1. Residual deviation left at surgery
   • A posterior bony spur, high deviation, or caudal/anterior deviation may not have been fully corrected.
   • Persistent posterior septal spurs are a recognized reason for continued obstruction after septoplasty. Cummings Otolaryngology Head and Neck Surgery, section “Complications of Septoplasty.”
2. Cartilage memory or healing-related shift
   • Septal cartilage can bend back toward its original shape, particularly in severe, S-shaped, caudal, or traumatic deviations.
   • Scar contraction during healing can also pull structures off-center.
3. New trauma
   • Even a seemingly minor nasal injury after surgery can re-deviate the septum.
4. Inferior turbinate enlargement
   • Turbinates can remain enlarged or enlarge again due to allergy, irritants, infection, or chronic rhinitis. A straight septum alone will not fix this. ENT Health notes that allergies and turbinate swelling commonly cause nasal blockage.
5. Nasal valve narrowing or collapse
   • The narrowest portion of the nasal airway may collapse during inspiration, especially if support is weak or was affected by prior surgery. This can feel exactly like a deviated septum.
   • It is more likely if an external nasal strip noticeably improves breathing. Mayo Clinic describes assessment for persistent obstruction, including valve problems and altered cartilage support.
6. Adhesions or scar bands
   • Internal scarring between the septum and turbinate/lateral nasal wall, called synechiae, can obstruct airflow.
7. Inflammatory nasal disease
   • Allergic rhinitis, non-allergic rhinitis, chronic rhinosinusitis, nasal polyps, and medication-related congestion can cause ongoing blockage even with a corrected septum.
8. Early postoperative swelling
   • If surgery was recent, swelling, crusting, and healing can mimic recurrence. Final airflow is often not judged until healing has progressed over several weeks to months.
9. Mismatch between the visible anatomy and symptoms
   • Nasal obstruction is partly subjective and can vary with the normal nasal cycle, seasons, allergies, and sleep position. A small residual bend is not always the actual cause of symptoms.

• 0-6 weeks: blockage is often from swelling, crusts, splints, or healing. Do not judge the final result yet.
• 6 weeks to 3 months: your ENT can assess healing and treat contributors such as allergies, turbinate swelling, infection, or adhesions.
• 3-6 months: persistent, clearly documented obstruction warrants a detailed reassessment, often including nasal endoscopy and evaluation for nasal-valve collapse.
• 6-12 months: usual window to consider revision if symptoms remain significant despite healing and appropriate medical treatment, and an anatomical cause is found.

1. ENT review with anterior examination and nasal endoscopy.
2. Assess airflow before and after a decongestant.
3. Check specifically for nasal-valve collapse.
4. If the cause is still unclear or revision is being considered, consider rhinomanometry/acoustic rhinometry and a CT if sinus disease or complex anatomy is suspected.

• In a large US study of 295,236 patients, about 1.1% underwent revision septoplasty. That measures repeat surgery, so it likely underestimates people who still have symptoms but do not choose another operation. Large revision-rate study
• A 2025 meta-analysis of randomized trials reported a revision rate of about 0.31%, with overall symptom improvement more apparent at 6 and 12 months. 2025 meta-analysis
• Studies of outcomes report a wider range of “not fully relieved” symptoms, sometimes up to about 15%, because this includes all persistent blockage, not just an actual recurrent septal bend.

• Actual septal re-deviation: relatively uncommon.
• Persistent feeling of blockage: more frequent, and often due to something other than recurrence, such as turbinate swelling from rhinitis/allergy, residual posterior bony deviation, scar adhesions, or unrecognized nasal-valve collapse.

• Maxillary sinuses: Both look largely air-filled and clear on this slice. I do not see obvious fluid levels or marked sinus opacification here.
• Nasal septum: It does not look perfectly midline on this one image. There appears to be a mild residual deviation/irregularity, with relative narrowing of one nasal passage. However, its exact direction and severity cannot be reliably established from one screenshot.
• Turbinates/nasal lining: There may be some turbinate prominence, but this needs assessment through the complete CT series and, more importantly, nasal endoscopy.
• No obvious destructive bone lesion or large mass is apparent on this one image.

Important limitation

1. Residual or recurrent septal deviation, including caudal and posterior bony spur
2. Inferior turbinate hypertrophy
3. Synechiae, meaning internal scar bands
4. Nasal-valve narrowing/collapse
5. Sinus drainage-pathway blockage or chronic sinus inflammation

Most common cause

• Hashimoto’s thyroiditis: the commonest cause. It may eventually cause an underactive thyroid, but TSH and free T4 can still be normal early on.

Other possible causes

• Graves’ disease, an autoimmune cause of overactive thyroid
• Postpartum thyroiditis or painless/silent thyroiditis
• Less commonly, other autoimmune conditions can coexist
• Sometimes it is positive in people with normal thyroid function who may never develop overt thyroid disease

• TSH: most important
• Free T4, sometimes Free T3
• Thyroglobulin antibody (TgAb)
• Thyroid ultrasound only if there is enlargement, a lump/nodule, pain, or an uncertain diagnosis

Levothyroxine basics

• Take it on an empty stomach with water, consistently at the same time daily, usually 30-60 minutes before breakfast.
• Separate it from iron, calcium, antacids, and multivitamins by at least 4 hours, because they can reduce absorption.
• TSH is usually rechecked about 6-8 weeks after starting or changing dose. Once stable, it is commonly checked every 6-12 months.
• Do not change the dose or stop the medication on your own.

