One of the most commonly misunderstood topics with the lay public and even the medical community is the deviated nasal septum. Quite often, I hear patients tell me, “my deviated septum is causing my sinus headaches,” or “I have a deviated septum from a baseball accident.” While both these statements are not completely false, they both imply that having the former always causes the latter, which is not true.
I made a video called “The Deviated Septum Myth” over 10 years ago to make the point that even if you have a deviated septum, it’s not always the sole cause of your stuffy nose or sinus infections. It’s one of the most popular videos that I’ve done, as well as the only video with an avalanche of derogatory, profanity-laden, hate-filled comments. Ultimately, I had to disable comments for this one video.
Before I cover the 5 deviated septum myths, a short anatomy lesson is needed. The nasal septum is a thin midline wall of cartilage and bone in the middle of your nasal cavity that starts in the front of your nose. It ends about half-way towards the back of your head, near the area of your ears. Only the front cartilaginous portion protrudes into the part of the nose that you can feel. There are four distinct portions: the qradrangular cartilage, which is in the front, the perpendicular plate of the ethmoid bone, which is behind the quadrangular cartilage, and the vomer, which is a triangle-shaped bone that makes up the back and lower part of the septum, close to the nasopohayrnx, where your ears drain through the eustachian tube. The palatine bone makes up the smallest area and is in the back.
The lower, bottom portion of the nasal septum sits in a groove on a slightly raised crest of bone, which is a part of the maxilla (which holds your upper teeth). Typically, the cartilage sits straight vertically within the groove and the small adjacent portions of maxillary crest bone is relatively narrow, with a mucous membrane covering on both sides. A normal nasal septum should look relatively flat with a 90 degree configuration between the septum and the nasal floor.
During normal development, the floor of the nose (roof of your mouth) drops down as the upper jaw enlarges and the nasal septum grows downward. If for whatever reason, the floor of the nose doesn’t drop fully, then the septum becomes compressed, and has no were to go, and buckles to one side or the other. Sometimes, the lower part of the septum pushes to one side of the maxillary crest groove, creating a bony “spur” that pushes to one side. Typically, during septum surgery, you’ll find a deviated bony spur along with the deviated septal cartilage.
I’ve talked extensively on this website and in my book, Sleep, Interrupted about why our jaws and faces are not growing optimally. As you can imagine, lack of expansion of the dental arches can lead to dental crowding and crooked teeth. (Here’s a video of my interview with an orthodontist about why we have crooked teeth.)
Now let’s go over the 5 most common myths and misconception about the nasal septum.
1. A deviated septum causes sinus infections.
Honestly, I see a lot of severely deviated nasal septums with no sinus problems whatsoever. Having a deviated septum alone is not the only reason for having a stuffy nose or being prone to sinus problems such as infections or headaches. The main point of my deviated septum myth video is that there are always a number of other reasons that contribute to your problems, such as enlarged nasal turbinates, flimsy nostrils, large adenoids, allergies, nasal polyps, and even acid reflux.
By definition, if you have a deviated septum, your nasal cavity sidewalls are more narrow, since you have more narrow upper jaws. This creates less space on both sides of your septum, and if you have even minor swelling of your nasal turbinates from allergies or colds, you’re more likely to get a stuffy nose. Additionally, the more narrow your nasal sidewalls, the more narrow the angle between your septum and your nostrils, making it more susceptible to caving in when you inhale through your nose.
Oftentimes, what may seem like an “infection” (sinus pain, pressure, nasal congestion, post-nasal drip and headache) is not really an infection, but a sinus migraine, where nerve endings in your sinuses are extra sensitive to weather changes, chemicals, scents, orders and smoke. This is why so often, a cat scan of the sinuses comes back completely normal despite a classic history of sinus infections. Sinus migraines, just like regular migraine headaches, are triggered by stress, certain foods, weather changes, and especially poor sleep.
