Nasal obstruction is one of the most common ailments that ENT physicians see. Nasal obstruction that refers to any blockage through nasal cavity to some extent caused by wide variety of problems which deeply deteriorate the comfort of life. Anyone who suffers from nasal obstruction should definitely see an ENT expert. Some of the complaints that cause nasal obstruction may even be life threatening if not cured by early diagnosis and treatment.
1 . Flu
Influenza is also among the most common reasons of nasal obstruction which is usually with runny nose and fatigue. There can’t be even one single individual in the world who hasn’t had flu in their lifetime. It is caused by a virus. Treatment requires plenty of fluid consumption and full rest. Current treatment approaches about flu are being developed in recent years. Sometimes if zinc-based solutions are applied into the nose by a physician before the flu starts, it can be prevented.
There are two types of structures in the nose; stable and variable. The stable tissues are formed of bones and cartilages. The latter covering coat over those patterns, which is called “mucosa”, forms the variable structure. Any particle inhaled to the nose from outside renders an unusual reaction on the mucosa, therefore it produces excretion and flow as if it is a fire extinguisher. This is called nose allergy.
Nose allergy can be induced by 20 to 30 known components. Even though these substances are identified after running the tests, new elements, which are formed by industrial waste and exhaust gases, emerge and diffuse into the athosphere and the nose has difficulty cleaning them. And, this situation reveals itself as the defense mechanism of the nose, which happens to be known as “the allergy”.
The contact must be avoided with the substance that is causing the allergy or if it is a food then the consumption should be stopped. If, that cannot be done, then anti allergic vaccinations are of choice. Another treatment option is intranasal spray applications or oral pills that can suppress mucosal reaction. Also “radio frequency” technique, that makes the nasal mucosa thinner, is another method to open up the airway. “Rhinolight” method is another treatment application that ultraviolet rays are projected into the nose to inhibit the inner secretion in multiple sessions. Thus, the nasal mucosa is stretched to some extent in order to inhibit the excretion production of nose against allergic substances.
3. Structural Deformities of Nose
a) Middle Septum Deviation
The middle wall called septum is made up of bone and cartilage, divides the nose to two equal parts. The deviation of this wall or any traumatic reason that may cause restriction inside the nose might impede the air passage. This is simply called septum deviation and could be either congenital or acquired later. Bones and cartilages of nose have an absorption capacity against traumas. Sometimes during birth baby’s nose, by pressure rubs against the pelvic wall and squashed or childhood traumas as collisions, crushes, falls likely damages the nasal septum. It is not always the situation that the baby’s nose is broken hence the deviation. The bones and cartilages of nose deviates towards left or right, depending on the amount of pressure exposed.
Septal deviation causes intranasal airway contraction over time. Subsequently, both side walls of inner nose grow thicker so the ventilation function lacks and ultimately renders blockage for air flow which is considered as a quite complicated clinical situation.
Septal deviation is usually described among public as having “puffed out flesh in the nose”. In fact there is no flesh growth in these cases. Actually, there is a slant in the nose. Generally patients consult the physician with breathing difficulty. And sometimes they consult about their complaints of nasal congestion, sleeping with open mouth and snoring at nights, while they do not have any such distresses during daytime, at all. They may also talk about frequent sinusitis attacks. When the air circulation in the nose is compromised, nasal mucosa dries. That may cause recurrent nosebleeds. Human lung recognizes the air coming through the nose, it is sensitive to that air and lung alveoli inflate optimally with that air (nasopulmonary reflex). Thus, blood oxygenation is provided in the best way possible. But when the patients with septum deviation starts breating through the mouth, for not being able to inhale through the nose, lung alveoli fail to inflate sufficiently and as a result, blood oxygenization reduces. In the future, this may lead to Pulmonary Hypertension and Cor Pulmonale which developes when the heart has difficulty pumping blood into high pressure areas.
The fundamental treatment of septum deviation is surgically improving the nasal wall. But every single deviation does not always require operation. Physicians recommend operation based on the severity of the deviation which they detect during physical examination, patient’s complaints and their professional opinion.
That is to say, people, who can breath comfortably through the nose, should not be operated just because they have deviation.
b ) Structural Nasal Abnormalities
Conchaes are turbinal patterns in the nose, as three conchae being on both sides; they are sausage-like shapes and extend along the lateral wall of the nasal cavity. They have have swelling and shrinking capability, which means they are erectile. They have a prominent role in the warming, humidification and turbulence of air passage through the nose. Depending on various reasons, any overgrowth as opposed to their actual sizes cause nasal congestion.
