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Summary Table

Category	Detail
Risk Factors	Nasal trauma (sports injuries, facial fractures), birth trauma (passage through birth canal), abnormal intrauterine compression, prior nasal surgery, normal developmental asymmetry during growth
Etiology	Displacement of the nasal septum (cartilaginous and/or bony portions) from the midline, caused by trauma or asymmetric growth of septal cartilage and adjacent structures
Patient Presentation	Chronic unilateral nasal obstruction, difficulty breathing through one side of the nose, recurrent sinusitis, epistaxis, snoring, disturbed sleep
Classic Physical Exam	Anterior rhinoscopy reveals a visibly deviated septum with asymmetric nasal passages; the obstructed side may show compensatory inferior turbinate hypertrophy on the contralateral (wider) side; external nasal asymmetry may or may not be present
Key Diagnostic Results	Primarily a clinical diagnosis on anterior rhinoscopy; CT paranasal sinuses (coronal cuts) confirms the degree and location of deviation, especially if surgery is planned
Management	Mild/asymptomatic: no treatment needed. Symptomatic: initial trial of nasal corticosteroid sprays and decongestants. Definitive treatment: septoplasty. If concurrent external deformity exists: septorhinoplasty
Keywords	"Unilateral nasal obstruction," "difficulty breathing through one nostril," "deviated septum on rhinoscopy," "compensatory turbinate hypertrophy," "septoplasty"

1. Pathophysiology

The nasal septum is a midline structure composed of the quadrilateral cartilage anteriorly, the perpendicular plate of the ethmoid superiorly, and the vomer posteroinferiorly. These components articulate at suture lines that serve as active growth centers during childhood and adolescence. Any asymmetric growth at these junctions, or any external force applied to the developing or mature septum, can produce a deviation from the midline.

Deviation narrows the nasal passage on the side of the deflection, directly increasing nasal airflow resistance on that side. Patients therefore report unilateral nasal obstruction that worsens during upper respiratory infections or allergic episodes because mucosal edema further narrows an already compromised airway. On the contralateral (wider) side, a phenomenon called compensatory inferior turbinate hypertrophy frequently develops. The turbinate enlarges because the wider passage allows excessive airflow, and the mucosa responds with chronic engorgement. This is why some patients eventually develop bilateral obstruction despite the septum deviating to only one side, a concept that is commonly tested.

Deviation also disrupts the normal laminar airflow within the nasal cavity. The resulting turbulent airflow dries the overlying mucosa, predisposing to crusting and recurrent epistaxis, particularly along the anterior septum at Kiesselbach plexus (Little area). Furthermore, a deviated septum can obstruct the ostiomeatal complex, impairing sinus drainage and predisposing the patient to recurrent or chronic rhinosinusitis.

2. Classification and Clinical Manifestation

Type of Deviation	Description	Clinical Significance
C-shaped deviation	Septum curves to one side along its length	Unilateral obstruction on the concave side; compensatory turbinate hypertrophy on the convex (wider) side
S-shaped deviation	Septum deviates to opposite sides at different levels (anterior vs. posterior)	Can cause bilateral obstruction; more complex surgical correction required
Septal spur	A sharp, localized bony or cartilaginous projection from the septum	May impinge on the lateral wall or turbinate; a common cause of contact headache and localized epistaxis
Septal subluxation / dislocation	The caudal (anterior-inferior) edge of the cartilaginous septum is displaced off the maxillary crest	Visible deviation at the nasal vestibule; causes obstruction at the nasal valve, the narrowest point of the nasal airway
Anterior deviation	Involves the cartilaginous septum near the nasal valve area	Disproportionately symptomatic because the nasal valve contributes the greatest resistance to airflow
Posterior deviation	Involves the bony septum (perpendicular plate of ethmoid or vomer)	May obstruct the choana or ostiomeatal complex, predisposing to sinusitis; often underappreciated on anterior rhinoscopy alone

A key teaching point: anterior deviations near the internal nasal valve (the angle between the upper lateral cartilage and the septum, normally 10 to 15 degrees) produce symptoms disproportionate to their apparent size because this is the area of greatest airflow resistance in the entire upper airway.

