Step 1 of 10
Presentation & Symptom Assessment
Obstruction (uni/bilateral, alternating) · epistaxis · sinusitis · snoring · contact-point headache · cosmetic
A deviated nasal septum presents most often with nasal obstruction — classically unilateral or worse on one side, sometimes alternating with the normal nasal cycle, and worse with mucosal triggers. Other presentations include recurrent epistaxis (typically from a convexity or spur where the mucosa is thin and dry), recurrent or unilateral sinusitis (when the deviation obstructs the osteomeatal complex), snoring and disturbed sleep, a contact-point headache (where a spur abuts the lateral wall), and cosmetic concern when the deviation is part of an external nasal deformity.
The essential first judgement is structural versus mucosal: nasal obstruction has many causes, and a deviated septum seen on examination is common and frequently asymptomatic, so the symptoms — their side, their triggers, and their response to decongestion — must be correlated with the structural finding before the deviation is blamed. The presentation defines what the patient actually wants fixed (airway, bleeding, sinus disease, sleep, or appearance), which in turn shapes the whole plan.
- Nasal obstruction — unilateral/worse one side, sometimes alternating with the nasal cycle
- Recurrent epistaxis (convexity/spur), recurrent/unilateral sinusitis, snoring, contact-point headache, cosmetic concern
- Septal deviation is common and often asymptomatic — correlate symptoms with the structural finding
- Define what the patient wants fixed — airway, bleeding, sinus disease, sleep, or appearance
★ High-yield pearls (chapter-wide)
- Septal deviation is extremely common and frequently asymptomatic — operate on the patient's symptoms, not on the CT or the endoscopic picture.
- Separate structural from mucosal obstruction before offering surgery — decongestion and the Cottle test tell you whether the deviation, the turbinates, or the nasal valve is the problem.
- A septal haematoma after trauma is a surgical emergency — drain it promptly, because an untreated haematoma becomes an abscess and destroys the cartilage, giving a saddle-nose deformity.
- A unilateral nasal mass is not 'just a deviation' — exclude a tumour before attributing one-sided obstruction to the septum.
- Medical therapy comes first — an intranasal steroid and allergy management treat the mucosal component, and septoplasty is offered only when a structural deviation still explains the symptoms.
- Septoplasty (with or without turbinate reduction) beats non-surgical management for the symptomatic deviated septum — the landmark randomised trial settled a long-standing debate.
- Preserve the L-strut — leave at least a 1–1.5 cm dorsal and caudal cartilaginous strut, or you risk saddling and tip ptosis; the strut, not the resected cartilage, holds the nose up.
- Address the turbinates and the nasal valve at the same sitting when they contribute — a perfect septoplasty fails if a hypertrophied inferior turbinate or a collapsing valve is left untreated.
- Caudal septal deviation is the hard one — straightening it needs dedicated techniques (swinging-door, scoring, batten or spreader grafts, suture fixation), not simple resection.
- Be cautious with the paediatric septum — conservative, growth-respecting septoplasty is reserved for significant functional deviation, because aggressive resection can disturb midface growth.
Evidence base
3 sources- HIGH
van Egmond MMHT et al. · Lancet · 2019RCTPMID 31227374
Landmark RCT confirming septoplasty (with or without turbinate reduction) is superior to non-surgical management for the deviated septum causing obstruction.
- HIGH
Stewart MG et al. · Otolaryngol Head Neck Surg · 2004Multicentre studyPMID 14990910
Development and validation of the NOSE score — the disease-specific patient-reported outcome measure for nasal obstruction.
- MOD
Rüzgar S & Tabaru A · Sci Prog · 2025Observational studyPMID 41442314
Relates nasal septal deviation types (Mladina classification) to operative findings — anchors deviation classification.
Decision tree
The triage screen is the first gate. Classification routes the stable patient to one of the aetiology-keyed pathways below. Cross-cut cards capture the chapter's must-not-miss rules.