KISEP

Original Article

J Rhinol 14(1), 2007

New Description Method and Classification System

for Septal Deviation
Hong-Ryul Jin, MD1, Joo-Yun Lee, MD2 and Woo-Jin Jung, MD3
1

Department of Otorhinolaryngology, Seoul National University, College of Medicine, Boramae Hospital, Seoul; and
2
Hana Otorhinolaryngology Clinic, Cheongju; and
3
Department of Otolaryngology, Chungbuk National University Hospital, Cheongju, Korea

ABSTRACT
Background and ObjectivesThe purpose of this study is to develop an efficient method of description and a new classification system for septal deviations (SD) and to study the applicability of the new description method and classification system to a
clinical setting. Materials and MethodsSixty-five patients with nasal obstruction (symptomatic group) and thirty-five
patients without nasal obstruction (asymptomatic group) were included in this prospective study. The characteristics of SD
were analyzed according to the new description method based on the morphology, site, severity, and its influence on the
external nose. Based on these observations, four classification categories of SD were introduced: localized deviation (type I),
curved/angulated deviation (type II), curved/angulated deviation combined with type I (type III), and curved/angulated deviation with associated dorsal nasal deviation (type IV). The incidence of each type of SD was calculated. ResultsIn both
groups, all pathologies of the SD could be precisely described using the new description method. In both groups, the curved
deviation (type II) was the most common pathology. Anterior/mid was the most common site of deviation. In the symptomatic
group, moderate was the most common form of severity while mild was the most common form in the asymptomatic group.
In both groups, type II was the most common. Types III and IV were significantly more common in the symptomatic group
while type I was predominant in the asymptomatic group (p<0.05). ConclusionThe new description method provides a
precise descriptive term for SD. The proposed classification system is suitable for documentation and determination of the
severity of SD.
KEY WORDSNasal septumClassificationNasal septal deviationDescription.

INTRODUCTION
Deviation of the nasal septum has particular significance because it is involved in almost all rhinological problems to some degree. However, commonly used descriptions such as severe septal deviation to right or left
septal spur are based on subjective descriptors, and they
do not reflect the precise morphology and location of the
septal deviation (SD). Moreover, deviation of the nasal
dorsum, which is commonly combined with SD, is usually
not addressed together.
Procedures on SD can present a great challenge even for
Address correspondences and reprint requests to Hong-Ryul Jin,
M.D., Department of Otorhinolaryngology, Seoul National University, College of Medicine, Boramae Hospital, 425 Shindaebang-2 dong, Dongjak-gu, Seoul 156-707, Korea
Tel82-2-840-2412, Fax82-2-831-2826
E-mailhrjin@paran.com
Received for publication on August 7, 2006
Accepted for publication on December 14, 2006

experienced surgeons. The diversity of SD and variety of

correction methods contribute to this difficulty. This has
prompted many attempts to establish a classification system,
which has failed to acquire widespread acceptance. Thus,
the ambiguity in description still causes communication
difficulties between surgeons and, in combination with the
absence of an efficient classification system, poses difficulty in interpreting the clinical implication of the SD, and
provides no assistance in choice of surgical techniques.
The purposes of this study are twofold: first, to develop
an efficient method to describe the various pathologies of
SD and introduce a new classification system that provides
reproducible guidelines for the severity and correction of
SDsecond, to study the applicability of the new description method and classification system in a clinical setting.

27

MATERIALS AND METHODS

One hundred consecutive patients visiting our depart-

28 / J Rhinol 14(1), 2007

Fig. 1. Proposed descriptors for morphology of SD. Localized deviation (A), curved deviation (B) and angulated deviations (C, D) of
the septum.

ment for SD who were at least 16 years old were prospectively enrolled in the study for the application of the
new description method and classification system. Sixtyfive patients (MF=4.51, mean age=37 years) had
nasal obstruction (symptomatic group) and 35 patients
(MF=2.21, mean age=43 years) had no nasal obstruction (asymptomatic group). Patients who had chronic
nasal obstruction (more than four days a week for more
than three months) that impaired daily activities and did
not respond to medical treatment were considered to be
symptomatic. Patients with allergic rhinitis, nasal polyp,
tumor, chronic sinusitis, or other systemic diseases which
may cause nasal obstruction were excluded from the study.
Morphology, site, and severity were the key elements
in describing SD. Morphology was divided into 4 categories1) localized deviation-which includes spur (spine),
crest, and caudal dislocation (Fig. 1A)2) curved deviation-meaning convexity of the septum (Fig. 1B)3)
angulated deviation-including vertical or horizontal angulations (Fig. 1C, D)and 4) complex deviation-consisting
of more than one form of deviation.
The site of deviation was described in the three dimensions of horizontal (right, left), cephalocaudal (anterior,
central, posterior), and dorsoventral (high, mid, basal).
Anterior, central, and posterior were defined as the cartilaginous septum, the junction of bony and cartilaginous
septum, and the bony septum, respectively (Fig. 2). The
dorsoventral aspect was divided into high, mid, and low
portions in even thirds from the dorsum to the bottom
(Fig. 2).
The severity of deviation was determined after full shrinkage of the nasal cavity with 0.25% phenylephrine
spray. The severity was assigned into three grades by
measuring the distance of the most deviated portion in
reference to the imaginary midline and the corresponding
lateral nasal wall (Table 1).
We classified the various SDs into four types consider-

Fig. 2. Anatomic sites of SD in cephalocaudal (A) and dorsoventral (B) directions.