3. Diagnostic Workup

Test	Role	Key Findings
Anterior rhinoscopy	Best initial test	Direct visualization of septal deflection, spurs, mucosal changes, turbinate size
Nasal endoscopy	More detailed evaluation	Assesses posterior deviations, polyps, ostiomeatal complex patency, adenoid hypertrophy
CT paranasal sinuses (coronal cuts)	Most accurate test / Preoperative planning	Defines bony vs. cartilaginous deviation, identifies concurrent sinusitis, delineates ostiomeatal complex anatomy
Cottle maneuver	Bedside functional test	Lateral traction on the cheek opens the nasal valve; symptomatic improvement suggests nasal valve collapse as a contributing factor
Acoustic rhinometry / Rhinomanometry	Objective measurement (rarely tested)	Quantifies nasal airway cross-sectional area and airflow resistance; used in research settings

Anterior rhinoscopy is the best initial step. Using a nasal speculum and headlight, the examiner can directly visualize the septum, identify the direction and location of the deviation, and inspect the mucosa for crusting, bleeding points, or polyps. This is sufficient to make the diagnosis in the majority of cases.

Nasal endoscopy with a flexible or rigid scope is the next step when the posterior nasal cavity needs evaluation, or when associated pathology (polyps, adenoid hypertrophy, tumors) must be excluded. It is particularly useful for identifying posterior deviations that anterior rhinoscopy may miss.

CT of the paranasal sinuses in coronal sections is the most accurate study and is considered the standard preoperative imaging. It provides a detailed map of the deviation (cartilaginous vs. bony component), identifies associated findings such as concha bullosa (pneumatized middle turbinate) that may contribute to obstruction, and evaluates the sinuses for concurrent disease. CT is not required to make the diagnosis but is essential before planning surgical correction.

The Cottle maneuver is a clinical pearl: if pulling the cheek laterally relieves obstruction, the problem may involve the nasal valve rather than (or in addition to) the septum itself. This distinction matters for surgical planning.

4. Management and Treatment

Setting	Treatment	Details
Asymptomatic	Observation	No intervention needed regardless of the degree of deviation
Mild symptoms	Medical therapy (trial)	Intranasal corticosteroid spray (e.g., fluticasone 50 mcg/spray, 1 to 2 sprays per nostril daily) to reduce mucosal inflammation; short-term topical decongestant (oxymetazoline 0.05%, max 3 to 5 days) for acute exacerbations; nasal saline irrigation
Moderate to severe / Failed medical therapy	Septoplasty	Definitive treatment; submucous resection and repositioning of deviated cartilage/bone; performed under general anesthesia; typically outpatient
Concurrent external deformity	Septorhinoplasty	Corrects both the internal septal deviation and the external nasal framework
Concurrent turbinate hypertrophy	Inferior turbinate reduction	Performed alongside septoplasty; methods include submucosal diathermy, partial turbinectomy, or radiofrequency ablation
Pediatric patients	Conservative management preferred	Surgery is generally deferred until nasal growth is complete (age 17 to 18 in males, 16 to 17 in females) to avoid disrupting septal growth centers, unless obstruction is severe

The first step in a patient presenting with unilateral nasal obstruction and a documented deviated septum is a trial of medical therapy. Intranasal corticosteroids (fluticasone or mometasone, one to two sprays per nostril once daily) reduce mucosal edema and may provide adequate symptom relief without surgery. Saline nasal irrigation is an effective adjunct. Topical decongestants such as oxymetazoline should be limited to 3 to 5 days maximum to avoid rhinitis medicamentosa (rebound nasal congestion from prolonged use), a commonly tested concept.

