Nasal obstruction

Nasal obstruction is a sensation of reduced airflow through one or both nasal passages. Most cases are due to rhinitis, nasal polyps, septal deviation or turbinate hypertrophy.

Anatomy and physiology. The nasal valve is the narrowest point; the turbinates regulate airflow and undergo a normal nasal cycle. The sensation of obstruction does not match measured resistance, and empty nose syndrome and rhinitis medicamentosa also cause it.

Classification. Unilateral (septal deviation, polyp, tumour, foreign body, choanal atresia) or bilateral (rhinitis, rhinosinusitis, polyps, adenoids, turbinate hypertrophy). Acute (under 4 weeks), subacute (4 to 12 weeks) and chronic (over 12 weeks).

Key distinctions. Unilateral persistent obstruction with blood stained discharge or epistaxis suggests tumour. Alternating obstruction suggests the nasal cycle or rhinitis. A child with unilateral foul discharge has a foreign body until proven otherwise.

History. Duration, laterality, constant or alternating, discharge (clear, purulent, bloody, foul), sneezing, itch, smell loss, facial pain, snoring, mouth breathing, sleep disturbance, epistaxis, hearing loss, trauma, surgery, allergens, occupational exposures, topical decongestant use, intranasal drug misuse (cocaine), and asthma, aspirin sensitivity and nasal polyps.

Drug history. Topical decongestants (oxymetazoline, xylometazoline), beta blockers, ACE inhibitors, alpha blockers, phosphodiesterase inhibitors, oral contraceptives, aspirin and NSAIDs (aspirin exacerbated respiratory disease), and cocaine.

Examination. External nose (deviation, collapse on inspiration, saddle deformity), anterior rhinoscopy (septal deviation, haematoma, perforation, mucosal colour, turbinates, polyps, crusting, foreign body), nasal endoscopy, Cottle manoeuvre (improvement with lateral cheek traction indicates nasal valve collapse), oropharynx (adenoids), ears (effusion), face, eyes and neck.

Red flags

• Unilateral obstruction with bleeding, ulceration or mass
• Facial swelling, pain, numbness, proptosis, diplopia or visual loss
• Cranial nerve palsy or neck mass
• Septal haematoma after trauma
• Foul unilateral discharge in a child
• Persistent obstruction with weight loss
• Diabetes or immunosuppression with black necrotic mucosa
• Meningism or fever with sinusitis

Special groups. Children: adenoidal hypertrophy, foreign body, choanal atresia (neonate), allergic rhinitis. Pregnancy: rhinitis of pregnancy. Older adults: tumour and atrophic rhinitis. Region specific: nasopharyngeal carcinoma, rhinosporidiosis, mucormycosis and leishmaniasis in some regions.

Inflammatory and mucosal

• Allergic rhinitis, non-allergic rhinitis, vasomotor rhinitis
• Acute viral rhinitis, acute and chronic rhinosinusitis
• Nasal polyposis (chronic rhinosinusitis with polyps), aspirin exacerbated respiratory disease, allergic fungal sinusitis
• Rhinitis medicamentosa, cocaine use, rhinitis of pregnancy and hormonal rhinitis
• Granulomatosis with polyangiitis, sarcoidosis, eosinophilic granulomatosis with polyangiitis

Structural

• Septal deviation, septal haematoma and abscess, septal perforation
• Inferior turbinate hypertrophy, concha bullosa
• Nasal valve collapse
• Adenoidal hypertrophy, choanal atresia
• Foreign body (including button battery, magnets), rhinolith

Neoplastic and invasive

• Inverted papilloma, nasal and sinus carcinoma, nasopharyngeal carcinoma, juvenile nasopharyngeal angiofibroma, olfactory neuroblastoma, lymphoma
• Antrochoanal polyp, encephalocele, glioma
• Rhinosporidiosis, mucormycosis, leishmaniasis, tuberculosis

Other

• Trauma and fracture, post-surgical synechiae
• Atrophic rhinitis, empty nose syndrome
• Functional (sensation without objective obstruction)

Reasoning. Examine the nose and decide on topical treatment trial for typical rhinitis and polyp disease, and on imaging or biopsy for unilateral, bleeding or atypical disease.

First line. Anterior rhinoscopy and nasal endoscopy. Peak nasal inspiratory flow for objective measure where available.

Targeted tests. Skin prick tests or specific IgE for allergic rhinitis. CT sinuses without contrast for chronic rhinosinusitis, polyps, suspected anatomical cause or before surgery. MRI with contrast for suspected tumour, orbital or intracranial extension. Biopsy of any suspicious mass (not an angiofibroma in a young male until imaged).

