Imaging Studies
A CT scan usually is obtained for concurrent reasons, such as assessing sinus disease or evaluating head and/or facial trauma. While septal deviations are readily apparent on CT scans (see the image below), obtaining a CT scan is not necessary in a patient in whom no other pathology is suspected (eg, concomitant sinus disease).
Axial CT scan demonstrating severe septal deviation. Note left-sided deflection of caudal septum and right-sided nasal airway obstruction due to bony and cartilaginous posterior deviation.
In addition, a study by Sedaghat et al indicated that CT-scan results do not correlate well with physical exam/anterior rhinoscopic/endoscopic findings in septal deviation. Although the study, which involved 39 patients, determined that such correlation was significant with regard to the bony septum, it was not significant with regard to the cartilaginous septum, maxillary crest, and nasal valve. [4]
Plain films are not indicated in most instances; they offer minimal benefit because the cartilaginous portion of a deviated septum is not easily visible on plain films. A direct or an endoscopic examination is generally the preferred approach.
Other Tests
Many proposed methods of nasal airway analysis exist, including rhinomanometry, acoustic rhinometry, and nasal peak flow. However, the measurements derived from these methods are not always reproducible and do not consistently correlate with a patient's subjective complaint of nasal obstruction. In general, these types of studies are useful for research in nasal obstruction but provide little clinical value in the decision-making process regarding surgery or medical management.
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Cross-sectional area of the nasal cavity at the middle vault level. The ideal angle the caudal edge of the upper lateral cartilage makes with the septum is 10-15°.
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Blood supply to the nasal septum derives contribution from the anterior and posterior ethmoidal arteries, the sphenopalatine artery, the septal branch of the superior labial artery (not labeled), and the greater and ascending palatine arteries (not labeled).
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Axial CT scan demonstrating severe septal deviation. Note left-sided deflection of caudal septum and right-sided nasal airway obstruction due to bony and cartilaginous posterior deviation.
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Location of the hemitransfixion and Killian incisions.
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Elevation of the mucoperichondrial flap with a Cottle elevator.
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(A) Transcartilaginous incision near the osseocartilaginous junction. (B) Excision of posteroinferior septal cartilage to achieve a swinging door effect. (C) Inferior strip excision of cartilage.
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The external nasal approach provides direct visualization of the anterior and dorsal septum and easy access for septal repair.
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One technique of incising the septal cartilage involves removing thin wedges from the convex side of the deviated septum to encourage midline repositioning.
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Excess and displaced septal cartilage along a hypertrophied maxillary crest can be excised. A straight osteotome may facilitate removal of the bony portion.
