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Abstract

  1. Top of page
  2. Abstract
  3. What should you cover in the history?
  4. What should you cover on examination?
  5. What management should you offer?
  6. Conflict of interest
  7. Search strategy
  8. References

Background:  Nasal obstruction is a common presenting symptom to the otolaryngology clinic. A variety of structural and mucosal abnormalities can interrupt the subjective sensation of nasal airflow.

Methods:  This review was based on a literature search last performed on 1 October 2008. Current texts and the MEDLINE, EMBASE and COCHRANE databases were searched using the subject heading nasal obstruction in combination with classification, diagnosis, therapy, drug therapy and surgery. Results were limited to include clinical trials, randomised controlled trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were also reviewed.

Conclusion:  We present an evidence-based approach to history-taking and clinical examination of an adult patient with nasal obstruction and provide an overview of management of the most common causative conditions.

A 23-year-old male presents to the outpatient clinic with a 1-year history of nasal obstruction.

Nasal obstruction is a common presenting symptom to the otolaryngology clinic. Various factors are thought to influence the subjective sensation of nasal airflow including volume of airflow, stimulation of cold receptors in the nasal vestibule and stimulation of sensory nerve endings in the nasal mucosa.1 During inspiration, air enters the nasal vestibule in an oblique vertical direction. Just past the nasal valve the cross-section of the airway becomes greatly expanded, generating a turbulent flow. This transition from laminar to turbulent airflow is functionally desirable; slowing the velocity of inspired air prolongs its contact with the nasal mucosa. This contributes to olfaction and enables the nose to clean, humidify and warm the inspired air. There are several structural and mucosal abnormalities, either singly or in combination, that can affect this process.

What should you cover in the history?

  1. Top of page
  2. Abstract
  3. What should you cover in the history?
  4. What should you cover on examination?
  5. What management should you offer?
  6. Conflict of interest
  7. Search strategy
  8. References
  • 1
    Is the obstruction bilateral, unilateral or alternating? The ‘nasal cycle’ is the physiological periodic alternation in mucosal engorgement, particularly of the inferior turbinate, and subsequent nasal airflow resistance between the two nasal cavities. Nasal obstruction from rhinosinusitis tends to cause obstruction that is bilateral and alternating, exacerbating the normal nasal cycle. Mechanical causes of obstruction such as nasal valve collapse or septal deviation tend to cause fixed unilateral or bilateral blockage, but severity of obstruction can also fluctuate due to the nasal cycle. Unilateral nasal obstruction, especially in the elderly, should raise awareness of the possibility of underlying sinonasal malignancy.
  • 2
    Ask about duration of symptoms. Nasal obstruction dating from an episode of nasal injury is likely to indicate a structural abnormality, most commonly septal deviation.
  • 3
    Is there any seasonal or diurnal variation? Fluctuation in severity suggests a mucosal abnormality rather than mechanical obstruction. Establish aggravating or relieving factors. Resolution of symptoms when the patient is removed from their normal environment, for example whilst on holiday, or seasonal variation points towards an allergic cause.
  • 4
    Ask about associated nasal symptoms. Co-existent nasal discharge, facial pressure/ pain or reduction in smell points towards rhinosinusitis. This term represents a spectrum of inflammatory disease involving the mucosa of the nose and sinuses as a continuum and disease can be classified as acute (symptoms <12 weeks) or chronic (symptoms >12 weeks) with or without polyps.2 Ask about the presence of any middle ear symptoms, as unilateral otitis media with effusion may result from an underlying nasopharyngeal malignancy. Sinonasal malignancy commonly manifests as unilateral nasal obstruction with epistaxis, but may also present with symptoms of disease extension such as facial pain or paraesthesia, epiphora, trismus, proptosis or diplopia. Nasal obstruction can sometimes present with more diverse, non-nasal manifestations such as dry mouth, chronic sore throat, snoring or halitosis.
  • 5
    Ask about sense of smell. Although obstruction of the olfactory cleft secondary to mucosal swelling, polyps, bony deformities and tumours can result in anosmia (inability to detect odours) or hyposmia (diminished olfactory sensitivity), olfactory sensitivity generally does not correlate with nasal patency alone. Cacosmia (perception of a malodorous smell) should raise suspicion of underlying acute or chronic rhinosinusitis, atrophic rhinitis or nasal malignancy.
  • 6
    Do they have any other medical problems? Ask about asthma, aspirin intolerance and cystic fibrosis, as these can be associated with nasal polyposis. Similarly patients with atopy and asthma often suffer from co-existent rhinosinusitis. Other systemic diseases that can present with nasal obstruction include Wegener’s granulomatosis, sarcoidosis, Churg-Strauss, rhinoscleroma, actinomycosis, tuberculosis, fungal infections, syphilis and lymphomas. Nasal symptoms may or may not precede the onset of other systemic features of the disease. In addition to nasal obstruction, these patients may also complain of crusting, blood stained nasal discharge and facial pain.
  • 7
    Has there been any previous nasal surgery or trauma? Previous trauma points towards structural abnormality, whereas previous surgery raises the possibility of postoperative adhesions or recurrent or residual disease.
  • 8
    Ask about current and past medications. Several medications are associated with the development of rhinitis and nasal obstruction including aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors, alpha-adrenoceptor antagonists, methyldopa, beta-blockers and the oral contraceptive pill. What nasal sprays have they used in the past and for how long? Rhinitis medicamentosa results from the overuse of topical nasal decongestants.
  • 9
    Enquire about illicit drug, alcohol and tobacco use. Cocaine abuse can cause extensive osteocartilaginous destruction within the nose that can mimic the clinical picture of other nasal disease. Alcohol can produce physiological vasodilation with nasal congestion and can occasionally provoke a hypersensitivity reaction. Smoking has been shown to impair mucociliary clearance and exacerbate symptoms of rhinitis.3
  • 10
    Ask about pregnancy. Hormonal rhinitis can present during puberty, the menstrual cycle and the last trimester of pregnancy. High levels of circulating oestrogen cause vascular engorgement, which leads to temporary nasal obstruction and hypersecretion.
  • 11
    Ask about work. Occupational rhinitis can result from allergy to airborne agents in the workplace including latex, hard wood dusts, grain, platinum salts, colophony fumes (electrical solder) and isocyanates (resins/paints). Hardwood workers have a higher incidence of sinonasal adenocarcinoma.

