Impact of Septal Deviation and Sinonasal Variations on Nasolacrimal Duct Obstruction in PANDO and Chronic Dacryocystitis: A CT-Based Study

Abstract

Objective

To assess the relationship between nasal septal deviation characteristics, sinonasal variations, and nasolacrimal duct (NLD) obstruction in primary Acquired Nasolacrimal Duct Obstruction (PANDO) and chronic dacryocystitis.

Methods

A total of 142 patients (48 PANDO, 46 chronic dacryocystitis, 48 controls) who underwent paranasal sinus computed tomography were included. Septal deviation characteristics and sinonasal variations were evaluated. Associations with NLD obstruction were analyzed using univariate and multivariate logistic regression.

Results

The septal deviation was significantly associated with NLD obstruction (p = 0.005). Multivariate analysis identified a higher classification of Mladina (OR = 1.37, 95% CI = 1.10–1.71; p = 0.006) and a lower coronal deviation (OR = 1.73, 95% CI = 1.00–2.99; p = 0.049) as independent predictors. Other deviation parameters and sinonasal variations were not independently associated with laterality or severity obstruction. In deviation-positive patients, morphological features did not predict the obstruction side.

Conclusions

Inferior septal deviation and higher Mladina scores showed independent associations with NLD obstruction; however, the general contribution of septal morphology appears limited. These findings may have implications for preoperative evaluation and surgical planning in patients with PANDO and chronic dacryocystitis.

Keywords

PANDO nasolacrimal duct obstruction septal deviation computed tomography dacryocystitis

Introduction

Primary acquired nasolacrimal duct obstruction (PANDO) is a common cause of epiphora in adults and predominantly affects women, representing a common clinical problem encountered by both ophthalmologists and otolaryngologists. The etiological factors associated with PANDO remain unclear and the condition is generally considered idiopathic.^1,2 The pathophysiology of PANDO is believed to involve obstruction of the nasolacrimal duct (NLD) leading to inflammation and subsequent fibrosis.^1,3 Obstruction of the NLD can lead to chronic dacryocystitis, characterized by recurrent medial canthal inflammation and mucopurulent discharge.^4-6 Treatment options include initial medical management followed by surgery or direct endoscopic dacryocystorhinostomy.^7,8 The distal NLD opens into the inferior nasal meatus, creating a close anatomical relationship with intranasal structures. This anatomical proximity may facilitate obstruction through altered airflow, mucosal interactions, or local inflammation, supporting the hypothesis of ascending inflammation of PANDO.⁹

Most previous studies have focused on the mere presence of septal deviation rather than its morphological characteristics. Consequently, it remains unclear whether specific deviation patterns contribute to NLD obstruction or whether the association is driven simply by the existence of the deviation. To address this gap, the present study was designed to evaluate the septal morphology in patients with septal deviation and to investigate the potential role of deviation characteristics and associated sinonasal variations in the development of PANDO and chronic dacryocystitis.

Patients and Methods

This retrospective study was conducted in the Departments of Otolaryngology and Ophthalmology. This study was approved by our hospital ethics committee (approval: 03.12.2025, number: 2025/23-14). Informed consent was not required due to the retrospective design. The study did not involve direct contact with participants and all data were analyzed anonymously in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines.

Patient Selection

Patients diagnosed with PANDO or chronic dacryocystitis in the ophthalmology department were referred to the otolaryngology department for nasal evaluation and paranasal sinus computed tomography (PSCT). Three groups were included: PANDO (n = 48; 12 man, 36 females; mean age 48.9 ± 8.6 years), chronic dacryocystitis (n = 46; 6 man, 40 females; mean age 47.7 ± 17.6 years) and control (n = 48; 13 man, 35 females; mean age 42.1 ± 8.6 years). Control subjects had a septal deviation but no history of NLD obstruction to assess the independent effect of septal deviation.

Exclusion criteria were previous nasal or paranasal sinus surgery, sinus tumors or destructive lesions, and congenital sinonasal abnormalities affecting septal or turbinate anatomy.