There may be many reasons of conchae hypertrophy (swelling/enlargement):
The treatment options should be offered to the patient by an ENT specialist if the conchae are enlarged and began to block the airflow at the opposite side of the deviated one.
Treatment is either medical or surgical. Depending on the cause of disease, drug treatment is preferred first. However in patients who do not respond to medical treatment surgical procedure must then be considered. The main goal of this surgical intervention is to downsize the mass of conchae without damaging the mucosal coating that covers the conchae.
Below are the methods of intervention:
ii ) Central Conchae Disorders
Mid-nasal fleshy tissue does not function for ventilation as much as lower nasal patterns due to its location. The capacity of swelling up and deflation is less effective than the lower nasal conchae. The middle nasal concha tissue, generally contains the end fibrils of the olfactory nerves, scattered in the nose for smelling function. Sometimes the total mass of mid conchae abnormally enlarges due to the amount of air confined inside, so they possibly can occupy the central nasal area. The invasion of the nasal lumen is called Konka Bullosa, and that can reduce inhalation through nasal cavity. Any abnormal enlargement in the middle nose may frequently cause sinusitis by blocking the pores of sinuses. In such cases, any unusual swollen tissue in the nasal mid zone can be resected surgically or minified by radio frequency method. Those procedures should be considered particularly for consistent nasal congestion cases in the childhood age group.
When nasal cavity examined, rarely, a polyp-like tissue can be discovered. But unlike polyps, a heartbeat sound is heard. Most probably it is not a polyp but some brain tissue itself. The unique treatment is surgical removal of that excessive brain tissue and the repair of the primary defect in order to eliminate the nasal obstruction.
4) Vasomotor Rhinitis
In case the nasal cavity is examined in patients, who developed vasomotor rhinitis, basic dark or pale purple color that resembles an allergic nose cannot be seen. But the lobes are larger than normal size and this causes nasal obstruction. The underlying cause is not allergy or sinusitis at all. The term Vasomotor Rhinitis denotes nasal inflammation manifest by enlargement and congestion on the cavital lobes without an identified allergic reaction or septal deviation. This condition is believed to result from disturbed regulation of the innervation hereby which dominates mucosal dilatation and congestion, and vice versa. Ultimately, the nasal mucosa remains congested due to a consistent edema.
In vasomotor rhinitis therapy, the enlarged nasal cavity lobes may be corrected with intranasal sprays or radiofrequency laser method. Some specific intranasal medications can also be applied with little cotton-tip sticks onto the enlarged mucosa via endoscopic access to cure the affected area without surgical intervention. Thus the congestion is terminated. This method can be fully accomplished in an outpatient office setting. In another alternative therapy, the main innervation supply that induces the enlargement of inner lining can be cut off via surgical operation. Besides that, the swollen inner lining can also be reduced in size by radiofrequency laser method.
Nasal polyps are soft growths in the nasal cavity, hanging down due to gravity like flabby bunch of grapes, which are not naturally meant to be there. They can grow in only one or both sides and some vastly larger growths can critically block nasal air flow. Patients sometimes mention serious trouble breathing through one or either sides.
There are miscellaneous disorders that may cause nasal polyps:
The primary goal of the treatment is to make the polyps shrink in size. Sometimes by means of nasal sprays and sometimes with oral or parenteral medications are used to get rid of the growths.
Medication Managements for Nasal Polyps:
1. Steroid Sprays applied inside the Nose
2. Systemic Steroid Therapy
3. Antihistaminic Drugs
Following medical therapy, computerized tomography for imaging nasal cavity and sinuses may be recommended. In some cases, polyp biopsy may be needed prior to medical cure. Even CT Imaging may be ordered immediately before biopsy or medical treatment. If drug treatment does not avail to shrink or eliminate polyps in severe cases, surgical intervention turns out to be the best option. A vast surgical removal of polyps is almost obligatory in cases mentioned below:
6) Rhinitis Medicamentosa (Nasal Addiction)
All decongestant nasal drops that constrict the vessel bed inside the mucosal lining provide fairly easy breathing to patients. Due to prolonged use, a patient may become accustomed to the comfort of the topical drops or sprays, so a gradual addiction occurs. Patients need larger doses of medications by time to get the same former effect. This is called drop addiction namely ‘ Rhinitis Medicamentosa’. In these cases the drops or sprays should immediately be discontinued and nasal mucosa enlargement must be reduced in size by radiofrequency method. Those drugs may also deteriorate the sense of smell and may cause hypertension as well.
