Septoplasty and nasal obstruction: what does the evidence show?

A deviated nasal septum is common, but its appearance alone does not establish that it is causing troublesome breathing symptoms. The clinical question is whether straightening the septum improves how people feel and function compared with a defined non-surgical approach. The UK NAIROS trial addressed that question in adults referred to ear, nose and throat services with a visible septal deviation and at least moderate nasal obstruction.^[1] It studied septoplasty for breathing symptoms; it did not test cosmetic rhinoplasty or promise a particular result for an individual.

What septoplasty changes, and what it does not

The nasal septum is the partition of cartilage and bone between the two nasal passages. When it is deviated, it may narrow one side. The opposite inferior turbinate can also become enlarged, so obstruction may be experienced on both sides. Septoplasty reshapes or repositions septal structures through the nostrils to widen the airway. In NAIROS, surgeons could also reduce the inferior turbinate on the anatomically wider side, using a mucosa-preserving technique, if they considered it appropriate. That additional procedure was not assigned at random.

Septoplasty and rhinoplasty answer different questions. Septoplasty in this trial was aimed at an internal partition and breathing-related symptoms. Rhinoplasty can alter the external shape of the nose and may involve other functional work. The NAIROS results therefore cannot be used to estimate cosmetic change, to compare rhinoplasty techniques, or to promise that breathing will become normal. A clinician has to assess whether the septum is the relevant cause of symptoms and whether other nasal or sinus conditions need attention.

How the NAIROS trial was run

NAIROS was a pragmatic, open-label, parallel-group randomised controlled trial at 17 NHS ear, nose and throat clinics in England, Scotland and Wales. Between January 2018 and December 2019, 378 adults were allocated in a 1:1 ratio: 188 to septoplasty, with or without turbinate reduction, and 190 to medical management. The study was funded by the UK National Institute for Health and Care Research (NIHR) Health Technology Assessment programme. Randomisation was stratified by sex and baseline nasal symptom severity.^[1]

Participants were eligible if they were adults newly referred with nasal obstruction associated with septal deviation, had at least moderate obstruction on the NOSE questionnaire (score above 30 on its 0–100 scale), and had septal deflection visible at nasendoscopy. People with relevant coexisting nasal or sinus pathology, previous septal surgery, external bony deformity, or certain surgical contraindications were excluded. This selection matters: the findings apply most directly to a referred group with appreciable symptoms and a visible deviation, rather than to everyone whose septum looks crooked.

The medical group received isotonic saline spray twice daily followed by mometasone nasal steroid spray twice daily for six weeks, then a reduced daily dose, continuing for six months. Participants assigned to this group could discuss septoplasty after the six-month primary outcome assessment. The surgical arm reflected routine NHS practice across sites: the approach was closed, without grafts, while surgeons could use different standard techniques to straighten the septum. The trial therefore compared care pathways, not one narrowly standardised operative manoeuvre against another.

How symptoms and airflow were measured

The primary outcome was the Sino-Nasal Outcome Test-22 (SNOT-22) at six months after randomisation. It is a 22-question patient-reported measure covering nasal symptoms and related effects such as sleep and emotional wellbeing. Each item is scored from 0 to 5, giving a total from 0 to 110; higher scores mean worse symptoms. A nine-point change had been selected in advance as the minimum clinically important difference.^[1] This is a group-level threshold to help interpret average change, not a guarantee that each person will notice the same benefit.

The researchers also collected SNOT-22 at 12 months, the five-item NOSE scale (transformed to 0–100, with higher scores indicating worse obstruction), quality-of-life questionnaires, and measures of nasal airflow such as peak nasal inspiratory flow and rhinospirometry. The trial was open label, so participants and clinicians knew the assigned treatment. That is difficult to avoid when comparing surgery with sprays, but expectations can influence reported symptoms. Objective airflow measurements can add context, although they do not replace how a person experiences breathing.

The six-month symptom results

At six months, primary outcome data were available for 307 participants: 152 assigned to septoplasty and 155 assigned to medical management. The adjusted intention-to-treat analysis compared groups according to their original random allocation, accounting for baseline SNOT-22 and the stratification factors. Mean SNOT-22 was 19.9 (95% confidence interval [CI] 17.0 to 22.7) in the septoplasty group and 39.5 (95% CI 36.1 to 42.9) in the medical-management group. The estimated between-group difference was 20.0 points in favour of assignment to surgery (95% CI 16.4 to 23.6 points greater improvement; p<0.001).^[1]

The confidence interval stayed beyond the pre-specified nine-point threshold, so the average advantage was larger than that threshold in this trial. Both groups improved from baseline: the surgical group’s mean score fell from 44.5 to 19.9, while the medical group’s fell from 44.1 to 39.5 among those with six-month data. These averages describe the study groups, not an individual forecast. Some participants may improve more, less, or not at all, and the questionnaires do not identify the cause of every person’s obstruction.

The effect varied with starting symptom severity. The exploratory analysis suggested a smaller average added benefit among participants near the lower end of the eligible NOSE range and larger differences at higher baseline scores. The moderate-symptom subgroup was small, so this pattern should not be treated as a precise prediction tool. It does support asking about symptom burden and its effect on daily life, rather than making a decision from the visible angle of the septum alone.

What remained at 12 months

The advantage was still present at one year, although smaller. The adjusted difference in SNOT-22 improvement was 10.1 points in favour of the surgical assignment (95% CI 5.6 to 14.5; p<0.001).^[1] Mean scores at 12 months were 21.2 (95% CI 17.7 to 24.6) for the septoplasty group and 30.4 (95% CI 26.6 to 34.3) for the medical-management group. Thirty-seven people assigned to medical management chose septoplasty after the six-month assessment; their later surgery contributed to narrowing the group difference. Follow-up beyond 12 months was not reported as a trial outcome.

