Difficulty breathing through the nose: septum, turbinates and other causes

Nasal obstruction is very common. SEORL-CCC estimates that one third of the population has some form of nasal obstruction and that at least a quarter of those people will need surgery. These are the main causes assessed.

A deviated septum

The septum is the cartilage and bone structure dividing the nose into two cavities. When it folds, becomes deformed or curves to one side, it can obstruct airflow. SEORL-CCC notes that deviation can result from trauma or changes during growth.

Enlarged turbinates

The turbinates are structures inside the nose. The lower ones filter, warm and moisten the air you breathe. With rhinitis or rhinosinusitis, they may become inflamed or enlarged and make breathing difficult.

The nasal valve

The nasal valve is the passage through which air enters, from the middle of the nose to the nostrils. Cleveland Clinic explains that it narrows when its supporting tissue, mainly cartilage, weakens, which can happen with age, after nasal surgery or following an injury. Breathing difficulty may worsen during exercise or when lying down.

Overuse of decongestant sprays

Cleveland Clinic warns that sprays containing oxymetazoline or phenylephrine, used beyond the usual three-day limit, can worsen congestion. This is called rhinitis medicamentosa or rebound congestion. The first step in treatment is gradually reducing their use; stopping abruptly can worsen symptoms, and the same source states that a doctor helps withdraw them gradually.

Other causes

The consultation also assesses possible associated causes, such as sinusitis or allergy, and whether further tests are needed.

A slightly crooked septum is very common. Cleveland Clinic estimates that around 8 in 10 people have one, and many never notice it. When deviation is significant, the most common symptoms are:

• difficulty breathing, often worse on one side;
• nosebleeds;
• facial pain;
• noisy breathing and snoring.

Congestion, nasal dryness, reduced sense of smell, tiredness or headache may also accompany a deviation.

Symptoms offer clues, but are not enough to locate the problem. A thorough examination with nasal endoscopy identifies the location and nature of the deviation, and distinguishes whether the problem is in the septum, the turbinates or also the external shape of the nose. The nasal valves are examined at the same time.

Deviations that cause no symptoms do not usually require correction. Surgery is recommended when deviation causes health problems affecting daily life and sleep quality. Medication can ease mild symptoms but does not straighten the septum: Cleveland Clinic notes that surgery is the only way to correct the deviation.

That surgery is septoplasty. It corrects the septum to improve airflow and is not intended to change the nose’s appearance. The endonasal approach uses the natural openings and leaves no external incision. According to SEORL-CCC, the endoscopic approach can be used for the vast majority of deviations and, in many cases, avoids sutures or nasal packing.

It is also useful to know its limits: septoplasty alone does not remove polyps or guarantee resolution of sinusitis, snoring or apnoea.

Before surgery, it is checked whether obstruction responds to medical treatment. Topical treatments and antihistamines are among the non-surgical options. If these are insufficient, turbinate surgery reduces their volume.

Radiofrequency is one option: it reduces tissue using controlled thermal energy. SEORL-CCC describes it as the most commonly used surgery to reduce obstructing turbinates, very often in patients with rhinitis. Techniques to reduce the submucosal tissue and bone component also exist. The procedure is performed through the nostrils, without external scars and generally without nasal packing. In selected patients, it can be performed at the clinic under local anaesthesia.

Two limits should be clear. Turbinate surgery does not treat rhinitis or allergy, although it is widely used in patients with rhinitis. It is not always definitive either: some people need a repeat procedure, especially if they have chronic allergic problems. Excessive tissue reduction can alter nasal function and be associated with empty nose syndrome, so the aim is to preserve functional tissue.

These are three different procedures. Septoplasty corrects the septum to address obstruction and improve breathing. Rhinoplasty changes the shape or size of the nose; functional rhinoplasty addresses alterations of nasal structures that hinder breathing, such as a narrow nasal valve. When both the septum and the shape need correction, the combined procedure is septorhinoplasty.

If the turbinates also restrict airflow, assessment takes this into account: turbinate surgery acts on another structure and is decided according to the location of the problem. Examination, rather than the name of a technique, determines the appropriate combination.