Endoscopic view of a high septal deviation.

Two patients came to the office with a high septal deviation that was associated with smell disturbance.

The first patient was a 47-year-old woman who complained of difficult nasal breathing, headaches, and intermittent anosmia associated with upper respiratory infections. A telescopic examination revealed an upper nasal airway obstruction that was caused by a marked superior deviation of the nasal septum on both sides and hypertrophy of the superior turbinates (figure, A). Computed tomography (CT) of the sinuses showed a marked pneumatization of the posterosuperior portion of the nasal septum, which was an anteroinferior extension of the sphenoid sinus. At surgery, the high septal deviation was found to be caused partly by a hyperpneumatization of the septum. The patient's smell sensation improved and her headaches resolved after an endoscopic surgical correction of her obstructive nasal septum.

The second patient was a 67-year-old man who complained of hyposmia, headaches, and nasal stuffiness associated with recurrent sinusitis. A telescopic examination revealed an almost total obstruction of the right upper nasal passage by a high septal deviation as well as an anteroinferior septal deformity (figure, B). He was also found to have a "compressed" polyp in the narrow space between the deviated septum and the supreme, superior, and middle turbinates. Septoplasty with an endoscopic excision of the high septal ridge and the sphenoethmoid recess polyps alleviated the patient's nasal obstruction, headaches, and smell disturbance.

High nasal cavity obstruction can be difficult to diagnose by endoscopy during an office examination because of limited accessibility. CT of the sinus is the most useful diagnostic tool for high septal deviation. Careful nasal endoscopy after nasal decongestion and topical anesthesia will confirm the diagnosis. The olfactory mucous membrane that contains the cells of origin of the olfactory nerve fibers is limited primarily to the region of the superior concha, a corresponding portion of the nasal septum, and the roof of the nasal cavity (the area of the cribriform plate). [1] Sufficient aeration to these areas might be hindered by the high septal deviation, its mucosal edema, or polyps in the superior nasal cavity, and can lead to an olfactory disturbance. These conditions might also obstruct the sphenoid sinus ostium and result in recurrent sphenoid sinusitis.

Effective treatment of the obstructive high septal deviation might require a careful endoscopic resection via the standard septoplasty approach and/or via an additional vertical septal incision just anterior to the obstruction. [2,3] The surgeon must take care to avoid an injury to the cribriform plate.

From the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven, Conn.; the Section of Otolaryngology, Hospital of St. Raphael, New Haven; and the Section of Otolaryngology, Yale University School of Medicine, New Haven.

References

(1.) Hollinshead WH. Anatomy for Surgeons. Vol. 1. The Head and Neck. 2nd ed. New York: Harper & Row, 1968.

(2.) Lanza DC, Rosin DF, Kennedy DW. Endoscopic septal spur resection. Am J Rhinol 1993;7:213-6.

(3.) Yanagisawa E. Atlas of Rhinoscopy: Endoscopic Sinonasal Anatomy and Pathology. Ch. 27. San Diego: Singular Publishing Group, 2000.