Septal deviation and turbinate hypertrophy

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Nasal obstruction can reflect fixed anatomy, reversible mucosal swelling or both. The septum divides the nasal cavities and consists of cartilage and bone. Deviation may arise during growth or after trauma and can narrow one side. The inferior turbinates contain vascular mucosa that warms and humidifies inspired air; enlargement can increase resistance, particularly with rhinitis. A patient with a visible deviation may still obtain useful benefit from treating the mucosal component.

The clinical task is to connect symptoms with findings rather than operate on an image. Some patients have severe functional obstruction, while others notice an asymmetry but breathe comfortably. A careful history, nasal examination and a trial directed at associated inflammation help clarify the likely benefit of surgery. Discuss uncertainty honestly: septoplasty can improve airflow but may leave residual blockage, and it does not by itself treat every cause of snoring, facial discomfort or sleep disturbance.

Key points

A deviated septum is common and may be asymptomatic; an anatomical finding alone is not an indication for surgery.
Turbinate tissue changes in size with the nasal cycle and inflammation, so blockage can alternate or fluctuate.
Ask how obstruction affects sleep, exercise, work and daily comfort before discussing intervention.
Nasal corticosteroids treat associated mucosal swelling but cannot straighten a fixed cartilage or bony deviation.
Consider septoplasty when symptoms are attributable to septal narrowing and an informed patient wants an operative solution.
Selected patients may need treatment of enlarged turbinates as well as septal surgery, after assessment of the whole airway.
Septoplasty aims to improve breathing; changing external appearance may require a different or combined procedure.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Development and injury

Septal shape may become asymmetric during growth or after trauma. Previous operations and subsequent scarring can also alter the nasal airway, so the time course helps interpret the examination.

Mucosal and compensatory enlargement

Turbinate enlargement can reflect inflammatory rhinitis and vascular engorgement, with structural contributions in some patients. A wider nasal cavity opposite a deviation may also contain a prominent turbinate.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Resistance through a narrowed passage
A septal bend reduces the space available for airflow and may make breathing more effortful. The experienced obstruction depends on the whole nasal airway rather than the septum alone.
2
Vascular mucosal variation
Turbinate mucosa can swell and shrink with autonomic activity and inflammation. This creates a reversible component of obstruction and explains why symptoms may fluctuate around a fixed anatomical narrowing.
3
Persistent obstruction after treatment
Residual structural narrowing, untreated inflammation or postoperative adhesions can continue to limit airflow. Distinguishing these mechanisms is necessary before repeating the same medicine or recommending further surgery.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Fixed and fluctuating blockage

Ask whether symptoms are continuously worse on the same side, alternate during the day or vary with allergens and irritants. These patterns guide assessment but are not definitive: structural narrowing and inflammation frequently coexist.

Functional burden

Record mouth breathing, exercise limitation, nocturnal symptoms and effects on quality of life. A history of witnessed apnoeas or substantial daytime sleepiness requires separate sleep-disordered breathing assessment rather than an assumption that straightening the septum will resolve it.

Trauma and previous intervention

Ask about old injuries, nasal surgery, scarring and repeated decongestant use. Recent trauma with new bilateral blockage needs examination for a haematoma even when the outside of the nose looks relatively normal.

Whole nasal airway examination

Inspect the external framework, septum, turbinates, secretions and accessible nasal cavity. Look for polyps, crusting or a lesion; assess whether the area of narrowing corresponds to the patient's symptoms and whether endoscopy is needed.

Red flags requiring action

Boggy septal swelling with increasing obstruction after trauma or surgery requires immediate assessment for a septal collection.
Progressive unilateral obstruction with recurrent bleeding, facial numbness or a visible mass warrants urgent ENT evaluation.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Clinical nasal assessmentFirst step
Why
Relate reported obstruction to structural and mucosal findings.
Interpretation and limitations
Inspection often identifies a substantial septal bend or enlarged turbinates. Symptoms and examination must agree sufficiently to support the proposed intervention; deviation alone does not prove the cause of every complaint.
02
Response to an appropriate medical trial
Why
Estimate how much associated mucosal inflammation contributes to blockage.
Interpretation and limitations
Improvement with correctly used nasal corticosteroid treatment supports a treatable inflammatory component. Failure may reflect poor delivery, adherence or a predominantly fixed obstruction and should lead to reassessment.
03
ENT endoscopy when indicated
Why
Examine areas not visible during an anterior nasal inspection.
Interpretation and limitations
Endoscopy can identify posterior deviation, polyps or another obstructing lesion. It is particularly useful where symptoms remain unexplained or a unilateral abnormality needs further assessment.
04
Targeted additional investigations
Why
Investigate a specific alternative diagnosis or associated condition.
Interpretation and limitations
Allergy tests, sinus CT or sleep studies are selected according to the clinical question. CT is not a routine requirement for every uncomplicated septal deviation and should not substitute for an airway examination.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Inflammatory nasal polyps

Polyps can cause persistent blockage and smell loss, often bilaterally. Endoscopic assessment distinguishes them from turbinate tissue and identifies a different long-term anti-inflammatory treatment pathway.

Nasal valve or external deformity

Narrowing of the external framework or nasal valve may contribute substantially to obstruction. Septoplasty alone may not address this component, making a full structural assessment necessary.

