Blocked Nose

Background

This is a very common symptom in the adult population.
It is difficult to tolerate for many patients as the sensation can be unpleasant and it can affect their ability to exercise and function normally. It can be associated with snoring.

Causes

There are many causes of nasal obstruction.
These include rhinitis and sinusitis, deviated nasal septum, large adenoids, nasal valve collapse, septal perforation, tumours and other rare causes.

 

Rhinitis

Rhinitis literally means inflammation of the nose and refers to the inside lining of the nose. The inflammation causes swelling of the lining, excess mucus production and irritation. The swelling causes the sensation of blockage and the excessive mucus production leads to a runny nose and/or too much mucus going backwards from the nose to the throat known as post nasal drip. If the rhinitis is caused by allergy then the patient may experience itching of the nose, eyes and throat. Rhinitis also causes sneezing.

Rhinitis is a very common condition. The severity of symptoms is extremely variable however. Some people have mild nose irritation which comes and goes and causes little trouble and others have severe symptoms causing discomfort, distress and difficulty carrying out daily activities.

What causes rhinitis?

The causes of persistent rhinitis can be divided into allergic and non-allergic.

Allergic rhinitis

The most common allergies causing rhinitis are pollen (hay fever), house dust mite and pets, most commonly cats. Hay fever is seasonal and occurs during a particular period each year.

Symptoms of allergy in the nose are due to the immune system reacting to the allergen (the individual cause of the allergy). Cells in the lining of the nose release histamine and other chemicals when they come into contact with the allergen. This causes inflammation in the nose with swelling, excess mucus production and irritation. Allergic rhinitis can be associated with asthma and eczema and can run in families.

Non-allergic rhinitis

Rhinitis commonly occurs without an allergic cause and there is often no identifiable cause for the condition. Many factors can influence the nasal lining however including:

•    Changes in temperature or humidity.
•    Hormonal changes e.g. during pregnancy.
•    Food and drink, e.g. alcohol
•    Emotion such as stress and anxiety.
•    Medication. Some medications can have side effects on the nose e.g. blood pressure medication and the contraceptive pill.
•    Use of decongestants.

Rhinitis medicamentosa is the name given to rhinitis that can occur due to the overuse of nasal decongestant sprays. These sprays are used to relieve a blocked nose and they reduce swelling inside the nose by causing blood vessels in the nose to constrict. However, with prolonged use they cause rebound nasal congestion which is more severe than the original swelling. The temptation is to use yet more decongestant and a vicious circle can be set up. A similar problem can occur in people who abuse cocaine.

In some people, no cause for their persistent rhinitis is found and it is called idiopathic or vasomotor rhinitis.

Are any tests needed?

You may require allergy tests if allergic rhinitis is suspected. These can be in the form of skin prick tests or blood tests.

Treatment
Allergic Rhinitis

The commonly used treatment options for allergic rhinitis include:

  • Avoiding the cause of the allergy
  • Antihistamine tablets
  • Steroid nose sprays
  • Steroid nose drops and tablets (for limited periods)
  • Nasal Douching (this involves spraying salt water into the nose)

In some cases other forms of medication are required. Severe allergic rhinitis can sometimes be treated with immunotherapy. This consists of a course of tablets or injections which modify your immune system in order to prevent the allergic reaction from occurring.

Non allergic rhinitis

The main form of treatment for this is a steroid nasal spray although sprays to reduce secretion from the nose and nasal douching are also used.

Surgery

This can be indicated when medical treatment has failed or if the rhinitis is associated with sinusitis (see section on sinusitis) or large adenoids (see section on adenoids). Nasal surgery for rhinitis involves reducing the size of the nasal turbinates. These are extensions of the side wall of the nose which become swollen in rhinitis.

 

Sinusitis

The sinuses are air containing cavities situated in the cheeks, between the eyes and in the forehead. They produce mucus which drains into the nose and can be regarded as extensions of the nose. Rhinitis can be associated with blockage and inflammation of the sinuses (sinusitis).
Sinusitis can be ‘acute’, for example, when associated with a cold or flu or ‘chronic’ when the condition is ongoing.

Investigations

As well as allergy tests the patient will require imaging of the sinuses to confirm the diagnosis. This is usually a CT scan although sometimes an MRI is performed.

Treatment

Treatment consists of:

  • Treating associated rhinitis
  • Antibiotics
  • Decongestants (short term use only)
  • Steroids (sprays and drops mainly but occasionally a course of tablets)
  • Nasal douching (this involves passing salt water through the nose to remove secretions and allergic particles)
  • Surgery (when medical treatment is not successful)
Surgery

Surgery involves opening the drainage points from the sinuses to the nose and removing inflammed tissue. The aim of the surgery is to enable the sinuses to secrete mucus freely into the nose without obstruction and to allow the lining of the sinuses to become healthy.

Surgery is performed using small endoscopes that project an image of the inside of the nose and sinuses onto a television monitor allowing the surgeon to operate with fine instruments inside the nose using the monitor as a guide. This is called endoscopic sinus surgery or functional endoscopic sinus surgery (FESS). No cuts are made on the outside of the nose or face. Sometimes small balloons are used to dilate passages between the nose and sinuses in a procedure called balloon sinuplasty.

 

Nasal Polyps

These are ‘grape like’ swellings inside the nose. They usually arise from the sinuses. Treatment consists of steroids which often shrink the polyps. If they are not controlled with medication then surgery to remove them will be offered.
They can be associated with asthma and sensitivity to non-steroidal anti-inflammatory drugs.

