ENT practice and frequently appear in university theory examinations, practical examinations, viva voce, and NEET PG multiple-choice questions. Among these, Deviated Nasal Septum (DNS), septal hematoma, and septal perforation represent the most clinically important and exam-relevant conditions.

Deviated Nasal Septum (DNS)

Definition. A deviated nasal septum refers to the displacement of the septum from the midline, resulting in asymmetry between the two nasal cavities. Consequently, it causes major nasal obstruction. Although minor deviations occur in a large proportion of the population, only symptomatic deviation requires clinical attention. Therefore, the presence of deviation alone does not justify surgery; symptoms guide management.

Causes

1.Developmental / Racial Causes

• During growth, disproportionate development between the septum and surrounding facial bones may cause bending or buckling.
• Genetic predisposition

2. Trauma

• Childhood injury. In many adults, the deviation originates from childhood trauma, although patients often fail to recall such injury. Thus, when you evaluate a patient with DNS, always enquire about childhood injury, even if the patient initially denies trauma.
• Accidental trauma. Such as falls, sports injuries, road traffic accidents, or physical assault, also contribute significantly.
• Birth trauma. During prolonged labour, the nasal cartilage may be compressed and lead to later deviation.

Types of Septal Deviation

Septal deviation presents in characteristic patterns.

1. C-shaped deviation is the most common type. In this condition, the septum bends to one side forming a single curve. The nasal cavity on the concave side becomes wider. As a result, the turbinate on that side may enlarge to compensate, which is called compensatory hypertrophy.
2. S-shaped deviation shows double curvature. The septum bends in two opposite directions. This deformity may occur in the vertical plane or in the anteroposterior plane. Since both nasal cavities become narrow at different levels, the patient may develop bilateral nasal obstruction.
3. Septal spur is a sharp projection usually seen at the junction of cartilage and bone. The spur may press against the lateral nasal wall. Because of this pressure, the patient may complain of nasal obstruction, recurrent epistaxis, or even headache.
4. Septal thickening refers to localized enlargement of the septum. This thickening may occur due to an organized hematoma or overlapping of fractured septal fragments after trauma.
5. Caudal dislocation means forward displacement of the lower end of the septum into one nasal cavity. This type is commonly visible on anterior rhinoscopy and may cause visible nasal deformity.

In practical examinations, examiners commonly ask you to identify the type of deviation on anterior rhinoscopy. Therefore, always describe the direction, location, and extent of deviation clearly.

Clinical Features

1. Nasal Obstruction. This is the most common symptom. It may be unilateral or bilateral, depending on the severity and type of deviation. High septal deviations cause more obstruction than low ones because airflow mainly passes through the upper nasal cavity. Importantly, constant obstruction usually indicates structural blockage, such as DNS. In contrast, intermittent obstruction suggests mucosal causes such as turbinate hypertrophy or allergic rhinitis. When obstruction changes sides periodically, the nasal cycle likely explains the symptom. Decongestant Test. A simple bedside method helps differentiate structural from mucosal causes. After applying a topical nasal decongestant, if obstruction improves significantly, mucosal elements contribute to the blockage. However, if no improvement occurs, anatomical deviation likely predominates. This clinical reasoning often appears in NEET PG MCQs.
2. Epistaxis. Patients, especially those with a septal spur, may develop recurrent nosebleeds. The spur stretches and thins the mucosa, leading to crust formation. When the crust is removed, bleeding occurs.
3. Headache. A deviated septum may touch the turbinate and stimulate the anterior ethmoidal nerve. This contact produces headache, sometimes referred to as Sluder’s neuralgia.
4. Recurrent Sinusitis. DNS may block sinus openings and interfere with normal drainage and ventilation. As a result, patients may experience recurrent sinus infections.
5. Anosmia or Hyposmia. Severe deviation may prevent inspired air from reaching the olfactory area, leading to partial or complete loss of smell.
6. External nasal deformity. Significant septal deformity may be associated with deviation of the nasal dorsum, tip, or columella, producing visible cosmetic deformity.
7. Predisposition to Middle ear infection. Chronic nasal obstruction may affect Eustachian tube function and increase the risk of otitis media, especially in children.

Examination and Diagnosis

Anterior rhinoscopy is the main diagnostic tool. It allows direct visualization of deviation, spur, thickening, or caudal dislocation. However, posterior deviations and associated conditions require diagnostic nasal endoscopy. Endoscopy also helps detect polyps, turbinate hypertrophy, sinus disease, or adenoid enlargement. When examining a patient with nasal obstruction, always identify the exact site of obstruction. It may occur at the vestibule, nasal valve, attic region (upper septum), turbinate region, or choana. Posterior causes such as choanal polyp may be missed without endoscopy.

Cottle’s test evaluates the internal nasal valve. When you gently pull the cheek laterally and upwards, the nasal valve area widens. If airflow improves, the test is positive and indicates obstruction at the level of the internal nasal valve. This area offers maximum resistance to airflow and therefore plays a crucial role in nasal physiology.

Grading and Clinical Significance

Septal deviation can be clinically categorized into simple, obstructed, and impacted types.

1. Simple deviation produces no symptoms.
2. Obstructed deviation causes symptoms but improves with decongestants, suggesting a mucosal component.
3. Impacted deviation impinges on the lateral nasal wall and does not improve with decongestants, indicating a purely structural problem.

Mladina’s Classification. Mladina classified septal deformities into seven types based on rhinoscopic or radiological findings. These include mild vertical deviation (Type I), anterior vertical deviation (Type II), posterior vertical deviation (Type III), S-shaped deformity (Type IV), horizontal crest (Type V), maxillary crest deformity (Type VI), and combination deformities (Type VII).

Management

Management depends entirely on symptoms. Asymptomatic deviation requires no treatment. However, symptomatic cases require surgical correction. 🔗Septoplasty remains the preferred procedure because it preserves the septal framework while correcting deviation. In contrast, 🔗Submucosal resection (SMR) removes larger portions of cartilage and bone and therefore carries a greater risk of complications such as septal perforation or saddle nose deformity. Modern practice strongly favours septoplasty over SMR.

Indications for septoplasty include persistent nasal obstruction, recurrent sinusitis due to poor drainage, epistaxis from a spur, contact point headache, and the need to improve surgical access before functional endoscopic sinus surgery.

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  Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

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