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NOSE BLOCK

June 09, 2012

Added By :
Dr Diong Kok Wah


Nose block or nasal obstruction remains as one of the commonest symptoms that brings the patient to a general practitioner, physician or ear, nose and throat surgeon.

“DOCTOR,  I CAN’T BREATHE THROUGH MY NOSE !” 

Nose block or nasal obstruction remains as one of the commonest symptoms that brings the patient to a general practitioner, physician or ear, nose and throat surgeon.  It refers to the subjective sensation of reduced airflow through the nose, either one-sided or in both nostrils. It can be a troublesome symptom affecting both the children and adults. However in a child who may not complain, the parents may notice the child frequently breathing through the mouth or snoring during sleep. The nasal blockage may only be of a recent onset or has been persistent for some time.

A “nasal cycle” is a normal (known as “physiological” in medical terminology) phenomenon where each nostril alternate with the other to undergo cyclical congestion and shrinkage. Each cycle lasts between one to four hours. While it is hardly noticeable at rest in a normal person, common factors below can aggravate the nasal obstruction (of which many, fortunately, are treatable):
•    Allergies (allergic rhinitis)
•    Nasal infection (acute and chronic rhinosinusitis)
•    Structural deformity (eg. deviated nasal septum, enlarged turbinates)
•    Adenoids
•    Nasal polyps, tumours and cancers in the nose
•    Foreign body in the nose
•    Medication (eg. high blood pressure pills, abuse of nasal decongestant spray)

Some of these conditions may coexist worsening the nasal blockage.

Allergic rhinitis (AR)
The incidence of allergy in the modern communities is increasing steadily indeed. Allergy is a general phenomenon encompassing many forms including bronchial asthma, skin allergy (eczema, urticaria), food allergy, and nose allergies. While many of us may have heard about asthma, the nasal counterpart known as ‘Allergic Rhinitis’ (AR), is less commonly known as such. In fact, many of the layman terms of so-called ‘sinusitis’ or ‘resdung’ (in Bahasa Malaysia) are commonly AR from the medical perspective.  AR is the inflammation of the inner lining (‘mucosa’) of the nose that occurs when an allergic individual encounters an airborne ‘allergen’ (triggers of allergy) such as house dust mites (HDM), pollen, mold, or animal dander like dogs and cats. Those with positive family history of allergy or other forms of allergy are more likely to have AR. Although AR can develop at any age, it usually appears in individuals before the age of 30 years old.

Our warm and humid tropical climate is also very suitable for the HDM to thrive very well. They grow best at humidity about 70% and temperature above 23 C. A mated female HDM can lay 60 to 100 eggs in the last 5 weeks of her life. In a 10-week life span, a HDM will produce approximately 2,000 allergenic (substance that can induce an allergic reaction) faecal particles and an even larger number of partially digested enzyme-covered dust particles.  So imagine the number of HDM on your mattress and your bedroom ! Millions ? Trillions?!  They are everywhere… A gram of dust can contain up to 1,000 HDM and 250,000 faecal droppings !

As if that is not bad enough, our shed skin squames/scales provide the main food supply for the HDM. In fact, 2 of the 3 commonest types of HDM are named after this habit – their name 'Dermatophagoides'  actually mean "skin eaters" ! To make matters worse, we also spend on average about 1/3 of our daily lives in our bedroom, making avoidance of these HDM and their allergenic material almost impossible. They are indeed the commonest culprit for AR. Their faecal material is inhaled into our airways, resulting in allergic response in our airways (nose, throat, lungs). Airway allergy symptoms include sneezing, coughing, runny nose, sore throat and itchy or watery eyes, phlegm dripping into the throat (postnasal drip), chronic cough and puffy/red itchy eyes. Besides, one with known bronchial asthma can have recurrence of asthmatic symptoms too.

Nasal infection
A nose block can occur temporarily, lasting a few days as in acute rhinosinusitis or upper respiratory tract infection, usually due to airborne viruses. As a result, the nasal lining is inflamed and congested leading to nose block. There may be accompanying cough, runny nose with clear or yellowish discharge and fever. An acute infection would normally resolve and the nasal obstruction disappears completely. However, in chronic infection of the nose (‘chronic rhinosinusitis’), these symptoms may persist or wax and wane with periods of resolution in between. The patients can also have bad breath, headache over the sinuses, postnasal drip, also commonly called ‘backflow’ (sensation of nasal mucus flowing into the back of the throat causing throat irritation or frequent throat clearing).

Acute rhinosinusitis: an endoscopic view of the nose showing yellowish pus draining from one of the sinuses

Structural deformities
The nasal septum is the midline partition which divides the nose into two halves.  One may be born with a deviated nasal septum (DNS), or may develop after an injury to nose. The external nasal bridge may or may not appear normal. In some cases the DNS is severe enough to narrow or block the nasal passage.  While some people naturally have large turbinates (shelf-like projection from the side wall of the nose), enlarged turbinates are more commonly found in association with AR. These structural deformities may result in nasal blockage and snoring problems. DNS and enlarged turbinates can be surgically corrected using endoscope (thus no external facial incision and scar) under general anaesthesia with good results.
 
