Nasal obstruction and deviated septum
The question is not whether your septum is crooked, because in most people it is. The question is what is blocking the air: the cartilage and bone, swollen lining of the nose, or both. The examination tells them apart in the same visit, and that decides whether the answer is medication or surgery.
Why does one side of my nose block up, then the other?
This is the first thing that confuses patients, and there is a normal explanation. The lining of the 2 sides of the nose does not swell at the same time. It alternates in a cycle every few hours, so that one side rests while the other does the work. In a nose that breathes normally, you never notice this.
When there is a fixed obstruction on one side, though, the problem shows up as soon as it is the other side's turn to swell. You are then left with no open side at all and you notice it strongly, usually at night or when lying down. That is why"first one side blocks, then the other"does not rule out a deviated septum, it often confirms it.
What can cause it?
When the cause is structural
- Deviated septum, from growth or after an injury you may not even remember
- Enlarged lower turbinates (the ridges along the side wall of the nose), which narrow the passage permanently and not only during flare-ups
- Narrowing of the nasal valve, the narrowest point of the nose, which is often overlooked and causes blockage even when the septum is otherwise normal
- Nasal polyps, which take up space and usually come with a reduced sense of smell
When the cause is the lining of the nose
- Allergic rhinitis, the most common of all, with sneezing, itching and a clear runny nose
- Non-allergic rhinitis, which reacts to cold, smells, changes in temperature or humidity, with no allergy on testing
- Long-term use of decongestant nasal sprays, which after a few days have the opposite effect and leave the nose permanently swollen
- Medications and hormonal changes, such as certain blood pressure medications and pregnancy
In practice, a combination is the rule: a deviated septum that caused no trouble for years, until allergy or enlarged turbinates are added and there is no room left.
When should you get it checked?
- You breathe through your mouth, especially during sleep, and wake up with a dry mouth
- Your nose never opens up fully, even outside allergy season
- You snore or your sleep is often interrupted
- You have been using a decongestant spray for more than a few days
- Your sense of smell is reduced
- The blockage started or got worse after an injury to the nose
What happens at the appointment?
We start with your history, which here guides almost everything: whether the blockage is constant or alternates, whether it affects one side or both, whether it is seasonal, which sprays you use and since when.
Nasal endoscopy
This is done with a thin endoscope, takes a few minutes and does not hurt. It shows the septum along its full length, not just the part visible from the entrance, as well as the turbinates, the condition of the lining and any polyps. A simple look from the front shows only a small part of the picture, and often not the part that matters.
The decongestant test
This is the simplest and most informative step. A decongestant is sprayed into the nose, we wait a few minutes and examine again. Whatever opened up was swollen lining and can be treated with medication. Whatever stayed closed is structural and will not change with a spray. This distinction shapes the whole plan, and it happens right in front of you.
When more is needed
Allergy testing when your history points to it, and a CT scan when chronic sinusitis is suspected or surgery is being planned. The nasal valve is assessed clinically, with simple maneuvers at the entrance of the nose.
Treatment
Medication first
When inflammation plays a part, it is treated first. This is not a delay, it is a prerequisite: international recommendations on septoplasty place medical treatment before any decision on surgery. In quite a few patients the nose opens up enough that surgery is not needed at all.
With decongestant sprays, stopping is a treatment in itself, and it is done gradually, with support.
Septoplasty (septum surgery)
The operation to straighten the septum is done from inside the nose, under general anesthesia and with no external incision. The cartilage and bone that are out of line are removed or repositioned so that the passage opens up. We do not touch the outer shape of the nose.
Turbinate reduction
When the lower turbinates are permanently enlarged and do not shrink with medication, they can be reduced, often in the same operation as the septoplasty. The aim is to make them smaller, not to remove them, because the turbinates have a job: they warm and humidify the air.
Frequently asked questions
No. Septoplasty concerns the inner wall and is not cosmetic nose surgery (rhinoplasty). If there is also a cosmetic wish or a nasal valve problem, this is discussed separately and planned in advance.
No. A deviated septum is extremely common and is not, on its own, a reason for treatment. It is operated on when it causes symptoms, not because it shows up on an examination.
Current techniques greatly reduce the need for classic nasal packing, and where material is used, it is usually soft and stays in for a short time. You will be told in advance exactly what will happen in your case.
The corrected part does not go back. Blockage can remain, however, if there is uncontrolled rhinitis or if the turbinates swell up again, which is why follow-up continues afterwards.
Because after a few days the lining reacts with more swelling as soon as the effect wears off. This creates a vicious circle of ever more frequent use and worse blockage. It is reversible, but it needs guidance.
As a rule it is avoided, because the nose is still growing. There are exceptions when the blockage is severe, and the decision is made using different criteria than in adults.
When should you not wait?
Immediately
Blockage on both sides right after an injury
This may be a septal hematoma (a collection of blood in the septum), which needs immediate treatment so that the cartilage is not damaged.
Soon
Blockage on one side with bloody discharge
A nose that is always blocked on the same side, with repeated nosebleeds, needs an endoscopy without delay.
Soon
A child with foul-smelling discharge from one side
This is the classic picture of an object stuck in the nose (foreign body), and it is not treated with antibiotics.
Medical review: Dr. Ioannis KotrotsosENT Surgeon and Specialist in Phoniatrics and Pediatric Audiology.
Πηγή: Han JK et al., Clinical Consensus Statement: Septoplasty with or without Inferior Turbinate Reduction, AAO-HNSF, 2015.
The information on this page is for general information only and does not replace a medical examination. For diagnosis and treatment, please consult a doctor.
