Nasal Obstruction from a Nasal Septal Deflection

Christopher R. Savage and David B. Hom

History

A 35-year-old man presents to the clinic complaining of a 10-year history of left nasal blockage. He is not bothered by his nasal appearance. He has a small bony hump on his nose and an amorphous nasal tip. His lower nose is bent slightly to the left. He complains of persistent difficulty breathing through the left side of his nose. He does not have any environmental allergies. In the past, he has tried decongestants and nasal steroid sprays for 3 months given to him by his primary care physician without any benefit; he quit using these 6 months ago. He states that his goal with surgery is to improve his breathing on the left side. He denies any nasal trauma and previous nasal surgery. He is currently married and has been an electrician for the past 10 years. He does not smoke or have any nasal allergy symptoms. He does not currently use any over-the-counter intranasal decongestants and is taking no medications. He denies recurrent sinus infections.

On physical examination, his facial skin is moderately thick but not very oily. His chin appears to be in proper anatomic position. He has adequate nasal tip projection, and his nasal tip rotation is 95 degrees. The dorsum of his nose has a small dorsal bony hump at the rhinion and slight leftward deviation. The tip is not ptotic and recoils nicely on removal of fingertip pressure. The nasal tip appears widened and slightly bulbous. He has no alar retraction. Intranasal examination reveals pink mucosa and slightly hypertrophied left inferior turbinate. By visual inspection and palpation, the anterior septum deviates significantly to the left, almost touching the inferior turbinate anteriorly. Administration of topical decongestant slightly reduces the inferior turbinate size, but it does not significantly improve left nasal airflow. Lifting the internal and external nasal valves with cotton-tipped applicators only provides minimal improvement in airflow. Nasal endoscopy shows no intranasal polyps, synechiae, or adenoid hypertrophy.

Differential Diagnosis—Key Points

2. The patient is realistic about his goals and does not expect life-altering changes to occur.

3. It is important to inquire about other nasal surgeries or trauma to determine the expected amount of scar tissue and help with surgical planning.

4. The patient is a nonsmoker with no obvious environmental allergens contributing to his nasal obstruction.

Test Interpretation

The diagnosis is made almost exclusively on the basis of the history and physical examination. Laboratory or radiologic testing is of little benefit.

Diagnosis

Septonasal deflection causing nasal obstruction can be from congenital or acquired causes. Because the nose consists of several different structures (nasal bones, maxillary crest, upper and lower lateral cartilages, nasal septum, and turbinates), a deflection of any one of these components can lead to significant airflow problems.

The general areas of nasal obstruction are the external nasal valve (septum, lower lateral cartilage) and internal nasal valve (bordered by the upper lateral cartilage, nasal septum, pyriform aperture, and inferior turbinate).