More than 60% of the adult population is estimated to suffer from a deviated nasal septum according to certain reports [1], but the clinical presentation varies depending on the location and severity of nasal septum deviation. Individuals may often be asymptomatic, but the most common signs include epistaxis, increased nasal crusting, altered nasal respiration and the necessity for mouth breathing due to obstruction of the nasal canal, and chronic or recurrent sinusitis, which is frequently encountered among patients in whom deviation causes obstruction of the ostium of the paranasal sinus [2] [3] [4]. Repetitive sneezing, snoring and sleep apnea are also reported, while less common symptoms include facial pain, variable loss of olfaction and headaches [3]. Recent trauma to the nose and face is the key risk factor for deviation, but congenital causes may be responsible as well. Neonates and infants commonly develop deviation of the nasal septum due to trauma during vaginal delivery [2], and in this population, poor feeding and choking due to the presence of food in the respiratory tract are reported in the case of a severe deviation, in addition to nasal obstruction and epistaxis [2]. Various anatomical anomalies, such as increased anterior facial height, mandible with increased overjet and constricted transverse maxillary dimension and a retrognathic maxilla have been documented in patients suffering from nasal septum deviation [4].

• Snoring

  Some patients had associated pre-operative symptoms of snoring (57.3%), headache (48.0%), rhinorrhoea (38.7%), sneezing (30.7%), hyposmia (30.7%) and epistaxis (21.3%). [ncbi.nlm.nih.gov]

  […] mostly without their knowledge.[1] Signs and symptoms[edit] Only more severe cases of a deviated septum will cause symptoms of difficulty breathing and require treatment.[1] Symptoms of a deviated septum include infections of the sinus and sleep apnea, snoring [en.wikipedia.org]

  A deviated nasal septum can cause sinus infections, sleep apnea, snoring, sneezing attacks, facial pain, nosebleeds, breathing difficulties and a slight to serious loss of sense of smell. [respifacile.com]

  A severely deviated nasal septum can block one side of your nose and reduce airflow, which can cause difficulty breathing, snoring, recurrent sinus infections, crusting or nosebleeds. [ent-sd.com]

  Having enlarged turbinates can lead to difficulty breathing, a blocked nose, snoring, and a tendency to get repeated sinus infections. [thelondonclinic.co.uk]

• Excessive Sneezing

  The incidence of excessive sneezing in this study is 15% and these patients were also having allergic rhinitis. The study made by Haytham Kubba, Brian J.G. showed an incidence of 12% sneezing [11]. Thickened septum is seen in 3% of cases. Table 1. [file.scirp.org]

• Mitral Valve Prolapse

  Mitral valve prolapse (MVP) is a characteristic of generalized collagen abnormality. Nasal septum (NS) is constituted by osseous and cartilaginous septums that are highly rich in collagen. [ncbi.nlm.nih.gov]

• Mouth Breathing

  Other symptoms of a deviated septum include nasal drainage, nosebleeds, mouth breathing, and facial pressure. A crooked or deviated septum is not usually caused by an injury. [nw-ent.com]

  A deviated septum and swelling of the intranasal tissues can negatively affect a patient’s quality of sleep and can lead to dry mouth due to chronic mouth breathing. [pacificneuroscienceinstitute.org]

  If the blockage is severe, it may force mouth-breathing at night, which can worsen sleep disorders. [entnet.org]

  Discussion Septal deviation can cause symptoms such as nasal obstruction, mouth breathing with variable symptoms such as headache and olfactory disorders. [ncbi.nlm.nih.gov]

  Chronic mouth breathing may worsen snoring or lead to dry mouth and/or sore throat. Usually nasal obstruction is worse on a particular side but may vary from side to side due to other factors, such as colds or allergies. [entallergy1.com]

• Bony Swelling

  The turbinates are bony swellings on the outer walls of the nasal cavities. Both the nasal septum and turbinates are covered with a delicate mucosal tissue that regularly swells to control airflow in the nose. [nycfacemd.com]

• Epistaxis

  Some patients had associated pre-operative symptoms of snoring (57.3%), headache (48.0%), rhinorrhoea (38.7%), sneezing (30.7%), hyposmia (30.7%) and epistaxis (21.3%). [ncbi.nlm.nih.gov]

  Symptomatic patients can present with unilateral nasal obstruction or less commonly epistaxis, obstructive sinusitis, and/or pain/pressure symptoms 4. Etiology Nasal septum deviation can be congenital or acquired. [radiopaedia.org]

  It may also predispose to repeated epistaxis from the vessels stretched on its convex surface. 5. Thickening of Nasal Septum It may be due to organized haematoma or overriding of dislocated septal cartilage fragments. 4. [slideshare.net]

  This obstruction may predispose the patient to sinusitis, infection and epistaxis (nose bleeds). Treatment Treatment of a deviated septum is based on the patient's symptoms. [healthcentral.com]

The diagnosis rests on suspecting a deviated nasal septum based on signs and symptoms that are reported by the patient, which is why a detailed patient history can often provide sufficient clues to develop clinical suspicion. Information about recent trauma, chronicity of symptoms, as well as their severity, can be helpful. A thorough physical examination comprised of a full ear, nose, and throat evaluation should follow, and anterior rhinoscopy or nasal endoscopy can confirm the diagnosis, as they provide a direct view into the nasal cavity [2]. Additional procedures have been proposed in the workup, including acoustic rhinometry (evaluation of the nasal cavity by means of acoustic reflection), rhinomanometry (a procedure that measures the resistance of the nasal cavity) and nasal spectral sound analysis, but their specificity and sensitivity remain to be solidified in regular practice [2]. More advanced imaging studies, such as computed tomography (CT), may be useful for preoperative assessment and determination of potential anatomical anomalies, but they are not superior to the standard physical examination when it comes to detecting a deviated nasal septum [5].

• Lymphocytic Infiltrate

  This study determined significantly higher rate of squamous metaplasia and lymphocytic infiltration in septal mucosa on concave side when compared with convex side. [ncbi.nlm.nih.gov]

1. Mohebbi A, Ahmadi A, Etemadi M, Safdarian M, Ghourchian S. An epidemiologic study of factors associated with nasal septum deviation by computed tomography scan: a cross sectional study. BMC Ear, Nose, and Throat Disord. 2012;12:15.
2. Aziz T, Biron VL, Ansari K, Flores-Mir C. Measurement tools for the diagnosis of nasal septal deviation: a systematic review. J Otolaryngol Head Neck Surg. 2014;43(1):11.
3. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
4. Aziz T, Biron VL, Ansari K, Flores-Mir C. Measurement tools for the diagnosis of nasal septal deviation: a systematic review. J Otolaryngol Head Neck Surg. 2014;43(1):11.
5. Sedaghat AR, Kieff DA, Bergmark RW, Cunnane ME, Busaba NY. Radiographic evaluation of nasal septal deviation from computed tomography correlates poorly with physical exam findings. Int Forum Allergy Rhinol. 2015;5(3):258-262.