Deviated Septum — Causes, Symptoms & Treatment Guide — Symptoms, Causes & Treatment | MyMedicPlus

The nasal septum is the cartilaginous and bony partition dividing the nasal cavity into left and right airways. A deviated septum occurs when this partition is displaced off the midline — either to one side or in an S-shape — restricting airflow through one or both nasal passages. Approximately 80% of people have some degree of septal deviation, but only 20-30% have deviation severe enough to cause significant symptoms. The degree of functional impairment depends on the extent of deviation, the site (anterior deviations near the nasal valve are more symptomatic), and whether associated anatomical abnormalities are present (turbinate hypertrophy, nasal polyps). Deviated septum is one of the most common causes of nasal obstruction and is frequently encountered in ENT outpatient clinics. It may coexist with and exacerbate chronic rhinosinusitis and contribute to obstructive sleep apnoea.

Deviated septum may be congenital or acquired. Congenital deviation: may result from compression of the nose during delivery (particularly in vertex deliveries) or develop idiopathically during facial growth. The septal cartilage grows faster than the bony nasal framework in some individuals, buckling off-centre. Acquired deviation: the most common cause is nasal trauma — sports injuries, falls, road traffic accidents, or direct blows to the nose during childhood or adulthood (nasal fractures typically involve the septum). Even seemingly minor nasal trauma in childhood can cause progressive septal deviation as the cartilage continues to grow. Facial bones may also sustain trauma leading to septal displacement. Risk factors: male sex (more prone to nasal trauma), contact sports participation, history of nasal fractures, and racial anatomical variation in nasal architecture.

The most common symptom of a clinically significant deviated septum is persistent unilateral or bilateral nasal obstruction — often worse on one side, particularly when congested. Patients frequently notice alternating nasal obstruction (the 'nasal cycle' — normal alternating congestion of each nostril — becomes more pronounced). Other symptoms: recurrent sinusitis (impaired sinus drainage due to obstruction); mouth breathing (especially at night); nasal dryness, crusting, and epistaxis (nosebleeds) on the narrower side from turbulent airflow drying the mucosa; hyposmia (reduced sense of smell) from impaired olfactory airflow; snoring and sleep-disordered breathing (deviated septum contributes to upper airway obstruction); facial pressure and headache; and recurrent ear infections or Eustachian tube dysfunction from pressure changes. On nasal examination, the septum is clearly displaced to one or both sides.

Diagnosis is primarily clinical through anterior rhinoscopy (nasal examination with speculum and light or headlamp) revealing the deviated septum. Rigid nasal endoscopy provides superior visualisation of the posterior septum, turbinates, ostiomeatal complex, and any associated pathology (polyps, adenoids). Anterior rhinomanometry objectively measures nasal airway resistance — useful to quantify functional impairment and assess treatment response. CT sinuses (coronal sections, non-contrast): the gold standard for preoperative assessment — characterises the full three-dimensional anatomy of the septum, turbinates, and sinuses; identifies sinus disease (mucosal thickening, opacification) that might benefit from concurrent sinus surgery (FESS). Acoustic rhinometry: measures nasal cross-sectional area and volume — a research and specialist tool. Sleep study (polysomnography) if obstructive sleep apnoea is suspected as a coexisting condition.

Medical management for mild-moderate symptoms: intranasal corticosteroid sprays (mometasone, fluticasone) reduce mucosal inflammation and turbinate hypertrophy, improving airflow — may be sufficient for mild deviation. Nasal decongestant sprays (oxymetazoline) provide short-term relief during congested periods (maximum 5-7 days to avoid rhinitis medicamentosa — rebound congestion). Nasal saline irrigation (neti pot, squeeze bottle, or Neilmed) clears secretions and improves nasal hygiene. Nasal dilators (Breathe Right strips) improve external nasal valve patency and may reduce snoring — useful for athletes and sleep. Surgical correction — septoplasty: the definitive treatment for symptomatic deviation that does not respond to medical management. A submucosal resection of the deviated cartilage and bone straightens the septum under general or local anaesthesia (30-60 minutes); typically performed as a day case procedure with nasal splints for 7-10 days. Success rate 80-85% for symptom improvement. Septorhinoplasty combines septoplasty with external cosmetic reshaping of the nose. Turbinate reduction surgery (submucous diathermy, radiofrequency, outfracture) is frequently performed concurrently to address compensatory turbinate hypertrophy on the opposite side.

Significant untreated septal deviation can lead to a cascade of secondary complications. Chronic rhinosinusitis is the most common complication — septal deviation impairs mucociliary clearance and sinus drainage, making patients 2-3 times more susceptible to recurrent sinusitis compared to those with a straight septum. Obstructive sleep apnoea (OSA) is worsened by nasal obstruction — nasal resistance accounts for approximately 50% of total airway resistance, and severe nasal obstruction can trigger or aggravate OSA, increasing cardiovascular risk. Chronic mouth breathing (bypassing nasal humidification and filtration) causes pharyngeal and laryngeal dryness, increased susceptibility to upper respiratory tract infections, halitosis, and dental caries. In children, chronic mouth breathing from severe nasal obstruction can affect craniofacial development — causing adenoid facies (open mouth posture, narrow upper jaw, and dental malocclusion). Epistaxis (nosebleeds) results from turbulent airflow causing dryness and mucosal crusting on the convex side of the septum. Eustachian tube dysfunction from impaired nasal pressure regulation may contribute to otitis media with effusion ('glue ear') and conductive hearing loss.

Prevent acquired deviated septum by protecting the nose during contact sports — use appropriate helmets and face guards, and wear a nasal splint for contact sports during the 6-week healing period after any nasal injury or surgery. Seek prompt ENT assessment after significant nasal trauma — a traumatic septal haematoma (collection of blood between the perichondrium and cartilage causing rapid, bilateral, boggy swelling of the septum) is a surgical emergency requiring drainage within 24 hours to prevent avascular necrosis of the nasal cartilage and saddle-nose deformity. Manage chronic nasal inflammation (allergic rhinitis, chronic sinusitis) to minimise symptoms exacerbated by the septal deviation. Avoid extended use of nasal decongestant sprays — they can cause rebound mucosal swelling (rhinitis medicamentosa).

See a GP if you have persistent nasal obstruction significantly affecting your breathing, sleep quality, or quality of life. Request ENT referral if: symptoms do not respond to nasal corticosteroid sprays after 4-8 weeks, recurrent sinusitis is occurring (3 or more episodes annually), snoring is worsening, or there is concern about obstructive sleep apnoea. Seek immediate emergency care for: sudden severe nasal swelling after trauma (septal haematoma — must be drained within 24 hours), epistaxis (nosebleed) that cannot be controlled with first aid after 20-30 minutes of direct pressure, or nasal trauma associated with facial bone fractures. If unilateral nasal symptoms are progressive with blood-stained discharge or worsening obstruction despite treatment, urgent ENT assessment is needed to exclude nasal malignancy.