A thirty-eight year old man sat down in my Harley Street clinic last week and told me he had not breathed properly through his nose since he was sixteen. He had been using Otrivine every night for nineteen years. Every night. He had tried Beconase, Avamys, Dymista, fexofenadine tablets, an air purifier, two different humidifiers and three GP referrals that all came back saying his allergies were under control. They were under control. The problem was not his allergies.
When I passed the endoscope through his right nostril it stopped at three centimetres. There was a sharp ridge of cartilage and bone running across the floor of the airway, fused to the lateral wall. The left side opened cleanly. His septum had drifted to the right at some point in his teens, probably during a rugby match he could not even remember, and his nose had been quietly compensating for two decades.
I have seen this presentation, in some version of it, almost every week of my consultant career. People who have been told their nose is fine, their allergies are well managed, their snoring is just snoring. And it isn't. The septum is deviated. The spray has stopped working. The body has adapted, badly, around a structural problem.
This post is what I wish more of my patients had read a decade earlier. I am Mr David Whitehead, a Consultant ENT and Facial Plastic Surgeon at NOSE London. I am dual-trained in ENT surgery and in facial plastic surgery, and a meaningful share of my week is taken up with septoplasty and septorhinoplasty. This is everything I tell patients in my consulting room about deviated septums, in roughly the order I tell them.
What a deviated septum actually is
The nasal septum is the central wall of the nose. It is built from cartilage at the front and bone at the back, covered on both sides by a thin lining called mucoperichondrium. When the septum is straight, the two nasal passages on either side are roughly equal in size, and air enters both nostrils evenly.
A deviated septum means that wall is not straight. It can bow to one side, twist along its length, develop a sharp spur where cartilage meets bone, or thicken in one area. The deviation is almost always a combination of these. Pure left-or-right deviation is uncommon. Most septums I operate on have at least two distinct components: a high cartilaginous bend and a low bony spur, often on opposite sides.
The functional consequence is simple. One nasal passage becomes narrower than the other. Sometimes much narrower. Sometimes so narrow that the airway is mechanically closed for parts of the breathing cycle. Patients feel this as a permanently blocked nose on one side, or as a nose that "switches sides" depending on which way they are lying down. That switching is the nasal cycle, which everyone has, becoming exaggerated by the structural narrowing.
Why so many people have one (and never knew)
The figures published in the British rhinology literature suggest that around 80% of adults have some degree of septal deviation on imaging. Most are minor and asymptomatic. A smaller proportion, perhaps 20%, have a deviation significant enough to cause symptoms. Of those, a smaller fraction again will eventually come to surgery.
Where does the deviation come from?
Some people are born with one. The septum develops from two cartilaginous plates that fuse in foetal life, and the join is not always perfect. The shape of the maxillary crest, which the septum sits on, also matters.
Most acquired deviations come from trauma, and a great deal of that trauma is forgotten. Patients tell me they have never broken their nose. Then I show them the CT and there is a healed fracture of the nasal bones with a clear deviation in the septum just behind it. A rugby tackle at school. Falling off a bike at eight. A sibling's elbow. The cartilage is forgiving in childhood, so the fracture heals quietly and the nose looks more or less normal from the outside, but the internal alignment is off. Twenty years later, when the lining starts swelling more easily or the nasal cycle shortens with age, the patient finally notices that they cannot breathe.
The signs you have a deviated septum
There is no single symptom that proves a deviated septum, but the cluster is unmistakeable once you know to look for it.
One nostril is worse than the other. This is the cardinal sign. Cover one nostril, then the other, and breathe in firmly. If one side flows freely and the other feels obstructed, the asymmetry usually has a structural cause.
Snoring, especially mouth breathing during sleep. Air resistance through a narrow nose drives mouth opening at night. Partners notice before the patient does.
A nose that blocks when you lie down. The vessels in the nasal lining engorge slightly when you are horizontal. In a healthy nose the engorgement is barely noticeable. In a deviated nose it tips an already narrow passage into full obstruction.
A history of "permanent colds" or "constant sinusitis" that GPs cannot quite cure. Recurrent infections often reflect impaired mucus drainage from a structurally compromised sinus opening.
