Nasal steroids: a breath of fresh air for septal deviation?

The only certainty in life is change (and, of course, death and taxes, but I’ve just paid my tax bill and have survived to tell the tale…).

Medicine is constantly changing. As new insights is gained, we must continually update our knowledge and evolve our practice. 

Which brings us on to Arjun. He has a problem: he can’t breathe through his nose properly. Sure, it isn’t going to kill him, but it’s affecting his sleep and making him miserable. No, he doesn’t have allergies. Yes, he got pretty bashed up as a teenager doing martial arts. 

Examining his nose it does look a little wonky. When you get out your otoscope (or should that be nasoscope if using it on a nose?) you can see he has a deviated nasal septum.

Many of us would initially try a steroid nasal spray. It doesn’t necessarily feel like the optimum approach – surely that would be to correct the deviation – but the theory is that the blockage may be compounded by swelling of the epithelium which an anti-inflammatory spray may be able to reduce, and let’s be honest, it’ll take him 2 years to see ENT and they probably won’t operate anyway.

Is this the best approach? 

Unfortunately, no. Not according to a recent UK National Institute of Health and Care Research Alert. An operation is likely to be much more effective.

The data supporting this was published in the BMJ in 2023. In this UK-based pragmatic RCT, 378 adults newly referred with nasal obstruction associated with septal deviation and moderate or worse symptoms as a result received either septoplasty or medical management (saline nasal douching then nasal steroid spray twice daily) and had their SNOT-22 score checked at 6 months. (Possibly winning the prize for the best named questionnaire, the SNOT-22 is a patient-reported measure of symptoms relating to chronic rhinosinusitis but has also been used after septal surgery). 

SNOT-22 mean baseline score was 44 points (20-50 = moderately severe symptoms, max. score 110, higher = worse). Nasal saline and steroids reduced this to 40, not a clinically meaningful improvement, but septoplasty resulted in a substantial fall of 24 to 20 points, representing significant improvements in symptoms and quality of life. Patients with more severe symptoms tended to see the greatest improvements.

The authors concluded that septoplasty is “a superior treatment for nasal obstruction associated with septal deviation compared to nasal steroid and saline sprays” and that these patients should be offered surgery as treatment. 

As the linked editorial suggests this represents an opportunity to streamline patient pathways and optimise referrals. This would be welcome as waits for specialist ENT services are significant around the UK and septoplasty for deviation nasal septum is not even funded in many regions. Yet this data show the alternative - continuing with the status quo - offering patients an ineffective treatment in the community, prolonging patients morbidity and inevitably creating further work for ourselves. This is one of those areas which needs to change.

Which brings us back to the importance of research and life-long learning in medicine so that we as clinicians can adapt practice when appropriate and continue to offer the best service for our patients. 

In the changing world of general practice this is exactly the kind of case that could end up being seen by any member of our diverse primary care clinical community. If you are an Advanced Clinical Practitioner and looking to stay up-to-date, then our new Hot Topics Advanced Clinical Practice Update on the 15^th March is for you. Led by Natalie Kempshall, an Advanced Nurse Practitioner with 20 years of nursing experience, the course covers the Four Pillars of Advanced Practice with a wide range of clinical topics including interpretation of ECGs and common abnormal blood results.