Septal collection or suspicious mass

Recent painful obstruction with boggy swelling suggests haematoma or abscess, while progressive bloody unilateral symptoms suggest a lesion. Both require more urgent assessment than uncomplicated longstanding deviation.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Low symptom burdenExplain the finding and observeFirst stepA septal deviation is present without important functional nasal obstruction.

1Explain that a bent septum can be left alone when its effect is acceptable to the patient.
2Offer advice about associated rhinitis or irritant exposure if these contribute to intermittent symptoms.
3Give a route back for reassessment if obstruction becomes progressive, unilateral bleeding develops or the functional impact increases.

02Mucosal componentTreat reversible swelling before reassessmentObstruction varies with rhinitis symptoms or examination shows inflamed turbinates.

1Use an appropriate intranasal corticosteroid trial, with technique demonstration and an agreed review point.
2Consider saline for secretions and comfort, and address relevant allergic or non-allergic triggers.
3Review actual use and the remaining fixed obstruction before deciding whether additional intervention is likely to help.
4Identify prolonged decongestant use and support withdrawal rather than using repeated vasoconstriction as a long-term solution.

03Significant fixed obstructionDiscuss septoplasty and selected turbinate treatmentPersistent symptoms are attributable to structural narrowing and remain unacceptable to the patient.

1Refer to ENT for assessment of septal, turbinate and external nasal contributions to obstruction.
2Explain expected breathing benefit, alternatives and uncertainty, including the possibility of persistent or recurrent blockage.
3Discuss whether the procedure is septoplasty alone or includes an individually selected turbinate or external framework intervention.
4Arrange postoperative advice and follow-up, emphasising that increasing pain and blockage require urgent assessment rather than waiting for the planned visit.

Key medicines and prescribing safety1 treatment · regimens, roles and cautions

Treats an inflammatory contributor to obstruction during assessment of structural disease.

Mometasone furoate nasal spray for associated allergic mucosal swelling

With the 50-microgram Nasonex device, the usual adult rhinitis regimen is two sprays into each nostril once daily, or 200 micrograms daily. Review response and reduce to one spray per nostril daily when controlled; continue only while clinically needed.

This medicine does not correct a fixed septal bend. Do not use before nasal trauma or surgery has healed, or with untreated local mucosal infection. Check epistaxis, interacting CYP3A inhibitors, cumulative corticosteroid exposure and any new visual disturbance.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Functional and sleep effects

Persistent obstruction can encourage mouth breathing and disturb sleep or exercise comfort. The presence of snoring does not prove that nasal surgery will treat coexisting obstructive sleep apnoea.

Surgical bleeding and infection

Septal surgery can be followed by bleeding or infection. Increasing pain, redness and blockage may signal a haematoma or abscess requiring prompt treatment rather than routine recovery advice.

Residual obstruction or perforation

Surgery may leave recurrent deviation, adhesions or a septal perforation. The latter can cause crusting, whistling or bleeding, although some perforations cause few symptoms.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

At the review visit, compare breathing and functional limitations with the agreed baseline rather than relying only on whether the septum still appears bent.
Check whether persistent symptoms are caused by incomplete treatment of rhinitis, a different site of narrowing or an alternative diagnosis.
After surgery, follow the operating service's instructions for saline, medicines, splints, activity and review; do not improvise postoperative nasal steroid timing.
Explain that early postoperative swelling and packing can obstruct breathing, but worsening pain, redness, fever or increasing blockage require prompt assessment.
Reassess persistent late obstruction for residual deviation, recurrent inflammation or adhesions, and discuss further management according to the identified cause.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Normal alternating airflow

The nasal cycle changes mucosal engorgement between sides. Noticing alternate nostril blockage does not automatically indicate two fixed lesions, although symptoms still deserve assessment when sleep or daily function is affected.

Preserving turbinate function

Turbinates are functional tissue rather than unwanted space-occupying structures. Any reduction should be selected by the surgeon with attention to airflow and mucosal preservation; a smaller anatomical volume is not the sole measure of a successful result.

Appearance and breathing goals

ENT UK distinguishes septoplasty from operations intended to reshape the external nose. A patient who wants a crooked external framework corrected should have that goal discussed explicitly, as a combined septorhinoplasty may be considered.

Recovery is not instantaneous

ENT UK advises that swelling may take several weeks to settle and breathing can continue improving over months. Provide individual work and activity advice, while keeping the separate urgent pathway for bleeding, infection or septal collection clear.

What the UK trial establishes

The NAIROS trial randomised 378 adults with symptomatic septal deviation to septoplasty or six months of steroid and saline treatment. Surgery improved six-month SNOT-22 more, with an adjusted difference of about twenty points. More severe baseline symptoms predicted greater benefit. Turbinate reduction was not randomised, so the study does not establish its separate causal contribution.

11Common pitfallsFrequent interpretation and management errors.

01
Offering surgery because a septal bend is visible without establishing that it causes important symptoms.
02
Promising that a corticosteroid spray will straighten cartilage rather than reduce associated inflammation.
03
Attributing daytime sleepiness and witnessed apnoeas solely to nasal obstruction without a broader sleep assessment.
04
Mistaking a new septal haematoma for an old deviation because the patient reports previous nasal injury.
05
Treating every painful postoperative blocked nose as expected swelling without checking for a collection.