Reduced sense of smell. The olfactory cleft sits at the top of the nasal cavity, and a high septal deviation can interfere with airflow to it.
Bleeding from one nostril. Deviations create areas of turbulent airflow and dry mucosa, particularly along the leading edge of the deviation. These crust, crack and bleed.
A whistle when you breathe in, especially after exercise. Air being forced through a narrowed channel makes a sound. Patients describe a faint high note when they sniff in hard.
The need to sleep on one specific side. Patients work this out empirically. Lying with the worse nostril uppermost lets gravity help drain that side, and they sleep better. Forcing them onto the other side keeps them awake.
A history of using a decongestant nasal spray every day for years. This last one matters enough to deserve its own section.
The chronic spray spiral
Decongestant sprays work. That is the problem.
The active ingredient in Otrivine is xylometazoline. In Sudafed Blocked Nose Spray it is also xylometazoline. In Vicks Sinex it is oxymetazoline. All three are sympathomimetic vasoconstrictors. They shrink the swollen nasal lining within ninety seconds, the nose clears, and the patient breathes properly for the first time in weeks. The relief is dramatic.
The licensed maximum is seven days. After roughly seven to ten days of regular use the receptors in the nasal lining downregulate. The patient stops getting the same effect from each dose. The lining rebounds, often worse than before. The patient sprays again. Within a few months they cannot breathe at all without it. This is rhinitis medicamentosa, and it is shockingly common.
Two important distinctions worth understanding here. Steroid sprays are not in this category. Beconase, Avamys, Nasonex, Flixonase and Dymista all contain corticosteroids or a steroid plus an antihistamine, and they do not cause rebound congestion. They are safe to use long term. The addictive sprays are the over-the-counter decongestants. The patient who hands me a half-empty Otrivine and says "I cannot live without this" has rhinitis medicamentosa, and a significant proportion of those patients also have an underlying deviated septum that started the cycle.
The taper is straightforward once a patient understands what is happening, but it is rarely durable until the structural problem is fixed. I will write a separate post on the taper protocol shortly, with a downloadable plan. For now, the point is this: if you have been using Otrivine, Sudafed Blocked Nose Spray or Sinex daily for more than two weeks, you almost certainly have a problem the spray is not solving.
How a deviated septum is diagnosed
A torch and a tongue depressor will not diagnose this properly. They will show the front of the septum and that is it. The clinically important deviations are often higher and further back, hidden from a basic examination.
In my clinic I use a flexible nasendoscope. This is a slim fibre-optic camera, four millimetres in diameter, passed gently through the nostril after a brief spray of local anaesthetic and decongestant. The whole examination takes about a minute per side. I can see the entire length of the septum, both inferior and middle turbinates, the sinus openings, the back of the nose, the eustachian tube openings and the larynx. Patients almost always ask to watch on the screen, and most are visibly surprised when they see their own anatomy for the first time.
For surgical planning I usually request a low-dose CT scan of the sinuses. The CT confirms the shape and extent of the deviation, shows any sinus disease, and tells me whether there is enough cartilage remaining to perform a safe septoplasty. A CT also helps me distinguish a deviated septum from the much rarer diagnoses that mimic it, including septal perforation, septal haematoma, antrochoanal polyps and, very occasionally, tumours.
Allergy testing has a role here too. If a patient has both structural narrowing and allergic rhinitis, treating one without the other rarely works. I use the ALEX 3 multiplex allergy test, which screens for over three hundred allergens from a single blood sample and is described in my hay fever post.
The treatment ladder
Surgery is not the first step. Most patients with a deviated septum should first try a proper trial of medical therapy.
That means a daily intranasal corticosteroid (Avamys, Nasonex, Flixonase or generic mometasone) used correctly for at least eight weeks. Correctly means head tilted slightly forward, spray angled outward toward the cheekbone, not pointing at the septum, and breath held briefly after the puff. Most people use steroid sprays incorrectly and conclude they do not work.