What is not routinely recommended

• Treating an elevated TPO antibody alone with thyroid hormone when TSH and free T4 are normal.
• Using T3 or desiccated thyroid routinely instead of levothyroxine.
• High-dose iodine or selenium supplements without clinician advice. Excess iodine can worsen autoimmune thyroid disease. Selenium is not a standard substitute for hormone replacement.

Pregnancy or planning pregnancy

Likely diagnosis

• Elevated TSH means the pituitary is working harder to stimulate the thyroid.
• Normal free T4 means thyroid hormone production is still adequate.
• Elevated anti-TPO antibody supports an autoimmune cause, most often Hashimoto’s.

Management for a 35-year-old man

1. Confirm and assess

• Repeat TSH and free T4 in about 2-3 months if this is a first abnormal result, especially if TSH is only mildly raised.
• Review symptoms: fatigue, cold intolerance, constipation, dry skin, weight gain, low mood, hair loss, reduced exercise tolerance, libido/sexual-function changes.
• Review medicines and factors that can affect TSH, including amiodarone, lithium, iodine-containing supplements, and recent acute illness.
• Check a lipid profile and cardiovascular risk factors.
• Do not repeatedly measure TPO antibodies. Once positive, following TSH and free T4 is more useful.
• Thyroid ultrasound is not routinely required. Use it if there is thyroid enlargement, a lump/nodule, asymmetry, neck pressure, hoarseness, or trouble swallowing.

2. Decide on levothyroxine based mainly on TSH

3. If levothyroxine is started

• The prescriber chooses the dose based on TSH level, body weight, symptoms, cardiac history, and other medicines. In mild/subclinical cases, treatment often begins with a lower dose and is adjusted, rather than automatically using a full replacement dose.
• Take it consistently on an empty stomach with water, typically 30-60 minutes before breakfast.
• Keep calcium, iron, antacids, and multivitamins at least 4 hours apart from it.
• Recheck TSH about 6-8 weeks after starting or changing a dose.
• Aim for a TSH in the laboratory reference range. Avoid overtreatment, which can cause palpitations, tremor, anxiety, and long-term bone/heart risks.

4. Avoid unproven approaches

• Do not take high-dose iodine or “thyroid support” products. Excess iodine can aggravate autoimmune thyroid disease.
• Selenium is not a replacement for levothyroxine and should not be self-prescribed at high doses.
• Surgery is not a standard treatment for Hashimoto’s unless there is a suspicious nodule, major goiter with compression, or another specific surgical indication.

Hashimoto’s Monitoring Plan

Now: baseline review

• Repeat TSH and free T4 to confirm the pattern if this was the first abnormal test.
• Record symptoms: fatigue, cold intolerance, constipation, dry skin, weight change, low mood, hair loss, reduced libido, muscle aches.
• Physical examination for thyroid enlargement, asymmetry, nodules, or neck pressure.
• Lipid profile and routine cardiovascular-risk assessment.
• Review medicines/supplements, especially lithium, amiodarone, iodine-containing products, biotin, and “thyroid support” supplements.
• Consider thyroid ultrasound only if there is a goiter, lump/nodule, asymmetry, persistent neck discomfort, swallowing difficulty, hoarseness, or abnormal examination. It is not needed routinely.

Blood-test schedule

Treatment decision points

1. TSH remains mildly high but is below 10 mIU/L

• Symptoms compatible with hypothyroidism
• TSH is rising over time
• TPO antibodies are positive
• Goiter
• High LDL cholesterol or significant cardiovascular risk
• Strong preference after discussing uncertain symptom benefit

2. TSH is 10 mIU/L or higher

3. Free T4 becomes low

If levothyroxine is prescribed

1. Take it at the same time every day, with water, on an empty stomach.
2. Take it 30-60 minutes before food, or at bedtime at least 3-4 hours after the evening meal.
3. Keep calcium, iron, antacids, multivitamins, and some cholesterol medicines at least 4 hours apart.
4. Do not alter the dose based only on symptoms or antibody levels.
5. Dose adjustments should be based primarily on TSH after 6-8 weeks.

What to track between visits

• Energy, sleep, mood, bowel pattern
• Weight trend
• Cold sensitivity and skin/hair changes
• Resting heart rate or palpitations
• New neck swelling, pain, swallowing symptoms, or voice change
• Adherence to any levothyroxine and timing with supplements

Seek an earlier review if

• Rapidly increasing fatigue, marked constipation, swelling, or unexplained weight gain
• Persistent palpitations, tremor, heat intolerance, or unexplained weight loss
• New thyroid swelling, neck lump, trouble swallowing, breathlessness when lying flat, or persistent hoarseness
• TSH rises to 10 mIU/L or above
• Free T4 becomes low

Common symptoms

• Tiredness, low energy, excessive sleepiness
• Feeling unusually cold
• Weight gain or difficulty losing weight
• Constipation
• Dry, coarse skin
• Hair thinning or hair loss, brittle nails
• Puffy face or swelling around the eyes
• Brain fog, poor concentration, slowed thinking
• Low mood or depression
• Muscle aches, joint pains, cramps, weakness
• Reduced exercise tolerance
• Hoarse voice
• Reduced libido or erectile difficulties in men

Signs a clinician may find

• Goiter: enlarged, firm thyroid gland in the front of the neck
• Slow pulse
• Dry/cool skin
• Puffiness
• Slowed reflexes
• High cholesterol
• In more advanced disease, anemia or low sodium can occur

Neck-related symptoms

• Neck fullness or pressure
• Discomfort when wearing a collar
• Difficulty swallowing
• Rarely, breathlessness or persistent hoarseness

In your current pattern