The control group was intentionally composed of individuals with septal deviation but without NLD obstruction to isolate the effect of the septal morphology regardless of presence the deviation. This design was chosen to minimize the confounding associated with the high prevalence of septal deviation in the general population and to specifically investigate whether particular deviation patterns are associated with obstruction.

Clinical Evaluation

The septal deviation was assessed using PSCT and nasal endoscopy. The side of deviation was identified by drawing a midline from the spina nasalis anterior to the crista galli in the coronal plane and determining the direction of the septal curvature relative to the nasal midline. The deviated side was defined as the convex side of the septum, and deviation was classified as right or left, and the location of the deviation was defined as anterior, posterior, or anteroposterior. Morphology was classified according to the Mladina¹⁰ classification (Types 1–7).

PSCT Evaluation

Bony anatomical variations, including agger nasi cells, paradoxical middle turbinates, concha bullosas, the location of sinusitis and sinus pathologies were evaluated using PSCT. The location of sinusitis was classified as ethmoid sinusitis, frontal sinusitis, maxillary sinusitis, or pansinusitis. Sinus pathologies were classified as partial sinus opacification, total sinus opacification, maxillary cyst, maxillary sinus septation, and hypoplastic maxillary sinus. Lesions with mucosal thickening greater than 5 mm that did not completely fill the maxillary sinus were classified as partial opacification, while complete filling of the sinus cavity was defined as total opacification.

The coronal septal deviation was measured on the PSCT slice showing the maximum curvature. It was calculated as: (Distance from the septal apex to the point of maximum deviation/total septal height) × 100. In the coronal plane, the length from the crista galli to the anterior nasal spine was measured as the total height of the septum.

The axial septal deviation was measured on the axial slice that demonstrates the greatest deviation: (Distance from the anterior septal border to the most deviated point/total septal length) × 100. In the axial plane at the lowest level of the nasal septum, the distance from the most anterior point to the most posterior point of the septum was measured and recorded as the total length of the septum.

The coronal and axial septal deviations were categorized into four classes: Class 1 (0–24%), Class 2 (25–49%), Class 3 (50–74%), and Class 4 (75–100%). Although expressed as percentage values, the classes of coronal and axial deviation primarily reflect the vertical and anteroposterior level of septal deviation rather than its absolute severity. In the coronal plane, lower percentage values correspond to deviations located closer to the upper septum. In the axial plane, low percentage values reflect more anterior deviations.

Statistical Analysis

Statistical analyzes were performed using SPSS Version 23. Descriptive data were presented as mean ± SD or median (IQR) for continuous variables and as frequencies (%) for categorical variables. According to the Shapiro–Wilk test, most variables did not show a normal distribution (p < 0.05). Group comparisons used the chi-square (χ²), Fisher’s exact, or Mann–Whitney U tests, as appropriate. Logistic regression analyzes were performed to identify variables independently associated with NLD obstruction. A two-sided p-value < 0.05 was considered statistically significant. Variables with p < 0.10 in the univariate analysis were entered into the multivariate logistic regression model. Due to the retrospective design, no a priori sample size calculation was performed. A post hoc power analysis indicated 88–91% power to detect clinically relevant differences.

Results

Characteristics of Septal Deviation

In the PANDO group (n = 48), the septal deviation was on the right side in 47.9% of the patients, left side in 37.5% of the patients, and absent in 14.6% of the patients. In the chronic dacryocystitis group (n = 46), the deviations were on the right side in 50.0% of the patients, left side in 34.7% of the patients, and absent in 15.3% of the patients. All control patients (n = 48) had septal deviation (54.2% right, 45.8% left).

The location of the septal deviation varied among the study groups. In PANDO, the deviations were anterior in 8.3%, posterior in 25.0%, and anteroposterior in 52.0%. Chronic dacryocystitis showed 17.3% anterior, 34.7% posterior, and 32.6% anteroposterior deviations. The controls had 12.5% anterior, 27.0% posterior and 60.4% anteroposterior deviations.

The distribution of Mladina classification was comparable between groups, with Type 3 predominating in all cohorts (PANDO 45.8%, chronic dacryocystitis 43.4% and controls 45.8%). Other sinonasal findings, including agger nasi, concha bullosa, paradoxical middle turbinate, and location of sinusitis, are summarized in Tables 1 and 2. The predominance of the Type 3 deviation across all groups likely reflects its high prevalence in the general population, which may limit its discriminative value in assessing disease-specific associations.