Add saline irrigation morning and evening, using a large-volume system such as NeilMed Sinus Rinse from any Boots. The Cochrane review evidence here is solid. It thins mucus, clears allergens and improves the local environment.
If symptoms remain bothersome after eight weeks of correctly used steroid spray plus saline, the next step is usually surgical assessment. Two questions then need answering. First, is the structural problem severe enough to warrant surgery? Second, is medical therapy genuinely failing, or has it not been used properly?
A patient who has tried five sprays for three weeks each is not the same as a patient who has used one spray correctly for eight weeks. The first patient often gets better with proper medical management. The second usually does not.
The NAIROS evidence: what UK trial data actually says
The strongest UK evidence on septoplasty is the NAIROS trial, published in Health Technology Assessment in 2024. NAIROS was a randomised controlled trial conducted across seventeen NHS hospitals, comparing septoplasty with medical management in adults with septal deviation and bothersome obstruction.
The headline result is large and important. Patients randomised to septoplasty showed a twenty-point improvement on the SNOT-22 symptom score at twelve months, compared with patients managed medically. A change of nine points on SNOT-22 is considered clinically meaningful. Twenty points is a transformation.
The trial also clarified who benefits. Patients with mild symptoms (SNOT-22 below 30) did not gain much from surgery. Patients with moderate to severe symptoms (SNOT-22 above 30) gained a great deal. The NAIROS authors recommended that NHS commissioners use SNOT-22 thresholds to triage referrals, which most Integrated Care Boards now do.
This matters because it tells you what to expect. If your symptoms are mild, surgery is a marginal intervention and you should stay on medical therapy. If your symptoms are moderate or severe, the trial data suggests a high probability of meaningful improvement.
Septoplasty: what actually happens
Septoplasty is an operation to straighten the nasal septum. It is performed entirely through the nostrils. There is no external incision. The nose does not look any different from the outside afterwards.
I perform septoplasty as a day case under general anaesthesia at Weymouth Street Hospital. The operation takes between forty-five and seventy-five minutes depending on complexity. Here is the sequence.
I infiltrate local anaesthetic with adrenaline along both sides of the septum to control bleeding. I make a small incision inside the nostril, lift the mucoperichondrial lining off the cartilage, and carefully separate the deviated cartilage and bone from their attachments. The deviated portions are then either reshaped, scored, repositioned, or selectively removed. A small strut of cartilage at the front is preserved to maintain support for the nasal tip. The lining is laid back down and either quilted with dissolving sutures or supported with small internal splints for a few days.
I do not use the old-style packing that older accounts of septoplasty describe. Most modern septoplasty uses dissolving sutures or soft silicone Doyle splints rather than gauze packing. The recovery is much more comfortable as a result.
The patient goes home the same day, usually within four hours of the operation finishing. Most are eating normally by the evening.
When septoplasty becomes septorhinoplasty
This is one of the most useful conversations I have in clinic, and most patients have not had it before.
Septoplasty fixes the inside of the nose. The outside is unchanged. If a patient is having septoplasty primarily for breathing but has always slightly disliked a dorsal hump, an asymmetry, or a drooping tip, we can combine the two operations into one. The combined operation is called septorhinoplasty, and from the patient's perspective it is one anaesthetic, one recovery and a nose that breathes and looks better.
The clinical case for combining is strong. The structural exposure during septoplasty already gives access to the underlying skeleton. Adding aesthetic refinements at the same time avoids a second anaesthetic and a second recovery. The marginal additional theatre time is usually thirty to ninety minutes.
The financial logic also matters. The hospital fee is paid once. The anaesthetist is paid once. The surgeon's fee for septorhinoplasty is higher than for septoplasty alone, but lower than the sum of two separate operations.
The functional case for combining is also real. A purely cosmetic rhinoplasty performed years after a septoplasty has to work around the previous surgery, and the result can be less predictable. A combined septorhinoplasty avoids that.
When I discuss this with a septoplasty patient, around a third decide to combine. The rest are happy with breathing alone. Both choices are reasonable.
