Deviated septum: symptoms, treatment and what causes it

The Glasgow and Clyde primary care guidance says people with a deviated septum typically have persistent blockage of one side of the nose, and often no other symptoms. Occasionally the septum takes a twisting course and both sides are blocked.

Newcastle Hospitals describes the situation as one nasal passage being narrower than the other, so it feels blocked. It says this can affect breathing, sleep or exercising.

Many people with a bent septum have no symptoms at all. A bend is not in itself a disease, and the Northern Care Alliance leaflet says most people (around 80%) do not have a completely straight septum.

A blocked nose has many causes. The Glasgow and Clyde guidance gives two useful pointers: blockage that changes through the day is unlikely to be due to septal deviation, and blockage that switches from side to side is more likely to be the normal nasal cycle.

In the nasal cycle, the turbinates (structures lining the inside of the nose) on one side swell for several hours and shrink when the other side swells instead. The same guidance says turbinate swelling is what the first-line sprays aim to reduce.

The Glasgow and Clyde guidance says all patients should have a trial of at least 6 weeks of saline nasal spray and a nasal steroid spray. This aims to minimise swelling of the turbinates and may give an adequate airway in some people, avoiding the need for referral.

If steroid sprays have failed, the guidance advises routine referral to ENT. Sussex says that if septal deformity is the cause of the blockage there is no other treatment than surgery; sprays and drops only treat swelling that might be making the nose feel blocked.

Septoplasty is the operation. It is usually done under general anaesthetic, takes about 30 to 45 minutes according to Sussex and about 45 minutes according to Northern Care Alliance, and most people go home the same day.

The Glasgow and Clyde guidance says some people have a developmental deviation, while for others it follows episodes of trauma that the person may not necessarily remember.

Sussex puts it similarly: the bend may be due to an injury to the nose, or the septum may just grow that way.

Newcastle Hospitals reports on the NAIROS trial, published in the BMJ. It involved 378 adults (average age 40; 67% men) with at least moderate symptoms of nasal obstruction linked to septal deviation. They were randomly given septoplasty (188 people) or nasal steroid and saline spray (190 people).

Symptoms were scored with the SNOT-22 questionnaire, where higher scores mean worse symptoms and a 9-point difference counts as clinically important.

The researchers recommended that adults with nasal obstruction associated with a deviated septum should be offered septoplasty. They also acknowledged that they did not diagnose or treat other possible causes of obstruction before randomisation.

A small cut is made inside the nose and the bent cartilage is removed or straightened. Sussex says small dissolvable stitches are left inside. Northern Care Alliance says the operation will not usually affect how the nose looks.

If combined with septorhinoplasty, which also changes the nasal bones, Sussex says it takes about 1 to 1.5 hours.

Before surgery you attend a pre-assessment clinic. Sussex describes MRSA screening, routine blood tests and a heart trace (ECG), and fasting instructions: nothing to eat for 6 hours and only clear fluids until 2 hours before.

Sussex adds that sometimes a bent septum is straightened to make room for other work such as sinus surgery.

Northern Care Alliance lists bleeding, soreness for a few weeks and rare infection. Uncommon complications include a hole in the septum, a change in the shape of the nose, numbness of the top teeth and upper lip, and a change in the sense of smell that may improve or sometimes be permanent.

Sussex says a hole in the septum can cause whistling, crusting or nosebleeds but usually causes no problems, and that it can be repaired. It also says a dip in the bridge of the nose is very rare.

For recovery, Northern Care Alliance says the nose may feel blocked for about 6 weeks, you should not blow it and should sneeze with your mouth open, and you should try to stay off work for 2 weeks. Sussex says at least a week off work and no heavy lifting or strenuous exercise for 2 weeks.

Northern Care Alliance recommends a shop-bought isotonic saline spray rather than home-made solutions after surgery.

See your GP if you have persistent one-sided blockage that does not settle. The NHS sinusitis page lists symptoms on only one side of the face as a reason a GP may refer to ENT, so do not assume a bent septum is the whole story.

The NHS nosebleed page says to see a GP for regular nosebleeds, and to go to A&E if a nosebleed lasts longer than 10 to 15 minutes, seems excessive, or comes with difficulty breathing. It advises not to drive yourself and to call 999 if you need an ambulance.

After septoplasty, Northern Care Alliance says to seek medical help if you notice a lot of fresh blood, and Sussex says to see a doctor if your nose is getting increasingly blocked or painful.

On the NHS the usual route is your GP, a trial of nasal sprays, then routine ENT referral if that fails. Local policies on funding septal surgery differ, so ask your GP what applies in your area.

Private ENT assessment and surgery are also available. Whichever route you use, it is reasonable to ask how the septum was confirmed as the main cause of blockage, because turbinate swelling and other nasal problems can contribute.