CBD: Rhinitis

Clinical scenario

A 21-year-old man presented to his GP with blockage of his left nostril.  The airway on the right side is usually normal.  He cannot recall any trauma to his nose, and says that his problems came on gradually during his teenage years.  When he lies on his right side at night, he feels unable to breathe at all from his nose, which affects his sleep.  He denies any sneezing, itching, rhinorrhoea or hyposmia.  He has never had surgery.  He has no past medical history.  He has taken a nasal steroid spray which he purchased over the counter for about three months, but to no effect.

His GP examines him, identifying that his nose is externally straight, but there is a significant inferior deviation of the nasal septum to the left side, such that there is no view down the left nostril.  There is no evidence of rhinitis or perforation.

The patient is very bothered by his symptoms and would consider surgical intervention.  His GP refers him to an ENT surgeon, who performs a septoplasty.

Anatomy

The nasal septum divides the nasal cavity into left and right sides. It also has a significant role in supporting the nasal dorsum and tip.  It is lined on both sides by mucosa; anteriorly it is made of cartilage, and posteriorly wafer-thin bone.  Inferiorly the septum sits on the maxilla/hard palate, and superiorly it joins the skull base.  Deviations of the septum commonly involve both the cartilaginous and bony portions.

Pathology

It is unusual for the nasal septum to be perfectly straight.  Septal deviations often have no definable cause, but it is believed that some “congenital” deviations may be due to trivial childhood trauma, which leads to aberrant growth over time.  Since the nose grows significantly during puberty, it is common for patients to become aware of structural nasal problems during this time.  Deviations can also be the result of acute trauma later in life.

Clinical features

Because so many patients’ septums have a slight deviation, the key factor is the patient’s history.  Many patients will have another reason for nasal obstruction, with their septal deviation being incidental.  A septal deviation that is clinically significant should cause stable, unchanging, usually unilateral nasal obstruction.  A blockage that fluctuates or moves from side to side should alert you to an inflammatory component to the symptoms (rhinitis/chronic rhinosinusitis).  Bilateral nasal obstruction is rarely due to septal deviation.

Septal deviations are occasionally associated with lateral deviation of the external nose.  This may be congenital or traumatic.  In certain types of deviation, in particular where the nose is twisted to one side in its entirety leading to obstruction, it is necessary to perform a septorhinoplasty to straighten the entire nose and correct the airway obstruction.  

Management

History

·      Ask:

o   When did you first notice the blockage?

o   It is on one side?  Or does it affect both nostrils, or move from side to side?

o   Do you have nasal discharge, sneezing or itching?

o   Have you had any injuries or surgery to your nose?

Examination

·      Examine the nose from the outside and note any substantial deviation of the pyramid to one side.

·      Perform anterior rhinoscopy on the left and right nostrils, using an otoscope or Thudichum speculum if you have one.  Note the position of the nasal septum.  It may be deviated entirely to one side, or have an S-shaped deformity, or a sharp inferior spur sticking into one nasal cavity.

·      Also note whether there is erythema or oedema, or hypertrophy of the inferior turbinates suggestive of rhinitis.

If you suspect that there is co-existent rhinitis or chronic rhinosinusitis, treat this for a few months before considering whether the septal deviation is important.

If the patient has no evidence of inflammatory pathology, and has a unilateral nasal blockage with a congruent deviation of the septum to that side, consider referring them for an ENT outpatient review and potential septoplasty.  If the patient complains of problems with the appearance of the nose, explain that this would only be corrected if necessary to improve their ability to breathe through the nose. 

Septoplasty

Septoplasty is performed as day-case surgery.  The mucosa is elevated from the septal cartilage/bone via an incision just within the nasal cavity.  Deviated cartilage or bone is conservatively disarticulated, mobilised, cut or excised in order to reshape the septum, and the layers are then re-approximated with dissolvable sutures.

Patients can expect mild postoperative discomfort, congestion and blood-stained discharge for a week or more.  An important complication is septal haematoma: the patient presents in the days after the operation with bilateral nasal blockage, pain and occasionally fever.  The entire septum is swollen, boggys and compressible, usually filling both nasal cavities.  If you suspect a septal haematoma, speak to the on-call ENT team and send the patient to A&E immediately.

Author: Mr Thomas Jacques, Consultant Rhinologist/ENT Surgeon, St. George’s Hospital, London