Polyps usually occur on both sides of the nose. If they occur on one side only they require investigation to exclude cancer of the nose and sinuses although a polyp in one side of the nose is often benign and not cancerous.

Surgery

Polyps are often removed during sinus surgery which is usually performed under general anaesthetic (patient asleep) as a day case. Polypectomy can be performed alone under local anaesthetic (patient awake) when the inside of the nose is numbed before surgery. Polyps themselves are not actually sensitive and an instrument called a microdebrider can be used to detach the polyp and suction it out of the nose.

 

Deviated Nasal Septum

This term refers to a twist or deformity of the central partition in the nose. It is a common condition and can cause nasal blockage. The cause is usually not known although can result from an injury to the nose.

Surgery to correct a deviated septum is often part of rhinoplasty surgery (see septorhinoplasty) although is more commonly performed on its own or with turbinate surgery (see treatment of rhinitis)
The nasal septum is made of bone and cartilage and the operation changes the shape by a combination of removing, moving and straightening bone and cartilage. The operation is called Septoplasty.

Post-operative advice for patients undergoing Sinus surgery, Polypectomy, Turbinate surgery and Septal surgery

1. You will either stay overnight or be discharged the morning after surgery depending on how well you are feeling. If you go home on the day of surgery you will require a friend or relative to pick you up from the hospital and you will need to have someone with you at home for the first night.

2. Depending on the degree of surgery on the internal nasal passages you will feel blocked for the first 1-2 weeks after the surgery and this will then gradually improve over the next four weeks. This is of course variable, depending on the extent of the surgery required.

3. Your nose may bleed a little after the operation and this can sometimes continue for several days. We may insert nasal packs to control bleeding during the operation and these are either removed before you leave hospital (non absorbable type) or left in the nose when you go home (fragmentable type). If bleeding starts when you are at home and is profuse then you need to phone for an ambulance to take you to Casualty. Remain calm! This can occasionally occur after nasal surgery. If it is relatively minor and persistent, phone the office for advice. Occasionally a patient may require further treatment to stop post-operative haemorrhage and may even require further surgery to stop it (< 1%).

4. The surgery is not particularly painful although you may feel ‘under the weather’ due to postoperative nasal blockage and the effects of the anaesthetic.

5. You will be given pain killers and sometimes antibiotics (if there are signs of infection or nasal packs or splints, see below, are used) to take home with you from the hospital.

6. You can use a decongestant spray (Otrivine or Sinex) for the first week after surgery if you are uncomfortable with nasal blockage. Two sprays should be applied to each side of the nose twice daily. The spray can be provided by the Hospital or can be bought from the Chemist.

7. Stitches used in the nose are almost always absorbable and do not require removal.

8. Occasionally during septal surgery we insert plastic splints inside the nose to prevent scar tissue formation and support the nasal septum. These are removed in the clinic one week after the surgery. You will require antibiotics to prevent infection when splints are inserted.

9. You should not blow your nose for the first week after your surgery. If you sneeze, try to let it out through your mouth!

10. The inside of your nose may be swollen and contain dry blood and mucus after the surgery depending on the type of surgery that you have had. This will clear between week 2 and 6.

11. Avoid physical exertion for 2 weeks after surgery and then gradually increase to your normal level of exercise.

12. Our aim is that your expectations are realized and we will do everything that we can to achieve this. If you have any concerns after the surgery please do not hesitate to contact us. We will routinely arrange a follow appointment, one to two weeks after your operation.

 

Nasal Valve/ Lateral Nasal Wall Collapse

This refers to a loss of support for the tissues of the roof and side wall of the nose causing collapse of the side wall when the patient breaths in through the nose.

This can result from previous surgery or injury, can occur with advancing age or can be present with no obvious cause. It is normal to have a mild degree of movement of the side wall of the nose when breathing in through the nose. If it is thought that nasal valve collapse is a significant factor in causing the patient’s nasal obstruction then this can potentially be corrected surgically using cartilage grafts.

Surgery

This consists of using cartilage from either the inside of the nose or the ear to strengthen the area of collapse. The type of surgery will depend on the area and severity of collapse.

 

Septal Perforation

This is when there is a hole in the nasal septum. It can be caused by injury, previous surgery or cautery, drug use, inflammatory conditions and rarely cancer in the nose. It can cause nasal obstruction, bleeding, crusting of dry mucus and whistling from the nose. The perforation can be repaired surgically if it is less than 2 cm in diameter.

Surgery

This consists of reconstructing the nasal septum. This is done by a combination of moving the existing lining inside the nose and grafting tissue to the septum in order to close the hole.

 

Large Adenoids

The adenoid is situated at the back of the nose and is composed of lymphoid tissue similar to the tonsils. This tissue is used in infancy to develop the immune system against common bacteria and viruses. It usually shrinks during childhood and becomes non functional. However, occasionally the adenoid remains large and causes nasal obstruction in adults. This can be easily diagnosed in the clinic by looking at the back of the nose with a small endoscope. Treatment consists of removing the adenoid surgically, ‘adenoidectomy’.

Surgery

The adenoid is removed using a curette through the mouth. Electrical cautery is also sometimes used. You will require pain relief although this is not as painful as Tonsillectomy. As with nasal surgery and Tonsillectomy there is a small incidence of post-operative bleeding.

 

Tumours

Rarely, a tumour can cause nasal obstruction. A tumour is an abnormal growth that can be benign or malignant. A malignant tumour is cancer that destroys local tissues and has the potential to spread to other parts of the body unlike a benign tumour. Tumours can occur in the nose, sinuses or at the back of the nose. Treatment depends on the site, size and nature of the tumour. Cancerous tumours are referred to surgeons specializing in this condition.