Table 1.

Table Summarizing Septal Deviation (Presence, Side, and Location), Coronal and Axial Classes, Sinonasal Variations (Agger Nasi Cells, Nasal Polyps, Paradoxical Middle Turbinate, Concha Bullosa), and Sinusitis Location in the Overall Study

		Group	PANDO	Control	Chronic dacryocystitis
Gender		Male	12	13	6	0.208*
Gender		Female	36	35	40	0.208*
Presence of deviation		Present	41	48	39	0.009 *
Presence of deviation		None	7	0	7	0.009 *
Location of deviation		None	7	0	7	0.023 *
		Anterior	4	6	8
		Posterior	12	13	16
		Anteroposterior	25	39	15
Deviation side		None	7	0	7	0.046 *
		Right	23	26	23
		Left	18	22	16
Right side agger nasi		Present	31	37	35	0.315*
Right side agger nasi		None	17	11	11	0.315*
Left side agger nasi		Present	29	34	34	0.335*
Left side agger nasi		None	19	14	12	0.335*
Right side nasal polyp		Present	1	1	3	0.449**
Right side nasal polyp		None	47	47	43	0.449**
Left side nasal polyp		Present	0	0	3	0.032 **
Left side nasal polyp		None	48	48	43	0.032 **
Right side paradoxical middle turbinate		Present	7	4	9	0.292*
Right side paradoxical middle turbinate		None	41	44	37	0.292*
Left side paradoxical middle turbinate		Present	9	2	5	0.077*
Left side paradoxical middle turbinate		None	39	46	41	0.077*
Right side concha bullosa		Present	13	21	14	0.190*
Right side concha bullosa		None	35	27	32	0.190*
Left side concha bullosa		Present	14	21	14	0.252*
Left side concha bullosa		None	34	27	32	0.252*
Location of sinusitis	None	Present	22	23	14	0.231**
	None	None	26	25	32
	Ethmoid sinus	Present	3	3	1
	Ethmoid sinus	None	45	45	45
	Frontal sinus	Present	1	0	0
	Frontal sinus	None	47	48	46
	Maxillary sinus	Present	22	20	29
	Maxillary sinus	None	26	28	15
	Pansinusitis	Present	0	2	2
	Pansinusitis	None	48	46	44
The coronal location of the septal deviation		None	7	0	7	0.019 **
		2	6	2	4
		3	23	35	28
		4	12	11	7
The axial location of the septal deviation		None	7	0	7	0.085**
		1	0	1	1
		2	16	18	17
		3	24	26	19
		4	1	3	2

*Pearson chi-square test.

**Fisher exact test.

Table 2.

Table of Sinus Pathology in PANDO, Chronic Dacryocystitis and Control Groups, in Left and Right Side in Overall Study

	Side	Group	None	Partial opacification	Total opacification	Maxillary cyst	Maxillary sinus septation	Hypoplastic maxillary sinus	p*
Sinus Pathology	Right	PANDO	24	8	4	3	6	3	0.583
		Control	28	11	0	2	3	4
		Chronic Dacryocystitis	19	11	3	2	6	5
	Left	PANDO	32	5	2	2	5	2	0.633
		Control	26	12	1	2	4	3
		Chronic Dacryocystitis	24	10	3	2	2	5

*Fisher exact test.

Association Between Septal Deviation and NLD Obstruction

In the overall analysis of the study, the presence of septal deviation was significantly associated with NLD obstruction (χ² = 12.79, p = 0.005). Ipsilateral deviation was correlated with unilateral obstruction (χ² = 17.64, p = 0.007), while bilateral obstruction was more frequent in patients without deviation. The location of deviation and the coronal class were also associated with obstruction (χ² = 22.05, p = 0.009; Monte Carlo p = 0.012). The axial class and the Mladina subtype showed weaker associations (p = 0.019 and p = 0.018, respectively).

