The short answers

Common cause of obstruction: Deviated nasal septumOften combined with turbinate enlargement or weakness of the nasal valve.
Assessment: Internal examination, not photographs aloneAirflow problems cannot be judged from external appearance.
Combined surgery: Septum and shape can be addressed togetherReferred to as septorhinoplasty when both are done in one operation.
Breathing improvement: Typically noticed once swelling subsidesInternal swelling can make breathing feel worse for the first weeks, which is expected.

Allergy, infection and inflammation of the lining all block the nose, and blockage from those causes improves with medical treatment. An operation cannot correct swelling that a spray would have settled.

Where the framework itself narrows the airway, a spray cannot straighten it. This page covers the causes, how obstruction is measured, what the randomised evidence covers, and why travelling is the harder decision.

Most blocked noses are not a surgical problem

The turbinates humidify inhaled air, and allergy, colds and irritants swell them. Blockage that comes and goes is usually lining rather than structure.

The pattern. Blockage that varies with seasons, pets or dust points to allergy, treated medically.
A proper trial. A nasal steroid or saline spray is normally used for several weeks before it is judged to have failed.
The decongestant test. What improves after it was swelling. What stays narrow is structural.
The 12 week threshold. Specialty society guidance puts valve repair at 12 weeks or more of persistent moderate to severe obstruction, with non-surgical options discussed first.

Surgery does not cure allergy, and it does not treat nasal polyps, chronic rhinosinusitis or obstructive sleep apnoea. Each needs its own assessment.

What actually narrows the airway

Obstruction is a symptom rather than a diagnosis, and more than one cause is usually present.

A deviated septum. The partition between the passages is bent, so one side is narrower. Sprays reduce lining swelling, not the deviation.
Enlarged turbinates. Allergy or chronic inflammation enlarges them. Turbinate reduction is usually added to another operation rather than done alone.
A narrow internal valve. The narrowest segment of the airway, about 1.5 cm inside the nostril, and often the cause when the septum looks straight. See nasal valve collapse.
External valve collapse. The nostril rim and soft side wall draw inwards on a deep breath in, so it shows only on inspiration.
An old injury. Bones and septum healed off centre after a fracture, so the twist outside and the blockage inside are one injury.
Narrowing after previous surgery. A hump reduced without rebuilding the middle third can leave the valve tighter than before.

Treating the septum alone while the valve collapses leaves the person blocked. Airway and shape corrected in one operation is septorhinoplasty.

Measuring obstruction, and why a photograph cannot

Obstruction is measured with a validated questionnaire, not an impression. The Nasal Obstruction Symptom Evaluation, or NOSE scale, was validated in 2004. Five items are scored from 0 to 4. The total is then multiplied by 5.

A severity classification derived from 345 patients grades the total:

Mild. 5 to 25.
Moderate. 30 to 50.
Severe. 55 to 75.
Extreme. 80 to 100.

A score of 30 best separated obstructed from unobstructed patients. The score is subjective and does not show where the narrowing sits, so it never replaces examination.

What a scan will not settle

In its position statement on nasal valve repair, the American Academy of Otolaryngology-Head and Neck Surgery calls symptomatic valve dysfunction a clinical diagnosis from history and examination. CT is unreliable, so a normal scan does not rule it out.

The examination takes minutes: a speculum or endoscope in each passage, repeated after a decongestant, and the side wall watched on a deep breath in.

What the randomised evidence shows

For genuine septal deviation, surgery has been tested against medical treatment. The NAIROS multicentre randomised controlled trial, published in the BMJ in 2023, enrolled 378 adults with septal deviation and a NOSE score above 30.

They received either septoplasty or medical management with a nasal steroid and saline spray.

20.0 points

Difference in mean SNOT-22 at six months. Scores were 19.9 after septoplasty and 39.5 with medical management, and a lower score means fewer symptoms. The trial pre-specified 9 points as clinically important.

NAIROS randomised controlled trial, BMJ 2023

The trial recorded harms in the septoplasty group: readmission with bleeding in about 4 per cent, and antibiotics in about 12 per cent.

Scope

NAIROS randomised septoplasty, the airway operation alone. It did not test a combined cosmetic and functional procedure, and should not be quoted as if it had.

Improvement means measurably better airflow, not a nose that never blocks. Breathing difficulty is itself a recognised risk of nasal surgery, usually temporary but occasionally lasting.

Why travelling for this deserves a harder look

A cosmetic consultation can begin from photographs. A breathing one cannot. The septum, the turbinates and the valve sit inside the nose, so a remote assessment cannot establish which is the problem.

A plan made without examination can be aimed at the wrong structure, and the patient has usually flown home before anyone finds out.

Much of what this page describes is treated medically, without an operation and without a flight. That is worth settling locally before a combined operation is booked abroad.

Before committing to a surgeon

A surgeon should examine both passages and record an obstruction score before operating on an airway. Ask whether they do, and ask before you book. Our doctors answer questions sent through the site.

Questions to ask a surgeon

Take these to a consultation. The consultation checklist is built to be printed and written on, and our doctors will answer questions sent through the site before you travel.

Which structure is blocking my nose: the septum, the turbinates, the valve, or more than one of them?
What did you find when you examined both passages, and what changed after the decongestant?
Have I had a proper trial of medical treatment, and for how long, before surgery is considered?
What is my NOSE score today, and will you record it again months after surgery?
Will this operation change the way my nose looks, and in which direction?
If my breathing is worse six months from now, who examines me, and where?

Sources

Every source below was opened and checked. We link to health authorities, peer-reviewed journals and professional bodies, and to nothing else.

Clinical effectiveness of septoplasty versus medical management for nasal airways obstruction: multicentre, open label, randomised controlled trialThe BMJ, via PubMedThe NAIROS trial. Randomised evidence that septoplasty outperforms medical management in adults with obstruction associated with a deviated septum.
Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scaleOtolaryngology-Head and Neck Surgery, via PubMedThe validated instrument used to measure nasal obstruction before and after surgery.
Position statement: nasal valve repairAmerican Academy of Otolaryngology-Head and Neck SurgerySpecialty society position that nasal valve compromise is a distinct, treatable cause of obstruction.
Development of a severity classification system for subjective nasal obstructionJAMA Facial Plastic Surgery, via PubMedHow NOSE scores translate into mild, moderate, severe and extreme obstruction.