Nasal Septal Deviation: Clinical Guidelines

List of Abbreviations

PNS – paranasal sinuses

CT – computed tomography

Terms and Definitions

Xerostomia - dry mouth caused by reduced or absent saliva secretion.

Hyposmia - decreased olfactory function.

Anosmia - absence of olfactory function.

Apnea - cessation of breathing during sleep.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Nasal septal deviation – an anatomical change in the structure and position of the nasal septum relative to the midline, causing impaired nasal breathing. Synonyms – nasal septal deviation, crooked nasal septum.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Nasal septal deviation without a traumatic agent can form due to a developmental imbalance in the prenatal period, during passage through the birth canal, as well as during periods of active growth—when the tissues of the osteocartilaginous framework of the nasal septum grow faster than the bone tissue of the nasal vault and floor. Nasal septal deviation can also form as a result of trauma. Depending on the type and mechanism of trauma, nasal septal deviations can vary characteristically. An atraumatic etiology of deviation is typical for children [1,2,3].

1.3 Epidemiology of the Disease or Condition

Scientific research data on the prevalence of nasal septal deviation are very variable: from 15% to 20% in children and from 39.7% to 87.6% in adults [4,5].

1.4 Features of Coding the Disease or Condition

J34.2 – Deviated nasal septum

1.5 Classification of the disease or condition

Currently, there are many classifications of nasal septal deviations. The most common are the classifications of Cottle M., R. Mladina, A.S. Lopatin, and G.Z. Piskunov [6,7,8,9].

Due to unification, we recommend using the following classification:

1) C-shaped deviation;

2) S-shaped curvature;

3) Crest;

4) Dislocation of the quadrangular cartilage;

5) Thickening ("bump").

1.6 Clinical presentation of the disease or condition

Objectively, the clinical presentation of nasal septum deformity is characterized by the displacement of the nasal septum from the midline and alteration of its shape. The primary symptom is unilateral or bilateral nasal breathing difficulty. Concomitant symptoms that form the clinical syndromic complex of nasal septum deformity may include: hyposmia or anosmia, snoring, sleep apnea, xerostomia, dryness of the nasal mucosa, external nasal deformity, recurrent epistaxis, recurrent rhinosinusitis, posterior nasal drip, closed nasal speech (rhinolalia clausa), and recurrent tension-type headaches [10].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnostic criteria:

1) Patient complaints of persistent unilateral or bilateral nasal breathing impairment. Possible concomitant complaints are described above (see 1.6).

2) Physical examination findings: anterior rhinoscopy visually reveals nasal septum deviation and its displacement from the midline, altered intranasal anatomy due to the deformation of other intranasal structures, and subtotal or total nasal obstruction.

3) Instrumental examination data (endoscopic endonasal examination of the nasal cavity and nasopharynx, radiography of the paranasal sinuses, or spiral computed tomography of the paranasal sinuses) visualize the nasal septum deformity, as well as the potential resulting deformation of other intranasal structures.

2.1 Complaints and Anamnesis

The main complaint of patients with nasal septum deformity is persistent unilateral or bilateral nasal breathing impairment. A number of potential concomitant complaints are described in section 1.6. In young children who have not yet developed speech skills, the main manifestations of nasal breathing difficulty are assessed based on the report of a parent/guardian.

2.2 Physical Examination

Comments: during the otorhinolaryngologist's examination, anterior rhinoscopy is routinely performed. During anterior rhinoscopy, the following anatomical structures must be evaluated: the nasal septum and its position, and the condition of adjacent anatomical structures (inferior and middle nasal conchae, condition of the nasal mucosa).

2.3 Laboratory Diagnostics

Not indicated for initial diagnostics.

2.4 Instrumental Diagnostics

2.5 Other Procedures

Not indicated for initial diagnostics.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Surgical Treatment

Comments: a characteristic feature of the pediatric and adolescent age groups is the presence of active growth zones with elevated mitotic activity—the sphenodorsal and spheno-osteo growth zones. Therefore, in pediatric and adolescent patients, gentle-approach principles must be observed: minimal resection and tissue caution during pressure and mucosal detachment in the projection of growth zones. Excessive resection in the anterior parts of the nasal septum due to the supportive function of the anterosuperior region of the caudal nasal septum, as well as damage to the sphenodorsal and spheno-osteo zones, leads to deformities of the external nose and the middle third of the face. Endoscopic or microscopic techniques are advisable as methods of intraoperative visualization. Surgical treatment in children under 12 years of age can be performed in tertiary-level healthcare facilities.