In patients with deviation-positive only (n = 126), none of the morphological parameters (including the deviation side, location, coronal or axial class, or Mladina type) independently predicted the laterality or severity of the obstruction (all p > 0.1), suggesting that the presence of baseline deviation, rather than detailed morphology, primarily influenced obstruction.

Comparisons Between Groups

In the overall analysis of the study, the direction of the deviation differed significantly between the groups (χ² = 9.71, p = 0.046); however, this was attributable to the absence of deviation in the control group. After restricting the analysis to deviation-positive patients (n = 126), the deviation direction no longer differed (χ² = 0.202, p = 0.904), indicating that baseline deviation status accounted for the initial finding (Table 1).

The location of the deviation also differed in the overall study (p = 0.023), mainly due to a higher frequency of anteroposterior deviations in controls and a lower frequency than expected in chronic dacryocystitis. This difference was not maintained in deviation-positive patients (χ² = 5.257, p = 0.262). The coronal deviation class showed a similar pattern, with significance in the overall study (χ² = 12.787, p = 0.047; Cramer’s V = 0.212), but not after restriction (p = 0.309). The axial deviation class did not differ significantly in either analysis (overall study: χ² = 10.136, p = 0.256; restricted: p = 0.904). The classification distribution of Mladina was comparable between groups (Pearson χ² = 17.8, p = 0.122; Fisher’s exact p = 0.055), with Type 3 predominating (Table 1).

Among sinonasal variables, no significant differences between groups were observed except for left nasal polyps (χ² = 6.396, p = 0.032), detected in a small subset of patients with chronic dacryocystitis (Table 1). Pairwise analyzes did not show differences between PANDO and chronic dacryocystitis in septal morphology or sinonasal variables. Compared to controls, both groups of patient differed in septal deviation presence and selected classification parameters in the overall study analyses; however, these differences were not maintained after restricting themselves to cases with deviation positive.

Sinonasal Findings and Septal Deviation

As shown in Table 2, sinus pathology (including partial or total opacification, maxillary cyst, septation, and hypoplastic maxillary sinus) did not differ significantly between PANDO, chronic dacryocystitis, and control groups on either side (p > 0.05, Fisher’s exact test). In terms of septal deviation, both the PANDO and chronic dacryocystitis groups showed a higher prevalence of deviation compared to controls, with significant differences in Mladina classification (Table 3, p = 0.001) and the presence of deviation (p = 0.002). No significant differences were observed between PANDO and chronic dacryocystitis on the deviation side or location (p > 0.05).

Table 3.

Comparison of Mladina Class, Septal Deviation (Presence, Location, Side, Coronal and Axial Class), Sinonasal Variations (Agger Nasi, Paradoxical Middle Turbinate, Concha Bullosa), Sinus Pathology, and Sinusitis Location Between PANDO, Chronic Dacryocystitis, and Control Groups in Overall Study

	Side	PANDO mean rank	Control mean rank	p*	Control mean rank	Chronic dacryocystitis mean rank	p*	PANDO mean rank	Chronic dacryocystitis mean rank	p*
Mladina’s class		39.88	57.13	0.001	54.67	40.02	0.006	46.35	48.70	0.662
Presence of deviation		53.00	44.00	0.002	44.00	51.15	0.005	48.31	46.65	0.650
Location of deviation		43.93	53.07	0.076	55.36	39.29	0.002	50.27	44.61	0.289
Deviation side		43.56	53.44	0.053	51.94	42.87	0.070	47.09	47.92	0.872
Agger nasi	Right	51.50	45.50	0.180	47.27	47.74	0.910	50.15	44.74	0.225
Agger nasi	Left	51.00	46.00	0.285	48.21	46.76	0.740	50.60	44.26	0.166
Location of sinusitis		48.64	48.36	0.958	44.32	50.82	0.196	44.41	50.73	0.205
Sinus Pathology	Right	51.02	45.98	0.331	43.07	52.12	0.083	45.55	49.53	0.454
Sinus Pathology	Left	46.19	50.81	0.355	46.63	48.41	0.728	44.56	50.57	0.228
Paradoxical middle turbinate	Right	47.00	50.00	0.339	50.08	44.80	0.117	48.65	46.30	0.523
Paradoxical middle turbinate	Left	45.00	52.00	0.026	49.04	45.89	0.218	45.69	49.39	0.286
Concha bullosa	Right	52.50	44.50	0.089	44.44	50.70	0.184	48.27	46.70	0.721
Concha bullosa	Left	52.00	45.00	0.140	44.44	50.70	0.184	47.79	47.20	0.894
The coronal location of the septal deviation		44.59	52.41	0.116	52.84	41.92	0.020	48.74	46.21	0.621
The axial location of the septal deviation		44.80	52.20	0.149	52.34	42.45	0.055	48.70	46.25	0.639