Full blood count with eosinophils, ANCA, angiotensin converting enzyme, and nasal biopsy for systemic granulomatous disease. Nasal swab and culture for crusted or refractory infection, and fungal microscopy for suspected mucormycosis or allergic fungal sinusitis (urgent). Chest radiograph for sarcoidosis or tuberculosis. Cystic fibrosis testing in children with polyps. Epstein Barr virus serology in suspected nasopharyngeal carcinoma.

Limitations. Nasal symptoms correlate poorly with objective findings. CT is abnormal in many asymptomatic adults.

Emergencies.

• Septal haematoma or abscess: urgent drainage by ENT, with antibiotics (co-amoxiclav 625 mg orally three times daily for 7 days), to prevent cartilage necrosis.
• Foreign body: removal; button battery or magnets need immediate removal.
• Suspected mucormycosis (diabetic ketoacidosis, immunosuppression, black necrotic mucosa): immediate ENT, ophthalmology and infectious disease referral; liposomal amphotericin B 5 mg/kg IV daily (up to 10 mg/kg with CNS disease), glycaemic control, urgent surgical debridement.
• Acute sinusitis with orbital or intracranial complication: admit, ceftriaxone 2 g IV every 12 hours plus metronidazole 500 mg IV every 8 hours, and urgent imaging and surgical review.

Allergic and non-allergic rhinitis.

• Intranasal corticosteroid: mometasone 50 micrograms, 2 sprays to each nostril once daily (maximum 200 micrograms daily), or fluticasone propionate 50 micrograms, 2 sprays to each nostril once daily; benefit after several days, continuous use; technique review; nosebleed and crusting as adverse effects.
• Oral non-sedating antihistamine: loratadine 10 mg orally once daily or cetirizine 10 mg orally once daily (5 mg in renal impairment). Intranasal azelastine 0.1 percent, 1 spray to each nostril twice daily.
• Saline nasal irrigation, allergen avoidance, and montelukast 10 mg orally at night for asthma coexistence.
• Short course oral prednisolone 30 mg daily for 5 to 7 days only for severe obstruction or polyps.
• Immunotherapy by specialists for refractory allergic rhinitis.

Rhinitis medicamentosa. Stop the topical decongestant (abrupt stop with intranasal corticosteroid and saline irrigation), and offer prednisolone 20 to 30 mg orally for 5 days in severe cases.

Chronic rhinosinusitis with or without polyps. Saline irrigation, intranasal corticosteroid (mometasone 50 micrograms, 2 sprays to each nostril once daily, maximum 200 micrograms daily; drops for polyps), prednisolone 30 mg orally daily for 7 to 14 days for polyps (check glucose and blood pressure), and ENT referral for surgery when medical treatment fails over 3 months. Doxycycline 100 mg orally twice daily for 3 weeks only by specialist decision.

Acute bacterial rhinosinusitis. Symptoms over 10 days or deterioration after initial improvement, with purulent discharge and facial pain. Amoxicillin 500 mg orally three times daily for 5 days (maximum 3 g daily); penicillin allergy: doxycycline 200 mg orally on day 1 then 100 mg daily for 5 days (avoid in pregnancy and under 12 years); intranasal corticosteroid and saline irrigation.

Structural causes. Septoplasty, turbinate reduction and nasal valve surgery by ENT after failed medical treatment. Adenoidectomy for adenoidal hypertrophy with obstruction in children. Choanal atresia: neonatal emergency (airway).

Neoplastic and granulomatous disease. Urgent ENT and oncology referral with biopsy. Granulomatosis with polyangiitis: prednisolone 1 mg/kg orally daily (maximum 60 to 80 mg) with rituximab or cyclophosphamide by specialists.

Nasal fracture. Reduction within 5 to 10 days after swelling settles.

Monitoring. Review at 4 to 6 weeks for response to topical treatment, and for blood stained crusting. Review after 3 months of therapy for chronic disease.

Referral and escalation. Same day for septal haematoma, complicated sinusitis, mucormycosis, button battery. ENT within 2 weeks for unilateral obstruction with bleeding or mass, persistent unilateral polyp, and unexplained cranial nerve signs. ENT routine for refractory obstruction after 3 months of medical treatment.

Admission criteria. Orbital or intracranial complications, mucormycosis, septal abscess with systemic illness, or airway compromise in a neonate.

Discharge and safety netting. Return for facial swelling, eye swelling or visual change, severe headache, fever with neck stiffness, nosebleed that does not stop, or unilateral obstruction with bloody discharge.