2. Deviated septum surgery changes your nose on the outside.
There seems to be a lot of confusion between pure septal surgery and rhinoplasty. Surgery for a deviated nasal septum involves only the internal nasal septum, and by definition, won’t change the external appearance of the nose. The one exception to this is if you violate the 1 cm L-strut rule: Preserve an L-shaped 1 cm strut of cartilage corresponding to the lower 2/3 of the front part nose (looking from the side) and the lower portion that meets your upper jaw. This L strut supports your nose and removing too much of any part of this L strut without reinforcement or reconstruction can lead to what’s called a saddle nose deformity (a depression in the middle of your nose), or your nasal tip can droop down.
Rhinoplasty simply means any kind of surgery for the external nose, whether done for functional or cosmetic reasons. It can be performed with or without septal surgery. Only if you have to break your nasal bones up top will you have black and blue eyes temporarily. Sometimes a patient may say he or she underwent a deviated septum repair to avoid saying that a rhinoplasty was performed.
3. You need packing after septal surgery.
Traditionally, nasal packs are used to keep the mucous membranes of the septum pressed together to keep blood from filling up after septal surgery. The worse case scenario is when you have a large blood clot in the space between the mucous membrane flaps, which separates away from the remaining L strut cartilage, which can weaken due to lack of blood flow. This is why most surgeons will use temporary packs made of expandable sponges, gauze, or silastic stents to keep the tissues sandwiched together for a few days.
Needless to say, having nasal packs can be a very uncomfortable experience. Taking them out can be even more uncomfortable. Some surgeons, like myself, don’t use any packs or splints. What I do is to spend a little more time to place a dissolvable quilting stitch back and forth to keep the flaps together, allowing the patient to breathe better right away. It does get clogged a few days later, so a cleaning is needed in the office on the first post-op visit.
4. A deviated septum comes from nasal trauma.
One commonly taught concept in our field (ENT) is that perhaps nasal trauma from coming out of the birth canal can contribute to a deviated nasal septum. The problem with this theory is that many children born via c-sections have severe deviated nasal septums, with no history of nasal trauma during their lifetimes. Yes, bad nasal trauma can cause a crooked septum, but not in a way that you may think.
A study many years ago showed that in general, traumatic septal deflections had a curvature in the front to back plane, whereas non-traumatic deviated septums had a side to side deflection, much deeper inside the nasal cavity, behind the facial bones. What I also notice is that deviated nasal septums are uncommon in young children. I start to see it more often as children get older, especially in the early teen years. This observation goes along with the above statement that a deviated nasal septum happens from improper facial growth and development.
5. A deviated nasal septum can come back after corrective surgery.
While this is theoretically possible, it’s very unlikely. After a septal operation, the tissues heal by scarring and stiffening. There are two major reasons why you can have persistent nasal congestion or recurrent nasal congestion after septal surgery. The most common reason is that you didn’t properly address the two other areas of the nose that can contribute to nasal congestion: enlarged turbinates and flimsy nostrils. Even if the turbinates are properly addressed, I find that due to most surgeons’ inclination for a more conservative procedure, results may be adequate initially, but with time, with persistent inflammation or allergies, the turbinates enlarge again. Weak nostrils are not addressed as often as it should. In most cases, external nasal dilation such as Breathe Right Strips, or various internal dilators (Brez, Nozovent, Mute, etc.) can address this without surgery. However, ENT surgeons are slowly recognizing that this is an issues that needs to be addressed.
I routinely see patients who underwent septoplasty and turbinoplasty with another surgeon within 6 to 12 months, I see both situations mentioned above. The septum is straight, but the turbinates are still too large, or the nostrils are too flimsy. Sometimes, it’s clear that the septal operation was not aggressive enough to treat all the areas of deviation.
Breathe Better, Sleep Better, Live Better
Since the nose the initial point of entry for air to enter your body, it’s important to address this first. Having a stuffy nose can affect your breathing downstream, potentially aggravating more vacuum forces that can make your soft palate or tongue base to collapse when your throat muscles are more relaxed. Additionally, having nasal congestion has been shown to prevent optimal use of CPAP or mandibular advancement devices. So before you consider ways to get more oxygen into your lungs and body, make sure you’re physically able to get the air you breathe properly past your nose.
Access my free report, “Unstuff Your Stuffy Nose,” to discover ways you can immediately breathe better, sleep better and live better.