Breathing problems and a deviated septum

The septum is the wall of bone and cartilage that divides the inside of your nose into two sides. In many people it is not perfectly straight. When it leans far enough to narrow one side of the nose, it is called a deviated septum. The American Society of Plastic Surgeons (ASPS) calls it “one of the most common causes of breathing impairment”.

This guide explains the symptoms, when surgery is considered, how the operation works, and how it relates to cosmetic rhinoplasty. If breathing is your main concern, it belongs in your first conversation with a surgeon.

What are the symptoms of a deviated septum?

A deviated septum can cause difficulty breathing through the nostrils, often worse on one side. Cleveland Clinic lists:

• nasal congestion and noisy breathing;
• nosebleeds;
• facial pain and headaches;
• loss of smell;
• snoring.

It also lists possible complications such as chronic sinusitis, sleep apnoea and a dry mouth. A severely deviated septum may make the nose look off-centre or the nostrils uneven. See crooked nose.

Many deviated septums cause no symptoms. Cleveland Clinic says most people with few or no symptoms do not need treatment.

What causes it?

Causes include being born with it or a difficult birth, growth that leans the septum to one side (the most common cause), and injury such as a broken nose. Cleveland Clinic lists car accidents, contact sports, falls, fights and inhaling substances such as cocaine as risk factors.

If you think you have broken your nose, Cleveland Clinic advises going to the nearest emergency room, and says not to try to push a deviated septum back into place.

How is it diagnosed?

A doctor diagnoses it by looking inside the nose with a nasal speculum. Cleveland Clinic says CT scans and nasal endoscopy may be used to see deeper tissue. StatPearls describes the same kinds of checks in a rhinoplasty assessment, including a test of the internal nasal valve and examination of the nostril walls when you breathe in.

When is surgery considered?

Surgery is considered when breathing problems or other bothersome symptoms persist. Cleveland Clinic says mild symptoms can be managed with over-the-counter antihistamines, nasal steroid sprays or decongestants, and that decongestant sprays should not be used for more than three days in a row because of rebound congestion. It also says septoplasty is the only way to correct the deviation. For children, surgery is usually delayed until the mid-teens, after the nose finishes growing.

Cleveland Clinic advises seeing a provider if symptoms interfere with breathing, disrupt sleep or affect other parts of your life.

Septoplasty or septorhinoplasty?

Septoplasty straightens the septum and does not change the outside of the nose, while septorhinoplasty also reshapes the nose. Cleveland Clinic describes septoplasty as reshaping the septum to address breathing problems, and rhinoplasty as reshaping the external appearance. A surgeon may combine the two if you want both. The operation is then called septorhinoplasty.

	Septoplasty	Septorhinoplasty
Goal	Improve breathing	Improve breathing and change the shape
Outside shape	Not changed	Changed
Duration (Cleveland Clinic)	About 30 to 90 minutes	Not given for the combined operation
Incision	Inside one side of the nose	Inside the nose, or also across the columella if open
Typical setting	Outpatient	Usually outpatient

Cleveland Clinic says septoplasty is usually done as outpatient surgery under general anaesthesia (local anaesthesia may be an option). The surgeon lifts the lining of the septum and reshapes the bone and cartilage. Splints, soft packing or dissolving stitches may be used.

If you want to change how your nose looks at the same time, read open rhinoplasty and closed rhinoplasty, which describe the external approach.

What is recovery like?

Initial recovery from septoplasty takes about one to two weeks, and full healing of bone and cartilage takes several months. Cleveland Clinic gives this timeline:

• gauze stays in until drainage stops, usually about two days;
• at about one week, a follow-up visit where any splints or packing are removed;
• one to two weeks of initial recovery, avoiding nose blowing and spicy foods;
• light activity such as walking from about one week;
• strenuous activity such as working out from about one month.

When rhinoplasty is combined, the outside of the nose follows the rhinoplasty timeline. MedlinePlus says the splint and any cast may stay on for one to two weeks, and Cleveland Clinic says breathing improvements after functional rhinoplasty are typically seen within up to six weeks. Read the recovery day by day guide.

What can go wrong?

The risks of septoplasty listed by Cleveland Clinic are infection, excessive bleeding, decreased sense of smell, scarring (usually not visible), a hole in the septum, septal haematoma (pooled blood in the septum), numbness of the nose and teeth (usually temporary), and, rarely, toxic shock syndrome and spinal fluid leak. See risks and complications for the general picture.

Breathing results are not guaranteed. In a single-centre study of 732 closed rhinoplasties, having a respiratory functional problem before surgery was the strongest functional factor linked to revision (adjusted odds ratio 3.30). That study was retrospective, so it shows an association, not a cause. It is a reason to ask your surgeon how they will treat your breathing, not only your appearance.

Which surgeon?

Both ENT surgeons and plastic surgeons perform nasal surgery. If breathing is the main problem, an ENT consultation is a natural first step. If shape is part of the goal, ask who will do the combined operation. Read plastic surgeon or ENT surgeon and how to verify a surgeon.

Next steps

If you want shape and breathing treated together, read septorhinoplasty. Then use questions to ask a clinic before you book.