If medical therapy fails after an adequate trial (typically 4 to 6 weeks), the next best step is septoplasty. This is the definitive and most commonly tested surgical answer. The procedure involves elevating mucoperichondrial flaps, removing or reshaping the deviated portions of cartilage and bone, and replacing the straightened septum in the midline. Nasal packing or splints are placed postoperatively for 24 to 48 hours.

When the deviation is accompanied by external nasal deformity (cosmetic or functional), septorhinoplasty addresses both components simultaneously. If compensatory inferior turbinate hypertrophy is contributing to bilateral obstruction, turbinate reduction should be performed at the same time as septoplasty.

In children, surgery is avoided whenever possible because the septum contains active growth cartilage. Premature resection can lead to saddle nose deformity due to loss of dorsal support and impaired nasal growth. The exception is severe obstruction causing sleep-disordered breathing or failure to thrive, where benefits outweigh risks.

Contraindications to septoplasty include active cocaine use (causes septal perforation and poor healing), uncontrolled bleeding disorders, and granulomatous diseases affecting the septum (granulomatosis with polyangiitis, sarcoidosis) where the underlying condition must be treated first.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Allergic rhinitis	Bilateral or alternating nasal congestion, sneezing, rhinorrhea	Symptoms are bilateral and fluctuating; pale, boggy, edematous turbinates on exam; no structural septal deviation; responds to antihistamines
Nasal polyps	Chronic nasal obstruction, often unilateral initially; may coexist with deviation	Polyps appear as pale, glistening, pedunculated, insensate masses on rhinoscopy; associated with asthma and aspirin sensitivity (Samter triad)
Chronic rhinosinusitis	Nasal obstruction, facial pressure, purulent discharge	Symptoms include facial pain, postnasal drip, and purulent discharge; CT shows mucosal thickening or air-fluid levels in sinuses; may coexist with deviation but is a mucosal disease, not structural
Adenoid hypertrophy	Nasal obstruction in children, mouth breathing, snoring	Obstruction is posterior (nasopharyngeal) rather than anterior; lateral neck X-ray shows enlarged adenoids; most common in children aged 3 to 7
Concha bullosa	Unilateral nasal obstruction due to a structural cause	Pneumatized (air-filled) middle turbinate seen on CT; can mimic or coexist with septal deviation; identified on coronal CT
Nasal foreign body	Unilateral nasal obstruction, especially in a child	Unilateral, foul-smelling, purulent discharge; acute onset; visible foreign body on rhinoscopy
Nasopharyngeal angiofibroma	Unilateral nasal obstruction with epistaxis in an adolescent male	Vascular tumor presenting in adolescent males with recurrent, profuse epistaxis; CT/MRI shows enhancing mass in the nasopharynx; do not biopsy (risk of hemorrhage)

6. Traps and High-Yield Pearls

The most common way students lose points on this topic is by jumping straight to septoplasty when the question describes a patient with mild symptoms. The tested principle is that medical therapy (nasal corticosteroid spray and saline irrigation) should always be tried first unless the obstruction is severe or the question stem explicitly states failure of conservative treatment. Septoplasty is the answer only when medical management has been attempted and failed.

A second frequent trap involves compensatory turbinate hypertrophy. A vignette may describe bilateral nasal obstruction and the student dismisses septal deviation because "the obstruction is bilateral." Recognizing that the contralateral turbinate can hypertrophy in response to a unilateral deviation is the concept being tested.

Third, in pediatric patients, students often select surgery too quickly. The tested pearl is that septoplasty should be deferred until nasal growth is complete to protect septal growth centers, unless the clinical situation demands earlier intervention.

Finally, watch for the vignette describing an adolescent male with unilateral obstruction and epistaxis. Students may reflexively choose "deviated septum" as the answer, but the combination of adolescent male, unilateral obstruction, and recurrent profuse nosebleeds should raise concern for nasopharyngeal angiofibroma, where biopsy is contraindicated and imaging is the next step. The core competency being tested is the ability to distinguish a benign structural variant (deviated septum) from a vascular tumor that requires a completely different management approach.

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