The COVID-19 pandemic interrupted face-to-face visits from March 2020. Some questionnaires were collected remotely, but in-person examinations and objective airflow measurements were unavailable for many later assessments. At 12 months, only 66 participants assigned to surgery and 72 assigned to medical management completed objective flow measures. The authors cautioned that this limited interpretation of between-group objective results at that time point. The primary six-month symptom finding remained supported by sensitivity analyses, but the later evidence is less complete for measured airflow than for questionnaire scores.

Complications and other trade-offs

Among participants who underwent septoplasty during the trial, including people who crossed over after six months, reported events with available denominators included readmission with bleeding (7/174; 4%), infection requiring antibiotics (20/172; 12%), changed sense of smell (19/171; 11%), upper-teeth numbness (18/171; 11%), and a reported change in nasal appearance (17/171; 10%). Denominators varied by event according to available reports. Clinicians recorded six septal perforations (3%) and seven intranasal adhesions (4%). No participant required repeat surgery during the reported follow-up.^[1] These are trial counts under its follow-up and definitions; they are not a complete list of possible risks or a rate that can be assumed for every setting.

The HTA report counted 132 adverse events in the surgical-assignment arm and 95 in the medical-management arm. It also recorded 14 and nine serious adverse events, respectively. Event totals are not the same as the number of people affected, and the categories included events beyond the specific surgical complications listed above. In a separate economic analysis from the NHS and Personal Social Services perspective, surgery cost more over 12 months and improved symptoms more; its estimated probability of being cost-effective at a £20,000 per quality-adjusted life-year (QALY) threshold was 15% at 12 months, rising in the report’s model to 99% at 24 months and 100% at 36 months. Those are UK health-system model estimates, not personal prices or proof of value in another country or healthcare system.^[2]

What the evidence can and cannot say

Random allocation and a defined spray regimen make NAIROS stronger evidence than an uncontrolled before-and-after series for the specific comparison it tested. Its pragmatic design also reflects variation in standard surgical practice. At the same time, the trial was open label, recruited through UK NHS referral clinics, and enrolled people with at least moderate symptoms and a visible deviation. It does not establish the best option for people with mild symptoms, a different underlying cause, prior surgery, substantial external deformity, or a different mix of services and follow-up.

The trial measured symptom questionnaires and selected airflow outcomes; it did not establish that septoplasty prevents sleep apnoea, cures every cause of nasal congestion, improves appearance, or produces a particular recovery time. Nor did it compare septoplasty with cosmetic rhinoplasty. A separate HTA report is a fuller publication of the same NAIROS trial, not an independent replication. The evidence supports a conversation about likely average symptom improvement and potential harms, while leaving individual suitability and expected results to a qualified clinician’s assessment.

Questions to discuss with a clinician

• What findings suggest that a deviated septum is contributing to my obstruction, and could another nasal condition be involved?
• What improvement would be realistic for my starting symptoms, and how will it be measured?
• What are the likely benefits and risks of continued medical management compared with surgery in my circumstances?
• Would turbinate reduction or another procedure be considered, and why?
• What follow-up and support would be available if symptoms persist or a complication occurs?

Using the evidence in a combined plan

NAIROS informs the discussion of septoplasty for obstruction linked to septal deviation; it does not set a price or define a commercial treatment package. People comparing broader nasal surgery options can read about rhinoplasty costs in Turkey and browse the rhinoplasty packages directory. These pages concern rhinoplasty information and a branch directory; neither is a septoplasty-specific price or a statement that the trial’s operation, assessment, or outcome is included. Ask the relevant healthcare partner to clarify the scope of any proposed service before making a decision.

Just Clinic Istanbul is an independent marketing and lead-generation platform, not a healthcare provider or medical tourism intermediary. Enquiries may be shared with authorised healthcare partners with your consent. This research summary is general information and does not replace clinical assessment.

References

1. Sean Carrie, James O’Hara, Tony Fouweather, Tara Homer, Nikki Rousseau, Leila Rooshenas, Alison Bray, Deborah D Stocken, Laura Ternent, Katherine Rennie, Emma Clark, Nichola Waugh, Alison J Steel, Jemima Dooley, Michael Drinnan, David Hamilton, Kelly Lloyd, Yemi Oluboyede, Caroline Wilson, Quentin Gardiner, Naveed Kara, Sadie Khwaja, Samuel C Leong, Sangeeta Maini, Jillian Morrison, Paul Nix, Janet A Wilson, M Dawn Teare Clinical effectiveness of septoplasty versus medical management for nasal airways obstruction: multicentre, open label, randomised controlled trial. The BMJ. 2023;383:e075445. Published 18 October 2023. doi: 10.1136/bmj-2023-075445. PMID: 37852641. PMCID: PMC10583133.
2. Sean Carrie, Tony Fouweather, Tara Homer, James O’Hara, Nikki Rousseau, Leila Rooshenas, Alison Bray, Deborah D Stocken, Laura Ternent, Katherine Rennie, Emma Clark, Nichola Waugh, Alison J Steel, Jemima Dooley, Michael Drinnan, David Hamilton, Kelly Lloyd, Yemi Oluboyede, Caroline Wilson, Quentin Gardiner, Naveed Kara, Sadie Khwaja, Samuel Chee Leong, Sangeeta Maini, Jillian Morrison, Paul Nix, Janet A Wilson, M Dawn Teare 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(10):1–213. Published March 2024. doi: 10.3310/MVFR4028. PMID: 38477237. PMCID: PMC11017631. Full report of the NAIROS trial reported in reference 1; not an independent trial.