A thorough rhinologic history is of fundamental importance when evaluating any patient with a suspected sinonasal problem. This is especially important in the context of a septal deviation, as symptoms may not always match the findings on physical examination. In fact, this may be the biggest pitfall in performing septoplasty: The presence of a septal deviation is not an absolute indication for surgical correction. Documenting the history carefully will allow the surgeon to identify the patient who will benefit from septal surgery. To this end, the first determination is whether patients are being evaluated for nasal airway symptoms or are there other concurrent sinonasal problems as well. If nasal obstruction is the primary concern, the side of obstruction, timing, and severity should be clearly elicited. The ideal candidate for septoplasty should have obstructive symptoms that parallel the side of the deviation. Issues of nasal congestion can be tricky, as this can reflect the dynamic and reactive nature of the nasal mucosa, something that is not addressed with surgery. In this regard, many patients will undergo a trial of conservative measures such as nasal steroid sprays prior to the consideration of septoplasty. Similarly, any suspected environmental allergies should be properly evaluated and treated.

Many patients with a septal deviation may not have any significant obstructive symptoms. Instead, they may be under investigation for other rhinologic issues, including epistaxis, chronic rhinosinusitis, or a skull base tumor. While a deviated septum can be a contributing factor in the etiology of epistaxis or obstruction of the osteomeatal complex, this anatomical finding may be incidental on physical examination. Nonetheless, the septum may still need to be treated surgically as it may prevent adequate endonasal access to the paranasal sinuses or the skull base.

Finally, patients should also be asked if they are seeking a consultation for any external/cosmetic changes to the nose. If so, it is preferable to correct a deviated septum during a formal septorhinoplasty approach (not discussed in this chapter). It is also important to ascertain if there is any history of prior nasal surgery, recreational nasal drug use, or a history of autoimmune conditions.