Nasal Obstruction
A deviated septum.
The septum is the wall of cartilage and bone that divides the nose into two passages. Few are perfectly straight, and most bends cause no trouble. When one narrows the airway enough to block breathing, it becomes a condition worth assessing properly, because congestion has many causes and not all of them are surgical.
General education only. Your diagnosis, options and coverage are individual, and are established at your consultation.
The Condition
What a deviated septum does, and doesn't do.
A deviated septum narrows one or both nasal passages. Sometimes the whole septum leans to one side; sometimes a ridge or spur of bone projects into the airway; sometimes the front, cartilaginous part is displaced after an injury. The nose still works, but with more effort, and the effort shows up as symptoms: breathing that is never quite free, a side that is always the worse one, congestion that intensifies when you lie down, mouth breathing, snoring, disturbed sleep, or sinus infections that keep returning because the drainage on the narrowed side is poor. Turbulent airflow across a bent segment can dry the lining and cause nosebleeds.
Two things a deviated septum does not do: it does not cause every blocked nose, and it does not need treatment just because it exists. A septum that looks bent on a scan but is not causing symptoms is a finding, not a disease. And congestion that comes and goes with the seasons, with allergies or with a cold is usually the lining swelling, not the wall behind it. The consultation exists to establish which is which, because the treatment for each is different.
The septum is also only one of three structures that can narrow the airway. The turbinates, the shelves of tissue on the side walls of the nose, swell and shrink with the nasal cycle, allergy and irritation; and the nasal valve, the narrowest part of the airway just inside the nostril, can collapse on breathing in. Very often more than one is involved, which is why an examination has to look at all three before anyone talks about an operation.
Symptoms that suggest the septum is involved
- One side of the nose that is persistently worse than the other
- Blocked breathing that does not clear with sprays or antihistamines
- Breathing that worsens lying down, mouth breathing at night, snoring
- Recurrent sinus infections on the same side
- Nosebleeds or crusting from one side
- A history of nasal injury, even a forgotten one in childhood
Having several of these does not confirm the diagnosis, and having few does not exclude it. The examination does that.
Why It Happens
Growth, injury, or both.
Most deviations develop as the nose grows: the septum's cartilage and bone grow at different rates and in a confined space, and a bend is the result. Others follow an injury, and the injury does not have to be memorable. A fall in childhood, a ball in the face, a sports collision years ago can displace the septum in a way that only becomes a problem as the adult airway takes its final shape. A deviated septum can also develop alongside a crooked external nose after a fracture, when the inside and the outside bend together.
None of this makes a deviated septum dangerous. It is a mechanical problem, and its consequences are the ones you can feel. What matters is whether it is the septum, the lining, the turbinates or the valve that is responsible for your symptoms, and in what proportion.
Common
Some degree of septal deviation is found in a large proportion of adults. Only a minority have symptoms from it.
Not progressive, usually
A deviation from growth is generally stable once growth is complete. Symptoms can still change over time as the lining and the turbinates change.
Often not alone
Enlarged turbinates, a weak nasal valve and inflammation of the lining frequently contribute alongside the septum.
Sprays don't straighten it
Intranasal corticosteroid and saline help the lining. They cannot move cartilage or bone, which is how the two causes are told apart.
Assessment First
How the airway is assessed.
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History
Which side, how long, what makes it worse, what has been tried, previous injuries and operations, sleep, and what you would like to be different.
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Examination
The outside and the inside of the nose, including the nasal valve on breathing in. Where indicated, nasal endoscopy, a thin camera passed into the nose after a topical spray, shows the septum, the turbinates and the sinus openings directly.
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Separating structure from swelling
Response to a trial of medical treatment for the lining, and examination after a decongestant spray, help establish how much of the blockage is fixed structure and how much is reversible swelling.
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Imaging, only if needed
A CT scan is not required to diagnose a deviated septum. It is ordered when chronic sinus disease is also suspected or when surgery on the sinuses may be planned.
Your Options
The options, with their trade-offs.
Set out side by side so you can weigh them yourself. Which of them fits your nose is established at consultation, and the decision is yours.
| Option | What it involves | Trade-offs to weigh |
|---|---|---|
| Leave it alone | No treatment. Reasonable when symptoms are mild, when the septum is not the main cause, or when you would simply rather not have surgery. | Nothing changes, and nothing is risked. You can return if your situation changes. |
| Medical treatment of the lining | Daily intranasal corticosteroid, saline irrigation, and treatment of allergy where it exists. Used first whenever the lining is contributing, and often continued afterwards. | Helps swelling, not structure. If the blockage is mostly the septum, sprays will improve things only partly, which is itself useful information. |
| Septoplasty, with turbinate reduction where indicated | Straightening the septum through the nostrils under general anesthesia, usually as day surgery, with no external incisions and no change to the outward shape of the nose. Generally OHIP-insured when medically indicated. | An operation, with an operation's risks: bleeding, infection, septal perforation, temporary numbness, and the possibility that obstruction persists or returns. Congested for the first weeks; breathing improves progressively after that. |
| Septorhinoplasty | When the septal deviation also bends the visible nose, or when you would like appearance addressed at the same time, the septum and the external nose are corrected in one operation. | Longer recovery and a staged result that refines over months. The breathing component is generally insured when medically indicated; the cosmetic component is not, and the two are separated clearly in writing. |
Nasal valve collapse, where it is the main problem, is addressed differently: with support of the valve rather than straightening of the septum. That distinction is made at consultation.
When not to wait
A blocked nose after an injury, with a new bend or with severe pain and swelling inside both nostrils, should be assessed within days, not weeks: a septal hematoma (a collection of blood inside the septum) needs draining promptly, and a displaced fracture is best repositioned within the first one to two weeks. Go to an emergency department for a suspected septal hematoma, uncontrolled bleeding, or clear watery drainage from the nose after a head injury.
Common Questions
Deviated Septum, answered plainly.
No. It is a mechanical narrowing of the airway, and its consequences are the ones you can feel: blocked breathing, poor sleep, recurrent infections on the narrowed side. It does not turn into anything else. The reason to treat it is quality of life, not danger, which is also why leaving it alone is a legitimate option when symptoms are mild.
No. Sprays reduce swelling of the lining, and if the lining is part of the problem they help; they cannot move cartilage or bone. A spray that helps only partly, or not at all, is one of the clues that the structure rather than the lining is responsible.
No. Septoplasty works entirely inside the nose. If the deviation is also bending the visible nose, or you would like appearance addressed at the same time, that becomes a septorhinoplasty, which is planned and priced differently and discussed openly at consultation.
It can contribute, and clearing the nasal airway sometimes improves snoring, but snoring and obstructive sleep apnea usually involve the throat as well as the nose. If sleep-disordered breathing is suspected, a sleep study may be arranged alongside the nasal assessment; septoplasty is not offered as a treatment for sleep apnea on its own.
Not to diagnose a deviated septum, which is seen directly on examination. A CT is ordered when chronic sinus disease is also suspected, or when sinus surgery may be planned, because then the scan changes the plan.
Septal surgery in children is approached cautiously because the septum is a growth centre of the face; it is generally reserved for significant obstruction and planned conservatively. Most childhood deviations are assessed and then reviewed as growth finishes.
Assessment first. Then the options are yours.
An OHIP-insured assessment begins with a referral from your physician or nurse practitioner. The office contacts you once it is received.