Table 1. Proposed descriptors for severity of SD
Type
Mild
Moderate
Severe

Description
Deviation less than half the total distance to the
lateral nasal wall
Deviation more than half the distance but less
than touching the lateral nasal wall
Deviation touching the lateral nasal wall

Table 2. Proposed classification system of SD

Type

Description

Localized deviation including spur (spine), crest,

caudal dislocation
Curved/angulated deviation without localized
deviation
Curved/angulated deviation with localized deviation

II
III
IV

Curved/angulated deviation with associated

external nasal deviation

ing the morphology of the deviation and the presence of

the dorsal nasal deviation associated with SD as shown in
Table 2. Presence of external nasal deviation was includeed in type IV deviation.
The differences between the two groups for site, morphology, severity, and type of SD were investigated. The
differences were statistically evaluated using SPSS 12.0

Jin et alDescription and Classification of Septal Deviation / 29

80

69

Symptomatic group

69

Symptomatic group
Asymptomatic group

40
20
0

*p<0.05

53

52

40
17

11

11

14

35

25

60

60

Asymptomatic group

22

20

13

0
Localized
deviation

Curved
deviation

Angulated
deviation

Complex
deviation

Fig. 3. The morphology of the septal deviation in the symptomatic and asymptomatic groups. In both groups, the curved
deviation was the most common form of septal deviation.
Complex deviation includes more than one form of deviation.

0
Mild

Dorsoventral

Asymptomatic

Anterior

80%

52%

Central

32%

42%

Posterior

06%

19%

High

38%

23%

Mid

86%

77%

Basal

23%

16%

*Each category is not mutually exclusive

(SPSS Inc., Chicago, IL). Chi-square test with a P-value

<.05 was considered statistically significant.

RESULTS
Curved deviation was the most common pathology
which comprised 69% of both the symptomatic and asymptomatic group. Angulated deviation was found in 17%
of the symptomatic group and 11% of the asymptomatic
group, while complex deviation was found in 14% and
9% in each group, respectively (Fig. 3). Localized deviation was absent in the symptomatic group but represented
11% of the asymptomatic group.
In the symptomatic group, the most common site of
deviation was anterior (80%) followed by central (32%)
and posterior (6%) in the cephalocaudal direction, and
mid (86%) followed by high (38%) and basal (23%) in
the dorsoventral direction. More than one site of deviation
was observed in the cephalocaudal and dorsoventral directions at 18% and 47%, respectively (Table 3).
In the asymptomatic group, the most common site of
obstruction was anterior (52%) followed by central (42%)
and posterior (19%) in the cephalocaudal direction and
mid (77%) followed by high (23%) and basal (16%) in
the dorsoventral direction. More than one site of deviation
was observed in 13% and 16% of the cephalocaudal and

77

80

*p<0.05
Symptomatic group

65

Asymptomatic group

60
%

Cephalocaudal

Symptomatic

Severe

Fig. 4. Severity of septal deviation in the symptomatic and asymptomatic groups. In each category of the severity, the differences between the two groups were significant (p<0.05).

Table 3. The site of SD in cephalocaudal and dorsoventral directions*

Site of deviation/Group

Moderate

40

*
20

11

0
Type I

20

15

Type II

Type III

6
Type III

Fig. 5. Types of septal deviation in the symptomatic and asymptomatic groups. In both groups, type II deviation was most common. Type III and IV deviations were significantly more common in the symptomatic group and type I deviation was significantly more common in the asymptomatic group (p<0.05).

dorsoventral directions, respectively (Table 3).

In the symptomatic group, moderate (53%) SD was
the most common category, followed by mild (25%) and
severe (22%). On the contrary, mild was the most common
category for the severity of SD (52%) followed by moderate (35%) and severe (13%) in the asymptomatic group.
In each category, the differences between the two groups
were statistically significant (p<0.05)(Fig. 4).
The frequencies of type II, type IV, and type III deviations in the symptomatic group were 65%, 20%, and 15%,
respectively. In the asymptomatic group, type II deviation
was most common (77%) followed by type I (11%),
type III (6%), and IV (6%) deviations. Type II deviation
was most common in both groups and type I deviation
was absent in the symptomatic group. Type III and IV deviations were significantly more common in the symptomatic group compared with the asymptomatic group while
type I deviation was significantly more common in the
asymptomatic group (p<0.05)(Fig. 5).