What should you cover on examination?

  1. Top of page
  2. Abstract
  3. What should you cover in the history?
  4. What should you cover on examination?
  5. What management should you offer?
  6. Conflict of interest
  7. Search strategy
  8. References
  • 1
    Examine the external framework of the nose for bony or cartilaginous deformity, which can lead to resultant narrowing of the internal nasal passages. Examine for tip ptosis by gently pushing the nasal tip superiorly to assess for improvement in nasal obstruction.
  • 2
    Both the external and internal nasal valve areas should be assessed for obstruction, which can be either static or dynamic, occurring only on inspiration. The internal nasal valve, bordered by the collapsible soft tissue between the upper and lower lateral cartilages, anterior end of the inferior turbinate and the nasal septum, forms the narrowest part of the airway. By providing maximal resistance to airflow even minor narrowing of this area can, according to Poiseuille’s law, lead to symptomatic obstruction for the patient. Manually elevating the cheek to restore nasal patency by indirectly widening the nasal valve has been traditionally used to diagnose this condition (Cottle’s manoeuvre) but there remains doubt over its specificity.4
  • 3
    Anterior rhinoscopy. Should be performed using a headlight and Thudichum speculum before the application of topical decongestant. Visualise the septum and assess for position, spurs, perforation or mucosal abnormality. Is there ulcerated, friable inflammatory tissue suggestive of granulomatous disease? Look for polyps, masses or foreign bodies. Assess the colour and size of the inferior turbinates and general condition of the mucosa.
  • 4
    Nasoendoscopy. Using a decongestant spray and a flexible or rigid (0 or 30° in either 2.7/4 mm diameter) nasoendoscope, the nasal cavity should be examined using a three-pass method to avoid missing any pathology. Note should be made of any mucosal abnormalities, polyps, purulent secretions or masses. Look for anatomic variants contributing to nasal obstruction such as posterior septal deviation, paradoxical middle turbinate, concha bullosa or a large ethmoid bulla. The post-nasal space should be inspected for epithelial lesions, choanal atresia and patency of Eustachian tube orifices.
  • 5
    Objective assessment of nasal airway resistance can be performed with acoustic rhinometry, nasal peak flow and rhinomanometry. Recorded airflow measurements have been found to correlate well with patients’ perception of obstruction,5 although they remain mainly as research tools. Holding a metal tongue depressor under the nose and assessing degree of fogging can give a crude impression of nasal patency.
  • 6
    Other. Palpation of the neck is essential to detect cervical lymphadenopathy if nasal malignancy is suspected. Assessment of olfactory function can be performed with a validated test kit, such as the University of Pennsylvania Smell Identification Test (UPSIT).