NHS versus private septoplasty in the UK
The NHS still funds septoplasty in most regions, but access has tightened significantly since 2018 when several CCGs (now ICBs) introduced thresholds restricting referral. NHS England's Evidence-Based Interventions programme placed septoplasty in Category 2, meaning it should be commissioned only when specific criteria are met.
Those criteria typically include all of the following: documented septal deviation visible on examination, persistent symptoms despite at least three months of optimal medical therapy, and a SNOT-22 score above the local commissioning threshold (often 30, sometimes higher).
If you meet those criteria, your GP can refer you to the NHS ENT department. Waiting times in 2025 to 2026 are running at twelve to eighteen months in most parts of England for routine septoplasty, longer in some areas. You will likely see a different consultant at each appointment.
Private septoplasty bypasses all of that. The path is direct. You book a consultation. If septoplasty is indicated, you book the operation, usually within four to six weeks. The same surgeon sees you preoperatively, performs the operation, and follows you up.
For self-pay patients I publish my septoplasty fee at £6,000 inclusive of surgeon, hospital, anaesthetist and follow-up. For BUPA, AXA, Aviva, WPA and Cigna members, septoplasty is generally covered subject to your policy and any excess. I am BUPA fee-assured, which means BUPA patients pay nothing in addition to their excess. For other insurers there may be a shortfall, which I will quote transparently before booking.
I should be honest about one thing. If you are a private patient, you are paying for direct access and continuity of care. You are not necessarily paying for a different operation. The septoplasty I perform privately is the same operation I was trained to perform on the NHS, and the same operation a good NHS consultant performs. What you are buying privately is time, attention and choice of surgeon.
Recovery from septoplasty: what to actually expect
The standard recovery from a straightforward septoplasty looks like this.
Day of surgery: home by mid-afternoon. Some bleeding from the nostrils that settles within hours. Mild discomfort, managed with paracetamol and ibuprofen.
Days one to three: the nose feels blocked, because the internal lining is swollen even though the structural problem has been fixed. Most patients are surprised by this. The blockage is temporary and resolves over the first one to two weeks.
Day three to five: this is often the most uncomfortable phase, because crusting and dryness peak. Frequent saline rinses help significantly. Avoid blowing your nose. Sneeze with your mouth open.
Day seven to ten: if internal splints were used they are removed in clinic at this point. The breathing improves audibly within minutes.
Week two: most patients are back at desk work by the end of week two. Some return earlier.
Week four: gentle exercise such as walking and cycling can usually resume. Heavy lifting and contact sport wait until week six.
Months one to three: airflow continues to improve as the lining settles. Most patients reach their final breathing result by three months.
A more detailed day-by-day recovery timeline is on my recovery page, which covers both septoplasty and rhinoplasty in more detail and includes a downloadable PDF you can keep on your phone.
What can go wrong
I would not be doing my job if I did not discuss this honestly.
The most common adverse outcome of septoplasty is failure to fully relieve symptoms. NAIROS showed that around 15% of patients still have meaningful obstruction at twelve months. Causes include incomplete correction of the deviation, persistent turbinate hypertrophy, valve collapse not addressed at the original operation, or coexisting allergic rhinitis that was not the structural fault.
The other recognised risks, in rough order of frequency, are bleeding (around 1% require intervention beyond pressure), septal perforation (around 1%), septal haematoma (under 1%, but requires urgent drainage), persistent crusting or dryness, alterations in sense of smell (usually temporary), and very rarely a change in the external shape of the nose if too much cartilage is removed from the dorsum.
The mortality of septoplasty is essentially zero. It is one of the safer operations in adult surgical practice. The risks of doing nothing, in a patient with severe symptoms, often outweigh the risks of operating.
When to come and see me
I see patients at 9 Harley Street, 25 Harley Street and Weymouth Street Hospital. The first appointment costs £250, lasts forty-five minutes, includes nasendoscopy and is credited against the surgical fee if you proceed.
You should consider booking a consultation if you have any of the following.
- A nose that has been blocked on one side for more than three months.
- A history of needing a decongestant spray every day to breathe properly.
- Persistent snoring or mouth breathing at night, particularly if your partner has noticed.
- Recurrent sinus infections.