Nasal tumors may be benign or cancerous that occur in the nose. It is always mandatory to visit an ENT specialist immediately in case you develop one or more symptoms below:
So many published studies suggest that fine hard-wood dust that could build up in the nose, may play a significant role on workers who are employed in wood industry. Such employees are exposed to nasal cancer risk 70 times greater than other individuals. If the occupational factors are ignored, the female-male ratio is 2 : 1. The incidence of the disease is slightly increased in women after menopause.
Tumors may vary histologically, according to their cellular patterns. If a physician suspects from a nasal neoplasia, then may resort to imaging tests such as CT or MRI. In case the tumor is viewed via imaging tests, biopsy should be taken. Ultimately, the definite diagnosis is made following the pathologic examination.
The treatment of benign nasal tumors that causes nasal obstruction is totally surgical removal intervention.
The treatment options of malignant tumors are radical surgical removal of the tumor which is followed by radiotherapy and chemotherapy both or radiotherapy only.
8. Nasal Encephalocele
Nasal encephalocele is a kind of herniation of the intracranial brain content down to the nasal cavity through a defect in the front skull base. The herniated tissue are frequently the cerebral membranes. Usually encephaloceles are congenital deformities diagnosed in early childhood. So the consistent nasal obstruction in early childhood might indicate the diagnosis of an encephalocele.
If the nasal cavity is examined, a polyp-like growth is seen. But unlikely, a pulse sound can be heard. The pulse comes from brain arteries. Surgical intervention includes the total removal of the protruded cerebral tissue or membranes and the repair of the defect.
9) Choanal Atresia (Blockage of posterior nostrils)
Nasal cavity, at the back, is connected to nasopharynx through two hole-like openings. Choanal atresia is described as a serious congenital blockage of the posterior nasal cavity that causes difficulty breathing. Since bilateral choanal atresia is almost always a life threatening condition, it is a stringent emergency situation. Just after delivery, physicians check the babies for apgar score. Apgar score is a quick test performed on newborn babies to assess how well the newborn is doing just after birth. The test examines the babys appearance, skin color, effective breathing, muscle and reflex activity etc. And every newborn is routinely given a nasogastric catheter to make sure the absence of choanal atresia. Absence of the disorder is confirmed if the tip of the catheter comes back through the oral cavity bilaterally. In case the baby is diagnosed with choanal atresia, immediate surgical intervention is then obligatory. Because such babies are mostly cyanotic and cannot suck milk.
Unilateral atresia usually presents with some symptoms:
A simple feeding probe can be helpful to confirm diagnosis when applied through nasal cavity or some colored solutions can be dripped in to the nose and checked to see if it is going to the mouth or not. More precisely, the diagnosis is made directly by endoscopic probes. Babies who suffer from unilateral choanal atresia without severe symptoms can maintain a normal life. In the following years, however, the obstructed passage must be opened to ensure efficient respiration is provided.
In choanal atresia, treatment is surgical. Atresia is unblocked by means of various surgical approaches.
10) Injuries Due To Previous Surgeries
Today, as a result of the increase in aesthetic surgeries, nose sustain permanent damages while aesthetic and beauty are considered as of primary concerns.
In aesthetic surgery, when the cartilages, that are not supposed to be touched, are tampered (tinkered with), the lower cartilages of lateral walls collapse inwards. This situation is called ‘Alar Collapse’, which resembles the view of a clothespin clasp on the nose. It is corrected surgically. And again, during the aesthetic nose surgery middle nasal wall (septum) may be perforated and the size of the rupture might be a problem. In these patients, breathing is the main challenge because the airflow travels from right to left or vice versa due to resistance changes. A set of adhesions may also develop resulting from careless intervention as well. The treatment of this condition is based on surgical correction also.
There are air-filled cavities in the facial bones. Each of those hollow cavities has many tunnel shaped conduits extending into the nasal cavity. If the conduits of these tunnels are swollen and clogged resulting from rhinitis, secretion accumulates in these narrow openings. If this accumulated excretion gets infected or inflamed, clinical sinusitis develops because of pathogenic bacteria. Sinusitis is a term used for the inflammation of facial bones. In such cases, nasal discharge, post pharyngeal secretion, cough and phlegm production are common symptoms. Mostly, nasal root and eye socket pain accompanies the condition. There may also be complaints such as discomfort in the gums, gum withdrawals and smelling disorders as well.
Due to the inflammation and swelling of the tissue in the lower zone, respiration capacity can be curbed to some degree. Merely sinusitis does not induce deviation but swells the inflamed mucosa that leads to congestion with a stuffy feeling inside the nose. The remedy for such obstruction is curing the sinusitis.