What management should you offer?

  1. Top of page
  2. Abstract
  3. What should you cover in the history?
  4. What should you cover on examination?
  5. What management should you offer?
  6. Conflict of interest
  7. Search strategy
  8. References
  • 1
    Blood tests including ACE (angiotensin-converting enzyme for sarcoidosis), PR3-ANCA (a highly sensitive and specific subset of cytoplasmic-staining antineutrophil cytoplasmic antibodies for Wegener’s granulomatosis), syphilis serology and ESR (erythrocyte sedimentation rate) are helpful if there is clinical suspicion of an underlying inflammatory process. Biopsy is helpful when a neoplastic or inflammatory process is suspected.
  • 2
    If allergy is suspected blood and/or skin-prick tests can be used to identify an allergen. Although skin prick tests are reliable and cheap, they are unhelpful in patients on antihistamines and cannot be used in those with previous anaphylactic reactions. Total immunoglobulin E assay (PRIST – paper radioimmunosorbent test) and specific IgE determination (RAST – radioallergosorbent test) can also be used in patients with suspected allergy. Although not affected by antihistamines and quicker to perform, they generally take longer to process are no more sensitive or specific than skin prick testing. Although allergen avoidance is desirable once a trigger substance has been identified, it is frequently expensive, time-consuming or sometimes, as with pollen, just not feasible for the patient. Many clinicians would argue that this therefore negates the benefit of obtaining the original allergy test, although on the contrary others argue that allergen identification is useful for desensitisation and helps reinforce nasal spray compliance.
  • 3
    A nasal swab can be taken if pus is seen. However, bacteria are only present in 60% of acute rhinosinusitis cases and in most instances infection resolves spontaneously without the need for antibiotics.6 The role of bacteria and therefore antibiotic therapy in chronic rhinosinusitis is also far from clear. Bhattacharyya7 found that both anaerobic and aerobic species could be recovered from both the diseased and non-diseased contralateral side of patients with chronic rhinosinusitis, casting doubt on the aetiological role of bacteria in this condition. Similarly a broad array of fungi have been identified in the sinus cavities of patients with chronic rhinosinusitis through various staining and culture techniques, but there is still no strong proof that these pathogens directly create or perpetuate disease.
  • 4
    Computed tomography (CT) can confirm the extent of pathology and anatomy of the nasal cavity in patients with chronic rhinosinusitis and is essential if surgical treatment is to be implemented. It should not be regarded as the primary step in the diagnosis of the condition, except where there are unilateral signs and symptoms or other sinister features, but rather corroborates history and endoscopic findings after failure of medical therapy.2 One drawback of CT is its inability to differentiate between different types of inflammation or between secretions, mucosal thickening, polyps or mass lesions. For sinonasal malignancy, CT should be performed early with the addition of magnetic resonance imaging (MRI) to provide enhanced soft tissue information.
  • 5
    Septal deformity is corrected with septoplasty. Although there is no doubt that many patients benefit from septoplasty, the number of patients with no or limited benefit from the procedure in the long-term is substantial; one study reported only 26% of patients to be free of symptoms 9 years postoperatively.8 This could be due to our poor understanding of the impact of septal deviation on nasal airflow or perhaps the propensity to attribute nasal obstruction to an obvious septal deviation whilst possibly overlooking additional pathology.
  • 6
    Nasal valve collapse can be corrected with a variety of surgical techniques and selection depends on proper identification of the anatomic cause of the collapse. Lateral crural J-flaps9 remain a popular technique but several other methods have been described with varying success including spreader grafts, alar batten grafts, flaring sutures, overlay grafts and lateral suture suspensions. Mechanical alar dilators, such as Breathe Right strips, are an option for those not keen on surgery, although individual responses vary.10
  • 7
    Acute rhinosinusitis. Change in terminology from purely ‘rhinitis’ and ‘sinusitis’ reflects the fact that both conditions usually co-exist and are now managed synergistically. Initial medical therapy for acute rhinosinusitis aims to improve osteomeatal complex drainage. Intranasal steroid is traditionally used in this setting, with good evidence to support its use as monotherapy11 and as adjunctive therapy.12 Current evidence suggests that antibiotic therapy (amoxicillin or penicillin) for acute rhinosinusitis results in only marginally better cure rates compared with placebo (90 versus 80%);6 a small benefit which needs to be weighed against the potential for adverse effects at both the individual and general population level.