DISCUSSION
There has been many attempts to establish an efficient

30 / J Rhinol 14(1), 2007

classification system for SD.1-7) While these systems have

certain advantages, they also have many drawbacks. Some
include only the deviations of the cartilaginous septum1-3)
or do not consider the contribution of the septum to the
external nose.4) Another system classifies the shape of SD
only by convexity or concavity.5) Other systems are too
simple to include various pathologies6) or cannot be applied
to most patients because they are based on the CT findings
alone.7) The new classification system must include all
pathologies of SD, facilitate documentation, and assist teaching and communication yet still is a simple one. Furthermore, the system needs to reflect both functional and
aesthetic points of the septum and indicate surgical methods if possible.
Morphology of the SD, which we focused on in our
study, is an important factor for both description and
classification because surgeons consider it first. Almost
all morphological types of SD could be described precisely
and simply with our method. Among the various morphologies, curved and angulated deviations are major deformities and require differentiation from a didactic standpoint.
As the results show, curved deviation is the most frequent
form while angulated deviation is comparatively less common. Usually, trauma causes angulated deviation or septal
dislocation, while developmental deformities that occur
during puberty and result from asymmetrical fetal growth
are usually curved deviations.4)8)
In the description method, we considered the caudal
septal dislocation as a form of localized deformity. Others
have considered a caudal septal dislocation as a major
septal deformity because it is usually combined with another major septal or dorsal nasal deviation.1)6) In some
cases, however, a caudal septal dislocation is an isolated
and localized deformity not combined with any other septal or dorsal deviation of the nose. In our system, these
differences were addressed by including the caudal septal
dislocation in a category of localized deformity.
Multiple deviations like an S-shaped convexity-concavity deviation or a straight tilt could be effectively described
by combining the types and sites of the deviation. For
example, a cephalocaudal S-shaped deviation would be
described as a right convexity at the central and high
portions with a left convexity at the anterior and basal
portions. A straight tilt would be described as a left convexity at the anterior and high portion with a right caudal
dislocation.
One advantage of our description method is that the
exact location of the deviation can be accurately described
by dividing the septum into 9 portions according to the

cephalocaudal and dorsoventral directions. Given that the

most common site of obstruction in both groups were the
anterior and mid portions, it means that cartilaginous septum is the major site of deviation. The higher percentage
of anterior and high deviations including the nasal valve
area in the symptomatic group as compared with the asymptomatic group also matches well with the fact that
narrowing of the nasal valve area is the main cause of
nasal obstruction in SD.9)
While the applicability of our definition on the severity
of the SD has been verified useful by the statistically
significant different percentages of mild and severe forms
between the two groups, the fact that moderate and severe
forms comprise 48% of the asymptomatic SD indicates
the difficulty of correlating nasal symptoms with the severity of the SD. Many of the patients with SD have had
it for a long period of time and, although they do not
breathe well through the one side of the nasal cavity, they
may not realize their problems. It is for this reason that
being asymptomatic does not mean that there is no SD.
Septoplasty is performed for the following three reasons1) soley for functional improvement, 2) as part of
a complex operation with both functional and aesthetic
goals, and 3) as means to effect purely aesthetic changes
in the shape of the nose. Whatever the indications are,
proper classification enhances communication and greatly
affects the choice of surgical procedures for the SD,
which can be complicated even for experienced surgeons.
In designing the classification, the SD morphology and
the association between the SD and dorsal nasal deviation
were considered vital because these two help to differentiate the severity and the choice of surgical methods. Under
most circumstances, the severity of the SD and association
of the SD with the dorsal deviation dictates the surgical
method.1)10)11) Type I deviation can be corrected more
easily than other types. Type II or type III deviations pose
similar difficulties for surgical correction, while type IV
deviations require additional attention to the correction of
dorsal deviation. If no deviation of the cartilaginous dorsum
is present, then the septal correction can be done endonasally in most cases. If septal bowing extends into the nasal
dorsum as in type IV deviation, it is advisable to separate
the upper lateral cartilages from the dorsal septum to achieve an adequate correction. Since most type IV patients
in the symptomatic group had a deviated nose, they needed
septorhinoplasty instead of septoplasty alone. Type IV
deviations in the asymptomatic group had dorsal deviations but they were not as conspicuous as type IV deviations in the symptomatic group and the percentage was low.

Jin et alDescription and Classification of Septal Deviation / 31

CONCLUSION

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The new description method provides a precise description term for SD while it documents and determines the
severity of SD. The application of this system for guidance of septal surgery needs further study.
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