- A blocked nose that hay fever sprays do not fully fix.
- A deviated nose externally that you have noticed since a childhood injury.
- Disappointment with a previous septoplasty done elsewhere.
If any of those apply, the diagnostic process is short and the answer is usually clear by the end of one consultation.
Frequently asked questions
Will my nose look different after septoplasty?
No. Septoplasty is internal. There is no external scar and the outward shape is preserved. If you want both functional and aesthetic change, the operation is called septorhinoplasty.
Is septoplasty painful?
Less than most patients expect. Most discomfort is mild and managed with paracetamol and ibuprofen. The most uncomfortable part is the feeling of internal blockage during the first week from swelling, not pain as such.
How long do I need off work?
For desk work, most patients return at the end of week two. For physical work, week four to six. For full contact sport, week six.
How long do I have to wait on the NHS?
In England, currently twelve to eighteen months for routine septoplasty in most regions. Some areas are longer. Some Integrated Care Boards no longer fund septoplasty at all unless specific objective criteria are met.
Does private septoplasty cost more than rhinoplasty?
Significantly less. A private septoplasty at my practice is from £6,000, fully inclusive. A primary rhinoplasty is from £10,000. Septorhinoplasty, which combines both, is from £10,500.
Will BUPA cover septoplasty?
Yes, in most cases, subject to your individual policy and excess. I am BUPA fee-assured, which means BUPA members are covered with no shortfall.
Can septoplasty be done at the same time as turbinate reduction?
Yes, and it often should be. Many patients with septal deviation also have compensatory turbinate hypertrophy on the wider side, and treating only the septum leaves them with a still-narrowed airway. I add turbinoplasty in around half the septoplasty cases I perform.
Is awake septoplasty an option?
Not in my practice. The operation is technically possible under local anaesthesia but it is uncomfortable, the operative view is compromised, and the surgical result is less predictable. I do all my septoplasties under general anaesthesia.
Can a deviated septum come back after septoplasty?
A small proportion of patients (around 5% to 10%) have some recurrence of cartilaginous deviation over years. This is usually mild and asymptomatic. Bony deviations, once corrected, do not recur.
Can I get a deviated septum without ever having broken my nose?
Yes. Around half of significant septal deviations have no clear traumatic history. They develop during growth, often without any single event.
Where to start
If your nose has been blocked for longer than you can really remember, if you cannot get through the night without a decongestant spray, or if hay fever season seems to last all year, a structural problem may be at the heart of it.
The first step is a proper examination by someone who can look. A nasendoscopy in clinic takes a minute. A CT, if needed, takes five. Most patients leave the first appointment knowing exactly what the problem is and what the options are.
You can book a consultation here or call 020 7183 0220.
References
- Carrie S, Barmby J, Bray D, et al. Effectiveness of septoplasty compared to medical management in adults with obstruction associated with a deviated nasal septum: the NAIROS RCT. Health Technology Assessment. 2024;28(4):1-120. doi:10.3310/MVFR4028
- Scadding GK, Kariyawasam HH, Scadding G, et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017). Clinical & Experimental Allergy. 2017;47(7):856-889. doi:10.1111/cea.12953
- NHS England. Evidence-Based Interventions: Guidance for CCGs. London: NHS England; 2019.
- Ghosh SK, Chakraborty D, Mukherjee S, et al. Role of bilateral inferior turbinoplasty as an adjunct to septoplasty. Ear, Nose & Throat Journal. 2021;102(7):NP297-NP302. doi:10.1177/01455613211015440
- Wu Y, Liu Y, Wang C, et al. The benefits of septoplasty for patients with deviated nasal septum and allergic rhinitis: a meta-analysis. Scientific Reports. 2024;14:28693. doi:10.1038/s41598-024-80377-3
- Lin SY, Azar A, Suarez-Cuervo C, et al. The role of immunotherapy in the treatment of asthma. Comparative Effectiveness Review No. 196. Agency for Healthcare Research and Quality; 2017.
- Private Healthcare Information Network (PHIN). Independent acute healthcare market data 2024-2025. London: PHIN; 2025.