  • 8
    Chronic rhinosinusitis is a multifactorial disease process and contributing factors include mucociliary impairment, bacterial infection, allergy or rarely physical obstructions or anatomical variations. First determine whether there are any allergens or precipitating factors which can be managed. Topical intranasal corticosteroid therapy remains the mainstay of treatment for chronic rhinosinusitis both with and without polyps. In those with nasal polyps, topical corticosteroids have been shown to significantly improve obstructive symptoms13 and reduce the recurrence of polyp tissue postoperatively.14 Although a short course of systemic corticosteroids can reduce the size of nasal polyps in the short term, long-term effect on polyp disease remains to be established and generally there is a high rate of recurrence of symptoms once steroids are stopped. Antileukotrienes are an option for those with nasal polyps and aspirin intolerance; 50% showed symptomatic improvement in one study.15 The role of antibiotics in chronic rhinosinusitis remains controversial. Low-dose prophylactic macrolide therapy (150 mg daily roxithromycin) has recently been shown to be of benefit,16 even when the bacterial pathogen identified was not sensitive and many institutions are now using macrolide therapy as first-line treatment. The exact mechanism of action is not known and further multi-centre randomised placebo-controlled trials are required. Other therapies such as short courses of topical oxymetazoline are often used to provide symptomatic relief in the management of both acute and chronic rhinosinusitis, although there is no real evidence to support their use. Likewise nasal douching reduces nasal symptoms and increases quality of life but has not been shown to have any effect on the nasal airway or on mucociliary clearance.17
  • 9
    Patients with allergic rhinitis, defined as IgE-mediated inflammation of nasal mucosa due to allergen exposure, represent a subset of patients with chronic rhinosinusitis. Intranasal corticosteroid remains the mainstay of treatment.18 Antihistamines can be helpful although only the more recent types such as desloratidine have any impact on nasal obstruction.19 Other drugs such as sodium cromoglycate, systemic decongestants, ipratropium bromide, systemic corticosteroids and antileukotrienes are considered as second line treatment for allergy. Immunotherapy is not widely practiced in the UK but recent trials suggest it can be highly effective long-term in patients with severe disease, a limited spectrum of allergies and in those who fail to respond to usual treatments.
  • 10
    Medical treatment of chronic rhinosinusitis is as effective as endoscopic sinus surgery combined with topical nasal steroids, both in polypoid and non-polypoid chronic rhinosinusitis.20 If symptoms persist however after a suitable period of medical management, then a CT scan should be obtained as a road map to performing endoscopic sinus surgery. Surgery to correct a co-existent septal deviation or turbinate enlargement, both of which can obstruct access or the delivery of topical medication, would seem sensible although impact on overall outcome for chronic rhinosinusitis has not been demonstrated.
  • 11
    Surgery to the inferior turbinates remains a contentious issue, with a distinct lack of prospective randomised controlled trials with long-term follow-up. In recent years attention has shifted more towards mucosal – sparing techniques in a bid to maintain normal turbinate function. Passali et al.’s large prospective randomised study comparing electrocautery, cryotherapy, laser cautery, submucosal resection with and without lateral displacement and turbinectomy found submucosal resection of the cavernous tissue of the inferior turbinate with lateral displacement achieved a long-standing improvement of symptomatic nasal obstruction.21 Similarly Sacks found a favourable reduction in obstructive symptoms and improvement in rhinometry with patients undergoing powered submucosal turbinoplasty over submucosal electrocautery.22 There is no concrete evidence governing timing or patient selection for turbinate surgery; as a general principle, it should be reserved only for those with turbinate hypertrophy with severe nasal obstruction whose symptoms persist despite maximal medical management.
  • 12
    Involve the relevant medical team when there is nasal manifestation of systemic disease.
  • 13
    Treatment decisions for patients with sinonasal malignancy should be made by a specialist head and neck multidisciplinary team and should take into account the type/ staging of the tumour and fitness of the patient.

