Septoplasty

What a deviated septum is, and isn't

The nasal septum is the wall of bone and cartilage that divides the inside of your nose into two passages. Almost everyone's septum sits a little off center — that alone isn't a diagnosis. A deviated septum becomes a clinical problem when it's bent or buckled enough to meaningfully narrow one nasal passage and reduce airflow, or when a septal spur (a sharp bony or cartilaginous projection) presses against the wall of the nose.

Most deviations come from one of two sources: cartilage that simply grew off center, or a prior nose injury — sports, a fall, an accident — sometimes years earlier. Symptoms typically include nasal obstruction that's often worse on one side, congestion that doesn't fully clear with sprays, noisy or blocked breathing at night, frequent nosebleeds on the dry side, and in some patients facial pressure or headaches from the deviation contacting a turbinate.

Here is the part that matters most for deciding whether surgery is the right answer: deviated-septum symptoms overlap heavily with allergies and chronic sinusitis. Allergic congestion tends to affect both sides and comes and goes; a structural deviation tends to stay on the same side and doesn't respond to allergy medicine. Both can be present in the same patient at once — which is exactly why an exam, not a mirror, is what tells you which one you have.

What septoplasty can — and can't — fix

Septoplasty is a functional procedure. The reason to do it is breathing, not appearance, and it only helps when a structural deviation is the source of the obstruction.

Septoplasty may be combined with turbinate reduction or endoscopic sinus surgery when those conditions also need treatment. It is intended to improve function, not reshape the external nose. An unintended change in appearance is a possible risk. Cosmetic reshaping is a separate discussion.

A dramatic-looking deviation is not always the one causing your symptoms—and a subtle one sometimes is. The important question is whether the anatomy, the examination and what you feel all point to the same source of obstruction.

Dr. John Fewins

Validated symptom questionnaire

NOSE Score — Nasal Obstruction Symptom Evaluation

The NOSE scale gives nasal obstruction a consistent 0–100 score that can be compared over time. Answer all five questions based on the past month. The score describes symptom burden; it does not identify the cause or determine whether septoplasty is appropriate.

1. Nasal congestion or stuffiness

0 None 1 Very mild 2 Moderate 3 Fairly bad 4 Severe

2. Nasal blockage or obstruction

0 None 1 Very mild 2 Moderate 3 Fairly bad 4 Severe

3. Trouble breathing through my nose

0 None 1 Very mild 2 Moderate 3 Fairly bad 4 Severe

4. Trouble sleeping

0 None 1 Very mild 2 Moderate 3 Fairly bad 4 Severe

5. Unable to get enough air through my nose during exercise or exertion

0 None 1 Very mild 2 Moderate 3 Fairly bad 4 Severe

Calculate my score

For general education only; not a diagnosis or treatment recommendation. Source: Stewart MG, et al. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngology–Head and Neck Surgery. 2004;130(2):157–163.

The operation

Small, limited deviations and septal spurs can sometimes be corrected in the office under local anesthesia. More complex deviations are done in the operating room under sedation or general anesthesia, which is where Dr. Fewins handles most full septoplasties. A straightforward septoplasty typically takes about 30 minutes; combined procedures — with turbinate reduction or sinus surgery — take longer.

Most septoplasties are done entirely through the nostrils, with no external incision, using either direct visualization or an endoscope for a clear, magnified view of the posterior septum. An open (external) approach, through a small incision at the base of the nose, is reserved for complex deformities or when septoplasty is combined with rhinoplasty. Dr. Fewins uses both endoscopic and open techniques and matches the approach to the anatomy, not to a one-size-fits-all script.

The reshaping itself is conservative by design: deviated cartilage is scored, trimmed, or repositioned, and deviated bone is removed, while a strong, straight framework — the keystone area and an adequate dorsal and caudal strut — is always preserved to keep the nose supported. Occasionally a piece of septal cartilage is used as a graft where extra support is needed. For most operating-room septoplasties, soft internal splints are placed for about three days; they align the septum, reduce swelling, and give more reproducible outcomes. Splints are often left out when septoplasty is combined with sinus surgery. There's usually no old-fashioned nasal packing.

Recovery

1. First several days

   Congestion, some bloody drainage, and a stuffy, blocked feeling are normal while internal swelling settles. Splints, if placed, typically come out around day three.

2. Early weeks

   Most patients return to desk work within a few days. Avoid forceful nose-blowing, heavy lifting, and contact sports for about two weeks; sneeze with your mouth open.

3. Longer term

   Breathing continues to improve as deep swelling resolves, with the final result typically clear within about three months.

For a comfortable recovery: use saline spray or rinses as directed, control discomfort with the medication provided and avoid aspirin/NSAIDs unless cleared, and keep your head elevated the first few nights.

Risks & alternatives

Risks include bleeding, infection, persistent obstruction and a septal perforation—a hole in the dividing wall. A perforation may cause no symptoms, or may lead to crusting, bleeding or whistling. Less common risks include a change in the nose’s appearance or numbness. Your anatomy and prior surgery influence the discussion.

Call the office promptly for heavy or persistent bleeding that doesn't slow with gentle pressure, fever or spreading redness, or symptoms that worsen rather than improve after the first week or two.

Alternatives to surgery: when obstruction is mild, or when allergy or inflammation is doing most of the work, nasal steroid sprays and allergy management come first — septoplasty is for obstruction that hasn't responded to that medical treatment. Balloon dilation is not an alternative for a deviated septum specifically; it opens sinus drainage pathways, not septal cartilage and bone.

Pediatric considerations

In children, timing matters because the nose and midface are still growing. Elective septoplasty is usually deferred until growth is largely complete, generally the mid-to-late teens, unless a significant functional problem — such as marked obstruction after trauma — clearly warrants earlier surgery. When surgery is needed in a younger child, it's kept as conservative as possible to protect ongoing growth. Dr. Fewins counsels families on whether to treat now or wait, based on the individual child rather than a rigid age cutoff.

Frequently asked questions