For individual indications, in patients with severe deformity of the nasal septum and nasal bones, patients with pronounced caudal deviation of the septum, patients with upper nasal septum deformities, and in cases of high risks of an unsatisfactory result or incomplete correction of the nasal septum deformity during septoplasty, rhinoseptoplasty or rhinoseptoplasty using video-endoscopic technologies or other visualization methods is recommended. In such situations, it is necessary to establish interdisciplinary collaboration at all stages of diagnosis, surgical treatment, and rehabilitation of this category of patients in conjunction with a plastic surgeon [3,11,17,19,20,21,22,23,24,25,26,27,28].

3.2 Other Treatment

Comment: as medicinal products for improving nasal breathing in the postoperative period, the following drugs are acceptable for use: Xylometazoline** (ATX code: R01AA07), Xylometazoline in combination with other drugs (ATX code: R01AB Sympathomimetics in combination with other drugs, excluding corticosteroids), Phenylephrine (ATX code: R01AA04), Phenylephrine in combination with other drugs (ATX code: R01AB Sympathomimetics in combination with other drugs, excluding corticosteroids), Oxymetazoline (ATX code: R01AA05). Dosage and frequency of administration in adult and pediatric patients are carried out in accordance with the instructions. Nasal irrigation with saline solutions (ATX code: B05CB) or sterile seawater (ATX code: R01AX10) is recommended for all patients in the postoperative period to remove accumulations of fibrin, hemorrhagic, and serous discharge from the nasal passages [34,35,36,37].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comment: other drug groups may be used in the presence of individual indications.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not indicated.

5. Prevention and Dispensary Observation

Regarding the duration of dispensary follow-up and the frequency of postoperative examinations, there are currently no specifically formulated recommendations. Based on established clinical observation experience, it is advisable to conduct scheduled examinations during the first year after surgery.

Comments: general social measures for injury prevention include organizing safe leisure activities for children and adolescents, organizing safe road traffic, etc. Parents should be informed about the possibility of developing concomitant diseases and the need for timely surgical treatment of nasal septum deformity in children.

6. Organization of Medical Care

Indications for hospitalization in a medical organization:

Hospitalization is recommended for elective surgical treatment for persistent nasal breathing difficulty caused by nasal septum deformity confirmed by examination results: rhinoscopy, or endoscopic endonasal examination of the nasal cavity and nasopharynx, and radiography of the paranasal sinuses, or computed tomography of the paranasal sinuses and larynx.

Specific indications for hospitalization in pediatric age:

1) Persistent nasal breathing difficulty in a child, unilateral or bilateral, and/or presence of sleep apnea, unrelated to other causes, according to the report of the parent/guardian.

2) Nasal septum deformity confirmed by instrumental diagnostic methods (endoscopic endonasal revision of the nasal cavity and nasopharynx, and computed tomography of the paranasal sinuses and larynx).

3) Surgical treatment in children under 12 years of age may be performed in tertiary-level healthcare facilities within the medical care delivery system.

Indications for patient discharge from a medical organization:

1) Absence of purulent-inflammatory processes in the nasal cavity.

2) Absence of local and systemic complications.

7. Additional Information

None.

Criteria for Evaluating the Quality of Medical Care

Criteria for evaluating the quality of primary health care

Criteria for evaluating the quality of specialized medical care

References

Appendix A1. Working Group Composition

1. Yunusov A.S., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

2. Artyushkin S.A., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

3. Zyabkin I.V., MD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

4. Grachev N.S., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

5. Averbukh V.M., PhD, Associate Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

6. Ivoylov A.Y., MD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

7. Dzhamaludinov Y.A., MD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

8. Tovmasyan A.S., PhD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of these clinical guidelines:

1) general practitioners (family physicians);

2) otorhinolaryngologists;

3) otolaryngologist-audiologists;

4) pediatricians;

5) municipal (district) pediatricians;

6) district pediatricians;

7) emergency medical physicians;

8) senior physicians of emergency medical stations (departments);

9) internal medicine physicians;

10) adolescent medicine physicians;

11) district internal medicine physicians;

12) occupational health district internal medicine physicians;

13) ship doctors.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Levels of Evidence (LoE) grading scale for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)

Table 3. Grades of Recommendation (GoR) scale for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitation interventions)

Appendix A3. Reference Materials

1. These clinical guidelines were developed taking into account the following regulatory legal documents:

Procedure for the provision of medical care in the profile «otorhinolaryngology»: Order of the Ministry of Health of the Russian Federation No. 905n dated November 12, 2012, «On approval of the Procedure for the provision of medical care to the population in the profile „otorhinolaryngology“».

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Septoplasty or nasal septum plastic surgery is a surgical procedure to correct a deviated nasal septum. The nasal septum consists of a thin cartilaginous plate anteriorly and bone plates posteriorly.

Nasal breathing difficulty is not always caused solely by a deviated septum—there are numerous other potential causes of nasal obstruction. The necessity of a specific surgery to improve nasal breathing can only be determined by an otorhinolaryngologist.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

No.