A deviated nasal septum (DNS) with a large septal spur blocking the right nostril

Adenoids
Adenoids are lymphoid tissue in the back of the nose, functioning as part of the body defence against local infection. In a normal child, the adenoids generally shrink by about 7 years old. However, in the presence of recurrent or persistent infection, inflammation, allergy of the nose, the adenoids continue to persist or even grow in size, eventually resulting in the blockage of the nasal airway. In an adult, this has to be differentiated from other tumours. Enlargement of adenoids is commonly associated with tonsillar enlargement as well. Vice versa, someone with large tonsils, especially with frequent tonsillar infection (‘tonsillitis’) ought to have enlarged adenoids ruled out as well.

Large adenoids: an endoscopic view of a large adenoids protruding from the back space of the nose into the nasal cavity

 
Large tonsils obstructing the oral cavity passageway.

Nasal polyps, tumours and cancers in the nose
‘Tumour’ is a general term indicating a growth which can be cancerous (malignant) or non-cancerous (benign). The commonest nose cancer in Malaysia is the nasopharyngeal carcinoma (NPC). It is commonest among the Chinese, especially in those over 50 year old, and people of the Bidayuh and Iban ethnic groups in Sarawak. This is the 3rd commonest cancer in Malaysia (based on the 2006 official Malaysian cancer registry) after colorectal (1st place) and lung (2nd place) cancers.  It arises from the back portion of the nose called the ‘nasopharynx ‘ and is silent in its early stage. By the time a patient complains of nose block, it is usually of a considerable size. Other sinister symptoms include nose bleed, one-sided ear blockage, neck swelling due to enlarged neck lymph nodes. However, if detected and treated early, the cure rate of this cancer is good.
On the other hand, non-cancerous tumours and polyps in the nose can also obstruct the nose. It can arise spontaneously and may be accompanied by other symptoms like runny nose and blood-stained discharge.

 
Nose cancer: an endoscopic view of a bleeding nose cancer
 
A non-cancerous nasal polyp obstructing the nasal passageway.


Foreign body in the nose
Parents beware ! This condition usually occurs in the children, sometimes right under your noses, literally ! Some parents may have caught their children in the act of inserting a foreign material into the nose and immediately seek medical attention. However, not so infrequently, parents only notice the child having one-sided nasal obstruction with foul-smelling, pus discharge from the nostril days or months after the actual foreign body insertion. The child may deny or does not remember the exact incident. Among the many objects (from button to tiny parts of their toys), button battery remains one of the commonest item retrieved. In the case of button battery, immediate removal is warranted as it may corrode and permanently damage the inner lining of the nose. In an uncooperative child, general anaesthesia is needed for the prompt removal. This condition is one of the commonest ENT EMERGENCY. At times, the neglected foreign material is discovered incidentally during a check-up for some non-related issue or the child presents with nose block after many months or years. A stone, ‘rhinolith’ (‘rhino’=nose, ‘lith’ =stones), due to chemical deposition with the foreign body at its core, can be found instead !

 
X rays in the same patient showing a button battery lodged in the nose

Medication
Nasal decongestant sprays are easily available over-the-counter medication. The active ingredient, eg. oxymetazoline, provides an immediate relief of nasal blockage. Unfortunately, this has often resulted in unsupervised or abuse of the medication beyond the recommended dosage and duration resulting in a medical condition called ‘rhinitis medicamentosa’. While in the beginning, the decongestant was effective in relieving the blockage, continuous use has now paradoxically worsened the nasal obstruction. To reverse this condition, one has to immediately stop using the medication and consult your doctor for a proper diagnosis of the nasal blockage. It is definitely wiser to treat the cause of the symptoms rather than the symptoms alone ! For people with high blood pressure, the hypertension medications can also interfere with the nasal lining causing the patient to experience nasal blockage.

Through complete history-taking and examination, your doctor will be able to differentiate between these conditions. Nowadays, the advent of fibreoptic technology has allowed endoscopes to be introduced into the nose and throat to visualize the problems within these narrow cavities. Even the patient can have a ‘live’ view into his/her own body cavities !  Generally, your doctor will be able to diagnose your condition soon after.  When masses or tumours are encountered in the nose, a biopsy (that is removal of part of the tissue) in the clinic is necessary to know its nature, whether if it is The Big ‘C’ (cancer) or otherwise. Sometimes, radiological imaging (eg CT scan, MRI) may be necessary to aid in the diagnosis. Once a definite diagnosis is established, your doctor will be able to advise you on the best form of treatment.

Certain conditions are initially treated with a non-surgical modality while some would require surgery at the outset. Whatever the decision, it is best to discuss the pros and cons with your doctor who has your best interest and clinical outcome at heart.



Prepared by:

DR. VINCENT TAN ENG SOON
Resident Consultant ENT, Head and Neck Surgeon,
KPJ Klang

MD (UKM), A.M. (Mal), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), MS ORL-HNS (UKM),
Postgraduate  Certificate  in Allergy (Southampton, UK)
Fellowship in Rhinology (Singapore)
Fellowship in Head and Neck Surgery (Amsterdam)

www.vincentENTHNS.com

Mobile: +6012-3760728
email: ENTdrvincenttan@gmail.com