I had nose surgery and still can't breathe well: why and what to do

It can happen even when the operation was done well: the septum may still be deviated, the nasal valve may close when you breathe in, the turbinates may block the airway, internal scars may form or the lining may be inflamed. After healing, an examination with endoscopy clarifies the cause and whether medical treatment or revision surgery is appropriate. This guide is for information only; it does not replace a medical assessment.

It is meant for people who have already had surgery (a septoplasty, a rhinoplasty or a septorhinoplasty) and still feel their nose is blocked. It is understandable to be worried, but it does not mean something was done wrong: several structures affect airflow, the nose heals at its own pace and its lining can become inflamed for reasons unrelated to surgery.

First, let your nose heal

During the first weeks the inside of the nose is swollen, with crusts and thick mucus, so feeling blocked is expected. That swelling goes down gradually over months, and after rhinoplasty the outer part of the nose also takes time to settle.

Studies reflect this timeline. In a pooled analysis of three trials with 721 patients, the advantage of septoplasty over non-surgical treatment was not apparent at 3 months, but it was at 6 and at 12 months [1].

That is why it is wise not to judge the final result too early. Waiting does not mean putting up with anything: if you develop fever, worsening pain, heavy bleeding or complete blockage on one side, seek medical advice without waiting for your follow-up visit.

When the problem lies in the structure of the nose

If you are still breathing poorly after a few months, it is time to look for something physical that narrows the airway. Having a second operation is not the usual course: in a US registry of more than 286,000 adults who had septal surgery, about 1 in 100 had another operation [2].

The septum is still, or again, deviated

The septum is made of cartilage at the front and bone at the back. A deviation can persist or come back at the front edge, next to the nostril, or in the back part, where cartilage meets bone.

Cartilage is also living tissue and can change shape slightly as it heals. That is why a deviation can come back even if the septum was straight at the end of the operation.

In a series of 82 people who had revision surgery because they were still breathing poorly, deviation of the back part of the septum was found in 8 out of 10 and narrowing of the nasal valve in just over half [3]. In other words, several causes often coexist.

The nasal valve closes when you breathe in

The nasal valve is a narrow point in the airway, just behind the nostrils. Doctors distinguish an internal valve, between the septum and the side cartilages, and an external valve, the ala or wing of the nose that surrounds the nostril.

If these side walls are weak, they cave in when you breathe in hard, like a straw that flattens when you suck through it. Septoplasty straightens the septum but does not strengthen these walls, so valve collapse can persist after a correctly performed septoplasty.

After rhinoplasty, healing and changes in support can also alter this area. A clue: if you breathe better when you gently pull your cheek outwards or wear an adhesive nasal strip, the valve may be involved.

Turbinates that are large or grow back

The turbinates are ridges on the side wall of the nose, covered with lining, that warm and humidify the air. If they were already large and were not treated, or if the lining thickens again after they were reduced, they can block the nose even when the septum is straight.

Also, when the septum has been deviated for years, the turbinate on the opposite side may have grown to fill the gap. Once the septum is straightened, that side may end up tighter than expected.

Adhesions and septal perforation

Synechiae (adhesions) are bridges of scar tissue between the septum and the side wall, which form when two raw surfaces touch while healing. A septal perforation is a hole in that wall, which can cause crusting, small bleeds, a whistling sound when breathing and, paradoxically, a feeling of blockage.

Both are uncommon: in a series of 1,506 septoplasties, adhesions appeared in 2.2% and perforation in 0.6% [4]. Adhesions can be divided with a minor procedure.

A perforation is treated according to its size and symptoms. Options range from moisturising care to closure with surgery or a silicone button that covers it.

When the cause does not depend on the operation

Surgery corrects shape, but it does not control inflammation of the lining. That is why a nose with a straight septum can still be blocked if any of these causes is present:

• Allergic rhinitis: the lining reacts to dust mites, pollen, moulds or animal dander.
• Non-allergic rhinitis: the lining becomes congested with temperature changes, strong smells, smoke, hormonal changes or prolonged use of decongestant sprays.
• Nasal polyps: soft growths of inflamed lining, like small grapes, inside the nose and sinuses.
• Chronic sinusitis: long-lasting inflammation of the paranasal sinuses, the air spaces around the nose.

These causes may already be present before the operation or appear afterwards, and sometimes they coexist with a structural problem. Identifying them changes the plan, because their first treatment is medical, not surgical.

How it is assessed

In clinic I examine the front of the nose before and after applying a decongestant, and I watch how the side walls behave when you breathe in. Then I perform a nasal endoscopy: after a local anaesthetic spray, a thin tube with a camera shows the back of the septum, the turbinates, adhesions or polyps.

Depending on the findings, a sinus CT scan or allergy tests may be useful. The NOSE scale, a five-question questionnaire on how much the blockage bothers you, also helps.

Filling it in before and after each treatment lets you compare your progress with more than the impression of the moment. Bring it to your appointment, because what you notice is an essential part of the assessment.

What options are there

If the cause is inflammatory

The first treatment is medical: steroid nasal sprays, saline rinses and, if there is allergy, antihistamines and measures to avoid allergens. For polyps and chronic sinusitis there are specific treatments, which in selected cases include endoscopic sinus surgery or biologic medicines.

Once the inflammation is under control, another operation may not be needed. If you have used decongestant sprays for a long time, it is advisable to stop them gradually and with medical guidance.

If the cause is structural

Functional revision surgery aims to improve breathing and is planned based on what the examination has shown. Depending on the case, it may include:

• Straightening the part of the septum that is still deviated.
• Strengthening the nasal valve with small cartilage grafts from your own body (from the septum, ear or rib).
• Reducing the turbinates or dividing adhesions.
• Closing a perforation if it causes symptoms.

A second operation is prepared with particular care, because there is scar tissue and sometimes less cartilage available. For some valve problems there are also less invasive alternatives, whose usefulness is still being studied.

It is important to have realistic expectations. In the revision series mentioned above, most people regained comfortable breathing, although about 1 in 6 noticed no change in their questionnaires, sometimes with an already straight septum [3].

That is why the decision is taken without rushing, weighing the expected benefit, the risks and what bothers you in daily life. No nasal surgery can guarantee a specific result.

Key points to remember

• Give healing time before judging the result.
• The cause may lie in the structure of the nose, in inflammation of the lining, or in both.
• Treatment depends on the cause: medical if it is inflammatory and revision surgery if it is structural.