*p value shows the results of Mann–Whitney U Test results.

Regarding sinonasal variations, the agger nasi and concha bullosa did not show significant differences (p > 0.05). Paradoxical middle turbinate was not different on the right side (p = 0.339) but was significantly more frequent on the left in PANDO compared to controls (Table 3, p = 0.026). The location of the coronal deviation differed between controls and chronic dacryocystitis (p = 0.020), while the axial location and distribution of sinusitis were similar between groups (p > 0.05).

Multivariate Analysis

The forward stepwise logistic regression identified the classification Mladina (OR = 1.37, 95% CI 1.10 to 1.71, p = 0.006) and the coronal deviation class (OR = 1.73, 95% CI 1.00 to2.99, p = 0.049) as independent predictors of NLD obstruction. The model explained 15.9% of the variance (Nagelkerke R² = 0.159) and correctly classified 68.3% of the cases, with high sensitivity (92.6%) but low specificity (20.8%). The modest explanatory power of the model suggests that additional unmeasured factors may contribute to the obstruction of NLD. Other variables, including the axial class direction of the deviation, and the overall deviation, were not independently predictive.

Discussion

Previous studies have demonstrated an association between PANDO and intranasal anatomical variations; however, the specific contribution of septal morphology to NLD obstruction remains unclear.^2,3,11-15 Several anatomical and inflammatory mechanisms have been proposed to explain the relationship between septal deviation and NLD obstruction; however, the specific contribution of septal morphology remains poorly defined. In the present study, septal deviation was associated with NLD obstruction in the overall analysis; however, this association was not observed when analyzes were restricted to patients with deviation positive, suggesting that the presence of deviation rather than its morphology primarily drives this relationship.

Multivariate analysis identified the Mladina score and inferior coronal deviation as independent predictors, whereas other morphological parameters were not significant. The lack of consistent laterality patterns and the presence of bilateral obstruction even in patients without septal deviation suggest that septal deviation alone is insufficient to explain obstruction patterns and should not be considered a primary determinant.

An important methodological consideration of this study is the absence of a control group without septal deviation. However, this was intentional, as the primary objective was not to evaluate the effect of the mere presence of deviation, but rather to investigate whether specific morphological characteristics influence the obstruction of the NLD. Given the high prevalence of septal deviation in the general population, including nondeviated controls might have predominantly reflected differences related to the presence of deviation rather than its morphology. Therefore, this study design allowed for a more focused evaluation of clinically relevant anatomical variations.

Although the overall analysis of the study suggested associations between specific deviation patterns (for example, Mladina Class 4, coronal Class 4) and obstruction of NLD, these associations were not observed in the deviation-positive only analyses. In deviation-positive patients, no specific deviation subtype demonstrated a consistent association with obstruction laterality, indicating the limited clinical utility of detailed septal classification to predict the involvement of NLD. The lack of variability in Mladina classification, with Type 3 predominating across groups, may further explain the limited discriminatory capacity of septal morphology to predict obstruction patterns.

These findings suggest that altered intranasal airflow dynamics and mucosal factors, rather than structural deviation alone, may contribute to the development of PANDO and NLD obstruction. This highlights the potential importance of functional nasal evaluation in addition to anatomical evaluation. This hypothesis is supported by recent evidence demonstrating altered internal nasal valve angles and reduced peak nasal inspiratory flow in patients with PANDO.¹⁶ Septal deviation may alter normal nasal airflow patterns and local pressure dynamics, particularly in the region of the inferior meatus where the nasolacrimal duct opens. This disruption could affect lacrimal drainage through changes in the mucosal environment and aerodynamics, suggesting a potential functional contribution to obstruction of NLD.