In today’s rhinology, a series of nasal washings, sprays and oral pills are very helpful as well as the medical endoscopic intranasal methods which manipulate the sinusoidal pores to open and thus aeration of sinusus and airflow is provided.
In advanced cases those conduits can be fully obliterated, but the fine intranasal endoscopic devices enable the whole cavity to be viewed effectively. So the conduits are washed and freed from any conglomeration and consequently opened.
Another treatment option is the endoscopic balloon sinuplasty via surgical intervention. This is relatively a new procedure. Balloon sinuplasty technique involves dilating the larger conduits leading into the frontal sinuses. A wire catheter is inserted into the sinus basement and a small balloon is advanced through that wire. Once the balloon is inflated the walls inside the sinusal conduits are forced to enlarge the opening to help maintain sinusal aeration as usual.
12) Enlarged Adenoids or Adenoid Vegetation
There are lymphoid tissues all around the throat that constitutes a significant component of immune mechanism. These are the tissues we see when we open our mouth; tissues such as tonsils, tonsil embedded at the base of the tongue, some intranasal lateral wall tissues and adenoids that particularly seen in childhood, that is called “post-nasal flesh” among public. The anatomic pattern may be considered as a two sided tunnel highway. The middle wall that split the tunnel is known as central intranasal septum.
On both side walls of the tunnel, there are sausage shaped cushion bulges, which has the capability to swell and deflate; the name of that structure is concha. The entrance is accessed through nostrils at the front. The exit is connected to nasopharynx through choanae at the back. These nostrils open up to a big place called eustachian tubes. Also the tubes that ventilate the ear, open up to this place. Nasopharynx adenoid, which cannot be seen when mouth is opened, is also at that place, at the back of the nose.
Adults do not have nasopharyngeal adenoids. Nasal adenoids and nasopharyngeal adenoids are totally different things. Nasopharyngeal adenoid which exist in childhood, is the condition when the tonsils in that area enlarge due to environmental factors or inflammation and subsequently clogs the posterior nostrils.
Child breathes in and out through the frontal nostrils but the posterior nostrils of nasal fossae are clogged by a cauliflower-shaped structure. Because of that reason, breathing function is impaired; and eads to night sweats at sleep, sleeping with mouth open, snoring, head sweats and uneasy sleep. If not reformed for a long time, mouth and jaw deformities contribute to pink colorization in the palate, development deficiency such as upper jaw’s being pushed towards to the front, hyperactivity and even have effect on the attention deficiency which is proven to have relation with absence of oxygenation.
Enlargement of tonsils, which happen to be a part of immune system, is a condition that is seen more commonly in children, day by day. Enlargement occurs when they over-function against the environmental factors.
Nasopharyngeal adenoid does not get smaller by medication. If the growth is on the borderline, then it can be kept under control with sprays. Yet, if they are removed by a simple surgery when the growth is over the limit, the air which is sucked in through the anterior nostrils, flows through the posterior openings and move down the path.
This way, lungs respirate better since actual ventilation is achieved. Consequently, complaints based on nasopharyngeal adenoids either diminish or disappear completely.
Nasopharyngeal adenoid, which occur as a part of immune system, reaches to its maximum size in children by the age of 5 – 6, then starts to regress at the age of 9 – 10 and cease to exist in consecutive ages. That is to say, besides rare occasions, adults do not have nasopharyngeal adenoid.
13) Empty Nose Syndrome
Nasal cavity is an indented syructure that needs to be protected. If the nose is interfered by non-specialists, meaning intervened more than needed, the opening gets too big but the patients feels like they cannot breath and their noses are clogged. Because the main creation of breathing is by the whirlpool that occur due to the pressures on certain spots inside, which is provided by the air flow into the nose. In order to solve this problem, some specific materials are placed into the nose in order to make the flattened areas inflate. However, it is very difficult for the nose to regain its original functions.
14) Foreign Body in the Nose
Generally, children stick foreign objects in their noses, unwittingly. If this situation, which creates blockage, is noticed by the parents right away, then the child should immediately be taken to a doctor so that he can remove the object with a probe. You should never try to take out the object with a tweezer at home or neither should be touched in the emergency room. As a result of such interference, the object might be pushed further more and thus it might stop the child’s breathing by clogging the airway. Therefore, the object must be removed by an ENT specialist, who is trained for such incidents.
Sometimes, a foreign object in the might remain unnoticed for a longer time. In such cases, there might be indications like unilateral stenched discharge in children. When that happens, parents usually take their kids to the doctor with the complaint of sinusits or such. At the examination, the foreign object is removed from the child’s nose.