Deviated Septum — Symptoms, Causes & Treatment | MyMedicPlus

A deviated septum is a structural abnormality of the nasal septum — the thin wall of bone and cartilage dividing the nasal cavity into left and right passages. When displaced off the midline, it narrows one or both nostrils and restricts airflow. Up to 80% of people have some degree of septal deviation, but only approximately 20% experience symptoms significant enough to affect quality of life or require medical attention. Septal deviation can be congenital (developing during fetal growth or birth trauma) or acquired (from nasal injury). Symptomatic deviation causes nasal obstruction, mouth breathing, sleep disturbance, and contributes to snoring and obstructive sleep apnoea in affected individuals. It is also a major predisposing factor for recurrent sinusitis by impairing drainage of the paranasal sinuses through the osteomeatal complex. Surgical correction — septoplasty — is one of the most commonly performed ENT procedures globally and provides durable improvement in nasal airflow.

Deviated nasal septum arises from two principal mechanisms. Congenital deviation occurs during fetal development or as a result of birth trauma — particularly in vertex deliveries where the nose is compressed against the maternal pelvis; studies suggest congenital deviation is identifiable in up to 20% of newborns. Developmental deviation: asymmetric growth of nasal cartilage and bone during adolescence can produce or worsen septal deviation even without trauma. Traumatic deviation (most commonly cited cause in adults): sports injuries (particularly contact sports — boxing, football, rugby, martial arts), falls, road traffic accidents, and nasal fractures. Any significant force applied to the nose can fracture the nasal bones and displace the septum from its vomerine groove. Risk factors include: participation in contact sports without adequate facial protection; history of prior nasal trauma or surgery (septoplasty, rhinoplasty — which may alter septal anatomy); and possibly a familial predisposition to asymmetric cartilage growth patterns.

Nasal obstruction is the cardinal symptom — typically worst on the side towards which the septum deviates and narrows the airway; in S-shaped deviations, both sides may be obstructed alternately. Recurrent epistaxis (nosebleeds): turbulent airflow over the deviated septum dries the mucosal surface, causing fragility and bleeding — most commonly from Kiesselbach's plexus (Little's area) on the anterior septum. Recurrent sinusitis: the deviated septum can obstruct the osteomeatal complex (the critical drainage site for the maxillary, frontal, and anterior ethmoid sinuses), predisposing to recurrent or chronic bacterial rhinosinusitis. Snoring and obstructive sleep apnoea: nasal obstruction forces mouth breathing during sleep, reducing upper airway calibre and increasing turbulence — septoplasty can significantly improve OSA severity in selected patients. Chronic mouth breathing (particularly problematic in children): dry mouth, altered dental arch development ('adenoid facies'), and recurrent pharyngitis. Hyposmia (reduced sense of smell) may occur from turbulent or reduced airflow past the olfactory cleft. Symptoms are frequently exacerbated by viral upper respiratory infections and allergic rhinitis, which cause mucosal oedema superimposed on already narrowed passages.

Diagnosis combines clinical history, physical examination, and selected imaging. History: pattern of nasal obstruction (unilateral, bilateral, or alternating), associated symptoms (epistaxis, sinusitis, snoring, anosmia), history of nasal trauma, and impact on quality of life. Anterior rhinoscopy using a nasal speculum and light provides a direct view of the anterior septum — identifying direction and severity of deviation, cartilaginous spurs (sharp ridges), and anterior turbinate hypertrophy. Nasal endoscopy (rigid or flexible, performed by ENT): superior visualisation of the posterior septum, posterior nasal cavity, and osteomeatal complex — essential before surgical planning to identify all contributing anatomical variants. CT scan of the paranasal sinuses (coronal and axial high-resolution): ordered when chronic sinusitis coexists, or as pre-operative planning to assess sinus anatomy and osteomeatal complex obstruction — also identifies concurrent pathology (nasal polyps, mucosal thickening). Nasal airflow can be objectively quantified by anterior active rhinomanometry (measures nasal resistance) or the NOSE questionnaire (validated patient-reported outcome measure) — useful for documenting severity, selecting candidates for surgery, and measuring post-operative improvement.

