When Should I Worry About...

What Is a Deviated Septum & When Is Surgery Needed to Fix It?

Sep. 28, 2022 - Katie McCallum

There are a lot of reasons you might be struggling with nasal congestion, poor sleep or trouble breathing through your nose.

Could it be allergies? A sinus infection?

It might be something else entirely.

"A lot of people think long-lasting nasal symptoms are related to allergies or having bad sinuses," says Dr. Fred Bressler, an ear, nose and throat (ENT) doctor specializing in reconstructive surgery and facial plastic surgery at Houston Methodist. "It turns out that the No. 1 reason people have a stuffy or runny nose is actually nasal obstruction, and the No. 1 cause of nasal obstruction is a deviated septum."

That's why ENT experts like Dr. Bressler recommend seeing a specialist for chronic nasal issues. And if the cause of your symptoms is a deviated septum, an ENT can help there, too.

What is a deviated septum?

"The septum of the nose is the thin wall of bone, cartilage and tissue that separates our two nasal passages," explains Dr. Bressler. "When it's displaced or off-center, such that the nasal passages are uneven, we call that a deviated septum."

The septum can deviate on one side or the other, but it can also be uneven on both sides at different points — an S-shaped curvature of the septum, for instance.

Regardless of where it occurs or at how many points, any septal deviation can obstruct the nasal passage and lead to issues, especially if the septum is very crooked.

Deviated septum symptoms include:

  • Stuffy nose (on one or both sides)
  • Trouble breathing through the nose
  • Mouth breathing, especially noticeable during exercise
  • Trouble sleeping and snoring
  • Higher incidence of nosebleeds and nasal infections
  • Headaches
  • Poor sense of smell
  • Postnasal drip or runny nose

A chronically runny nose, in particular, is often mistaken for solely allergy problems — when, in fact, it's often a sign of a deviated septum.

"When the septum is deviated, the extra air received on one side can dry out the lining of the nose," explains Dr. Bressler. "Your body fights this by making more mucus, leading to a runny nose."

How do you know if you have a deviated septum?

A person can be born with a deviated septum, but a deviation can also occur as a result of trauma or injury, such as those suffered playing sports or in an automobile accident.

"Even if your nose didn't break, a contact injury can change the shape of the flexible cartilage that makes up the septum," explains Dr. Bressler. "Additionally, an injury can affect how the septum grows in the future. This is especially true for ones sustained during childhood, since both cartilage and bone are spongier and more easily manipulated in children."

Some deviations can be seen easily: One nostril can appear larger than the other, just looking at the bottom of the nose; or nasal passage unevenness is evident looking up the nose. But in many cases, deviations aren't so noticeable.

"What we see when we look at the nose is just the tip of the iceberg," says Dr. Bressler. "Your nasal cavity and nasal passages stretch back inward about three or four inches, to help direct air toward your lungs. A deviation anywhere in the septum can cause symptoms."

That's why the best course of action for those experiencing symptoms of a deviated septum is to consult an ENT doctor. These specialists have the tools needed to rule out or confirm whether the septum is deviated, as well as determine the severity if a diagnosis is made.

How is deviated septum treated?

How deviated septum symptoms are managed depends on the severity.

"A large part of the first consultation is determining whether the issue is mild and can be treated medically or if there is a serious structural issue that needs to be fixed surgically," says Dr. Bressler. "We collect a thorough history of the problem, document your symptoms, and then we begin our physical evaluation — using an endoscope and a headlight to view the septum, but also sometimes X-rays or CT scans."

Minor deviations that lead to only mild congestion or breathing issues can often be managed symptomatically — via nasal steroid sprays, decongestants or antihistamines. These medications don't fix the problem, though, and symptomatic treatment isn't always enough for some people.

Deviated septum surgery — also called septoplasty — is the only true fix for a deviated septum. It's an outpatient procedure that takes about an hour.

"During septoplasty, we put you to sleep and correct the structural problem(s) in the septum using traditional techniques or endoscopes, both using special surgical instruments," explains Dr. Bressler. "We enter through the inside of your nose, so there are no incisions on the outside of your nose."

This means that there are no physical signs anything was done to your nose after a septoplasty, though the inside of your nose will need time to recover.

"I think there are some old tales about how terrible this surgery is, but that's really not the case anymore with modern medicine," adds Dr. Bressler. "We don't break any bones. There's no cast on your nose. There is some discomfort and a period of recovery after the surgery, but the benefits and symptom improvement are significant."

When is deviated septum surgery necessary?

Many people with septal deviations find symptomatic relief via medications sufficient and don't require surgery. For that reason, treatment almost always begins with medical interventions.

But for people who have major structural issues or those don't respond to medications, surgery likely is needed.

"It only takes a few months to determine whether medications are going to be enough to treat a person's specific issue," explains Dr. Bressler. "And for patients really obstructed, sometimes we just cut right to the chase and recommend surgery — letting them know that, while we can try medications, severe foundational problems in the septum almost always require surgery to achieve symptom relief."

He adds that whether surgery is right for you doesn't just depend on the severity of your obstruction. It can also depend on how much relief you're hoping to get out of treatment — even if a deviation is only moderate.

"Your nose is a very essential part of your body and having chronic nasal issues can really impact your quality of life," says Dr. Bressler. "Much of the feedback I get from patients after surgery is related to how well they can breathe now, how much better they're sleeping or how their exercise has improved."

Another benefit to septoplasty is that it can be combined with other nasal procedures that might also be needed, or desired, such as:

  • Endoscopic sinus surgery
  • Turbinate surgery
  • Nasal valve repair surgery
  • DISE (an endoscopic procedure for sleep apnea)

"It can also be combined with rhinoplasty, a cosmetic surgery where we reshape the nose to improve its appearance," adds Dr. Bressler. "This is a very popular option for many patients. While it lengthens the duration of the surgery and adds cost, the recovery time is generally the same as septoplasty alone."

What to expect after deviated septum surgery

As an outpatient procedure, there's no overnight stay in the hospital after a septoplasty. There is still a recovery period, though — which starts at home later that day.

"You do need to rest and take it easy the first couple of days, but you don't have to be sitting in bed the whole time," says Dr. Bressler. "It can be uncomfortable, and most people take about a week off of work."

After the first week, your surgeon will periodically inspect the surgical area and clean your nose.

"You also need to avoid full-on exercising for a couple of weeks, and you can't blow your nose until your surgeon gives you the OK that everything has healed," Dr. Bressler adds.

Symptom relief can be noticed in as little as three to four weeks.

"And by three months, the improvements are night and day," says Dr. Bressler. "It's around this time when a lot of folks start tell me what a game changer this surgery was for them."

Executed properly, septoplasty comes with a very high rate of success. Dr. Bressler adds that the beauty of the surgery is that once the septum is fixed, it's almost always fixed for life.

In rare cases, though, the corrected cartilage can retain some structural memory and return to its crooked state. But while some septoplasties do have to be revised, Dr. Bressler adds that it's a very small percentage of cases.

"By far and away, the majority of the feedback I get is about how life-changing the procedure is for the person," explains Dr. Bressler. "They're sleeping better. Their exercise is better. Their partners aren't kept awake by their snoring anymore. The patient satisfaction is very high."

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