In acquired dacryocystitis, obstruction occurs most frequently in the distal segment of the nasolacrimal system. The proximity of nasal and paranasal sinus pathology to this anatomical region often contributes to the pathogenesis of dacryocystitis.² Mauriello et al.¹⁷ found that the pathology of the lacrimal sac and nasal mucosa in complete obstruction of the NLD was similar to that of the NLD. They suggested that nasal inflammation may have originated from dacryocystitis or, alternatively, may have contributed to the dacryocystitis.¹⁷ This suggests that inflammatory changes may be bidirectional rather than purely causal. Our results showed that in chronic dacryocystitis, septal deviation was significantly less frequent than in controls, particularly in terms of presence, Mladina classification, and deviation location. In contrast, other sinonasal variations, including concha bullosa, agger nasi cells, and sinusitis patterns, were not significantly associated, suggesting a limited independent role of these factors.

Deviations located in the inferior (coronal) and middle (axial) segments, in close proximity to the inferior meatus, are more likely to alter lacrimal drainage. This finding may be clinically relevant during preoperative evaluation, particularly in patients considered for dacryocystorhinostomy. Although the deviation side was not statistically significant, the association with deviation location indicates that spatial configuration may be more important than simple right–left laterality. This supports the concept that narrowing near the inferior nasal passage could facilitate tear stasis and predispose to chronic infection. Overall, sinonasal anatomical variations did not demonstrate an independent association with PANDO or chronic dacryocystitis, suggesting a limited role in isolation.

Under normal circumstances, the the lacrimal sac mucosa exhibits a high resistance to infection. However, distal obstruction of the NLD can lead to sac infection and dacryocystitis.^5,6 Previous studies have reported conflicting findings about the relationship between sinonasal inflammation and NLD obstruction. Although some authors demonstrated increased osteomeatal or ethmoidal involvement, others found no independent association.^2,3,14,18,19 Consistent with some previous reports, they found no independent association between sinonasal inflammatory disease and obstruction of NLD. Although the spread of inflammatory from the sinonasal region has been proposed as a contributing factor, their findings suggest that it is more likely a secondary or modifying process rather than a primary cause.^13,18 Borges Dinis et al.¹⁸ found no correlation between adjacent sinonasal inflammation and chronic NLD obstruction, while other studies indicate that such inflammation may contribute to NLD obstruction in acute dacryocystitis.²⁰ Structural enlargement of the NLD and lacrimal sac fossa has been reported in congenital obstruction of NLD, particularly in cases with chronic dacryocystitis, and suggesting a role for infectious factors in addition to elevated hydrostatic pressure.²¹ No significant association was identified between sinus pathologies or maxillary sinus variations and PANDO or chronic dacryocystitis. Nasal polyps were detected in only a small number of patients with dacryocystitis. While they may contribute to NLD obstruction through localized mechanical narrowing or inflammatory effects, the limited number of cases prevents definitive conclusions. These findings suggest that concomitant sinonasal inflammatory disease and common anatomical variations do not demonstrate a clear independent relationship with PANDO or chronic dacryocystitis in our study. Localized nasal anatomy can create a predisposition to impaired drainage, while sinonasal inflammation appears to function more as a modifying or secondary factor rather than a primary cause.

These findings argue against a purely mechanical compression model and instead support a multifactorial mechanism involving airflow alteration, mucosal susceptibility, and distal obstruction. Septal deviation may act as a structural modifier influencing airflow and mucosal environment, with obstruction likely resulting from multifactorial interactions between distal NLD blockage, mucosal susceptibility, and altered intranasal airflow.

Although septal deviation has been investigated as a potential contributing factor to NLD obstruction in previous studies, its presence alone should not be considered a reliable predictor of NLD obstruction or its laterality, as obstruction is also frequently observed in patients without septal deviation. Accordingly, detailed septal morphology appears to have limited additional value in risk stratification, and a more comprehensive evaluation, including evalution of distal obstruction and, when feasible, functional analysis of nasal airflow may provide more meaningful clinical insight.