Search strategy

  1. Top of page
  2. Abstract
  3. What should you cover in the history?
  4. What should you cover on examination?
  5. What management should you offer?
  6. Conflict of interest
  7. Search strategy
  8. References

This review was based on a literature search last performed on 1st October 2008. Current texts and the MEDLINE, EMBASE and COCHRANE databases were searched using the subject heading nasal obstruction in combination with classification, diagnosis, therapy, drug therapy and surgery. Results were limited to include clinical trials, randomised controlled trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were also reviewed.

References

  1. Top of page
  2. Abstract
  3. What should you cover in the history?
  4. What should you cover on examination?
  5. What management should you offer?
  6. Conflict of interest
  7. Search strategy
  8. References
  • 1
    Wrobel B.B. & Leopold D.A. (2005) Olfactory and sensory attributes of the nose. Otolaryngol. Clin. North Am. 38, 11631170
  • 2
    Thomas M., Yawn B.P., Price D. et al. (2008) EPOS primary care guidelines: European position paper on the primary care diagnosis and management of rhinosinusitis and nasal polyps 2007. Prim Care Respir J 17, 7989
  • 3
    Annesi-Maesano I., Oryszczyn M.P., Neukirch F. et al. (1997) Relationship of upper airway disease to tobacco smoking and allergic markers: a cohort study of men followed up for 5 years. Int. Arch. Allergy Immunol. 114, 193201
  • 4
    Gomes G., Felix F., De Almeida Lima S. et al. (2006) Positive cottle test in randomly selected volunteers. Otolaryngol. Head Neck Surg. 135, 273
  • 5
    Kjaergaard T., Cvancarova M. & Steinsvag S.K. (2008) Does nasal obstruction mean that the nose is obstructed? Laryngoscope 118, 14761481
  • 6
    Ahovuo-Saloranta A., Borisenko O.V., Kovanen N. et al. (2008) Antibiotics for acute maxillary sinusitis. Cochrane. Database. Syst Rev. 16, CD000243
  • 7
    Bhattacharyya N. (2005) Bacterial infection in chronic rhinosinusitis. A controlled paired analysis. Amer. J. Rhinol. 19, 544548
  • 8
    Jessen M., Ivarsson A. & Malm L. (1989) Nasal airway resistance and symptoms after functional septoplasty: comparison of findings at 9 months and 9 years. Clin. Otolaryngol. Allied. Sci. 14, 231234
  • 9
    O’Halloran L. (2003) The lateral crural J-flap repair of nasal valve collapse. Otolaryngol. Head Neck Surg. 128, 640649
  • 10
    Ellegard E. (2006) Mechanical nasal alar dilators. Rhinology 44, 239248
  • 11
    Meltzer E.O., Bachert C. & Staudinger H. (2005) Treating acute rhinosinusitis: comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin and placebo. J. Allerg. Clin. Immunol. 116, 12891295
  • 12
    Nayak A.S., Settipane G.A., Pedinoff A. et al. (2002) Effective dose range of mometasone furoate nasal spray in the treatment of acute rhinosinusitis. Ann. Allergy Asthma Immunol. 89, 271278
  • 13
    Stjarne P., Blomgren K., Caye-Thomasen P. et al. (2006) The efficacy and safety of once-daily mometasone furoate nasal spray in nasal polyposis: a randomized, double-blind, placebo-controlled study. Acta Otolaryngol. 126, 606612
  • 14
    Rowe-Jones J.M., Medcalf M., Durham S.R. et al. (2005) Functional endoscopic sinus surgery: 5 year follow up and results of a prospective, randomised, stratified, double-blind, placebo controlled study of postoperative fluticasone propionate aqueous nasal spray. Rhinology 43, 210
  • 15
    Ragab S., Parikh A., Darby Y.C. et al. (2001) An open audit of Montelukast, a leukotriene receptor antagonist, in nasal polyposis associated with asthma. Clin. Exper. Allergy. 31, 13851391
  • 16
    Wallwork B., Coman W., Mackay-Sim A. et al. (2006) A double-blind randomized placebo-controlled trial of macrolide in the treatment of chronic rhinosinusitis. Laryngoscope 116, 189193
  • 17
    Harvey R., Hannan S.A., Badia L. et al. (2007) Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane. Database. Syst. Rev. 3, CD006394
  • 18
    Weiner J.M., Abramson M.J. & Puy R.M. (1998) Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ 317, 16241629
  • 19
    Canonica G.W., Tarantini F., Compalati E. et al. (2007) Efficacy of desloratidine in the treatment of allergic rhinitis: a meta-analysis of randomised, double-blinded, controlled trials. Allergy 62, 359366
  • 20
    Ragab S.M., Lund V.J. & Scadding G. (2004) Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomised controlled trial. Laryngoscope 114, 923930
  • 21
    Passali D., Lauriello M., Anselmi M. et al. (1999) Treatment of hypertrophy of the inferior turbinate: long-term results in 382 patients randomly assigned to therapy. Ann. Otol. Rhinol. Laryngol. 108, 569575
  • 22
    Sacks R. & Boustred N. (2005). Powered turbinoplasty – the long term results as compared to electrocautery and submucosal turbinoplasty. Presented at the American Rhinologic Society May 13 2005