Management is stratified by symptom severity. Conservative (non-surgical) management for mild-moderate symptoms: intranasal corticosteroid sprays (mometasone furoate 200 mcg, fluticasone propionate 200 mcg — reduce mucosal inflammation and compensatory turbinate hypertrophy, improving effective airway calibre); nasal saline irrigation (hypertonic saline 2% twice daily — reduces mucosal swelling, clears secretions, reduces sinusitis frequency); antihistamines for co-existing allergic rhinitis; short-term topical decongestants (xylometazoline 0.1% — maximum 7 days to avoid rhinitis medicamentosa). Septoplasty: the definitive treatment for symptomatic deviated septum — an intranasal procedure (no external nasal incision) performed under general or local anaesthesia. The surgeon makes incisions inside the nasal cavity, elevates the mucoperichondrial flap, and removes or reshapes the deviated cartilage and bone. Performed as a day-case procedure; packs are removed at 24-48 hours; nasal splints remain for 7-10 days; patients avoid strenuous activity for 3-4 weeks. Turbinate reduction surgery (submucous diathermy, radiofrequency ablation, or outfracture) is frequently performed concurrently — compensatory hypertrophy of the inferior turbinate on the convex side of the deviation is almost universal and must be addressed for optimal airway improvement. Septorhinoplasty combines septoplasty with external nasal reshaping for patients seeking both functional and cosmetic improvement.

Untreated symptomatic deviated septum leads to progressive local and systemic complications. Chronic rhinosinusitis (CRS): osteomeatal complex obstruction increases susceptibility to bacterial sinusitis — affected individuals are 2-3x more likely to develop CRS, with mucosal thickening, polyp formation, and anosmia. Obstructive sleep apnoea (OSA): persistent nasal obstruction forces chronic mouth breathing, worsening upper airway collapse during sleep — contributing to excessive daytime somnolence, impaired concentration, hypertension, and cardiovascular risk. Chronic mouth breathing: causes dry mouth, halitosis, dental caries, gingivitis, and in children during growth — altered craniofacial development ('adenoid facies': elongated face, elevated palate, dental malocclusion). Epistaxis: turbulent airflow dries septal mucosa, causing recurrent nosebleeds from Little's area — may be difficult to control in severe cases. Eustachian tube dysfunction: impaired nasopharyngeal pressure regulation can cause middle ear effusion, conductive hearing loss, and recurrent otitis media. Surgical septoplasty complications (rare but important to discuss pre-operatively): septal haematoma (blood between mucosa and cartilage — requires urgent drainage to prevent avascular necrosis and saddle-nose deformity), septal perforation (1-2% — causes nasal crusting and whistling), over-resection causing saddle-nose deformity, and rarely CSF leak.

Traumatic septal deviation — the most common acquired cause — can be reduced with protective equipment: properly fitted helmets with face guards for contact sports (boxing, football, rugby, martial arts); seatbelts at all times in motor vehicles; and avoiding high-impact recreational activities without facial protection. After any nasal injury, prompt ENT assessment within 5-7 days allows closed reduction of displaced nasal fractures before bones set. For individuals with a deviated septum, proactive management of co-existing allergic rhinitis (intranasal corticosteroids, antihistamines, allergen immunotherapy) minimises mucosal swelling that exacerbates obstruction through the already narrowed passage. Daily nasal saline irrigation reduces sinusitis risk by maintaining mucosal clearance. Avoid prolonged use of topical decongestants (maximum 7 days) to prevent rhinitis medicamentosa (rebound congestion). Post-septoplasty recovery care: gentle nasal saline sprays from day 2, avoid nose-blowing for the first week, no strenuous exercise for 3-4 weeks, no contact sports for 6 weeks, attend all follow-up appointments for pack removal, splint removal, and endoscopic wound assessment.

See your GP if: one or both nostrils are persistently blocked causing significant difficulty breathing through the nose that is affecting your sleep, exercise tolerance, or quality of life; you are experiencing recurrent sinus infections (sinusitis) — more than three episodes per year — which may be related to impaired nasal drainage from septal deviation; you are snoring loudly or have been told you stop breathing during sleep (possible obstructive sleep apnoea, which a deviated septum can contribute to); and recurrent nosebleeds that are difficult to control. Go to A&E immediately for: a nasal injury (blow to the face, sports injury, accident) with significant swelling, deformity, or difficulty breathing — the nasal bones may be fractured and the septum may have developed a septal haematoma (blood between the septal cartilage and mucosa — appears as a boggy, bilateral bluish swelling in the nasal passages) which is a surgical emergency as it can cause septal cartilage necrosis ('saddle nose' deformity) within 24-48 hours if not drained; severe nosebleed that is not controlled after 20 minutes of pressure; and any nasal injury in a contact sports player with suspected fractured nose requiring ENT assessment within 5-7 days (optimal window for closed reduction of nasal fractures before bones set).