The present findings have direct implications for the surgical management of patients undergoing dacryocystorhinostomy (DCR). Previous studies have reported that causes of DCR failure include septal deviation, incomplete removal of the lacrimal bone, and postoperative complications such as synechia, granulation tissue formation, membrane formation, and cicatricial closure at the rhinostomy site.²² In this context, septal deviation has traditionally been considered a potential technical obstacle, primarily due to its proximity to the surgical field.

However, septal deviation may still play a relevant role in the surgical setting. Septoplasty is frequently performed during endoscopic DCR primarily to improve surgical access and visualization rather than to correct nasal obstruction symptoms.²³ Importantly, current evidence indicates that concomitant septoplasty does not negatively affect surgical outcomes, with combined procedures demonstrating success and complication rates comparable to endoscopic DCR alone.²⁴ The present findings highlight the importance of preoperative nasal evaluation in patients undergoing DCR. Septal deviation is frequently encountered in patients with NLD obstruction and although our results do not support a strong role for septal morphology in predicting obstruction patterns, its presence may still have relevant surgical implications. In particular, the assessment of septal deviation that may interfere with endoscopic access during endoscopic DCR is clinically important for optimal surgical exposure and instrumentation.

In addition, evaluation of adjacent intranasal anatomical variations is essential to minimize technical difficulties and postoperative complications. Structures such as paradoxical middle turbinates and other turbinate abnormalities may contribute to limited surgical access and may increase the risk of postoperative edema, adhesions, and synechiae formation, potentially affecting surgical success. Although sinonasal inflammatory pathologies were not independently associated with NLD obstruction in our study, localized conditions such as nasal polyposis should be considered, as they may contribute to impaired drainage and recurrent inflammatory processes in selected patients.

Furthermore, in both external and endoscopic DCR procedures, unrecognized intranasal anatomical variations may increase the risk of intraoperative mucosal trauma, which can lead to complications such as epistaxis and postoperative scarring. Therefore, a comprehensive preoperative evaluation is recommended using both nasal endoscopy and computed tomography to identify relevant anatomical factors that can influence surgical planning and intraoperative management.

From a clinical perspective, these findings suggest that septal morphology alone should not be used to predict the presence, laterality, or severity of NLD obstruction. Instead, attention should be focused on inferior septal deviations that can interfere with surgical access and contribute to local airflow alterations. Therefore, routine septal classification alone is unlikely to alter clinical decision-making in patients with NLD obstruction.

In general, these findings emphasize the value of a multidisciplinary approach that includes both ophthalmology and otolaryngology in the preoperative evalution of patients with PANDO and chronic dacryocystitis. This collaboration may improve patient selection, optimize surgical strategy, and potentially improve postoperative outcomes.

The limitations of this study include its retrospective design, relatively small sample size, and reliance on static imaging without functional airflow assessment. The absence of microbiological data and longitudinal follow-up further limits the causal interpretation.

Conclusion

The septal deviation is associated with NLD obstruction at the group level; however, its detailed morphological characteristics do not reliably predict obstruction patterns. Only a higher Mladina classification and an inferior coronal deviation showed limited independent associations.

These findings support a multifactorial pathophysiology in which septal deviation can act as a modifying factor rather than a primary cause. Clinically, the septal evaluation should focus primarily on its possible impact on surgical access during dacryocystorhinostomy rather than its role as a predictive marker of obstruction.

Footnotes

ORCID iD

Oğuzhan DİKİCİ

Ethical Considerations

The study was approved by the Ethics Committee of Bursa City Hospital on 03.12.2025, no: 2025/23-14. As this was a retrospective study, informed consent was not required.

Author Contributions

Oğuzhan DİKİCİ, M.D.: Literature survey, design, planning, data collection, intellectual review of the results, writing, approval of the final manuscript.

Mehmet Emin ASLANCI, M.D.: Literature survey, design, planning, data collection, intellectual review of the results, approval of the final manuscript.

İsmail Alkan, M.D.: Data collection, intellectual review of the results, approval of the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and/or analysed during the present study are available from the corresponding author upon request.*

Appendix

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