Nasal Obstruction

Summary Dr Toby Corlette ENT via HMRI ENT update 2023

Overview

• Most people have both nasal obstruction and sinusitis

Nasal obstruction

• Septal deviation

  • Constant and all the time if severe

  • Sometimes trauma but usually developmental

  • Sprays and washes don’t work

• Inferior turbinate hypertrophy (structural and functional)

  • Fluctates

  • Usually worse at night

  • Worse lying down

  • Blod drains away from turbinates with gravity

  • Backlog of venous BP in face

  • Downhill side will block (e.g. lying on the left = left side blocks, rolls over and right side blocks

  • Improves with INCS and decongestants

• Most people have a combination of bent septum and enlarged turbinates

• Nasal valve compromise

  • Relief when holding cheek to side or holding side wall of nostril out

  • Basically entry to nostril

Benefits

• More comfortable

• Better sleep quality

• Can improve OSA (Moderate to mild)

• Easier aerobic exercise

Investigations

• None

Management

• INCS

  • 2 spray each side twice daily

  • Mometasone

• +/- intranasal antiistamine if atopy

  • Azep, Dymsita, Ryaltris)

  • Needs to be 3 months

• If a nasal valve problem

  • Nasal Splint

    • Rhinomed mute split

      • Cheap, comfortable

    • Breath right strips

    • Nasal aid

    • Airmax

• Surgery

  • Septoplasty

  • Turboplasty

Sinusitis

Duration

• Acute < 12 weeks

• Chronic > 12 weeks

Consequences

• Post nasal drip

• Facial pressure

• Nasal obstruction

• URTIs that persist longer than usual

Sinuses make 1-2L of mucous per day normally

Causes

• Narrow opening

• Inflammatory/allergic

• Infective

• Combination of 2 or 3 of these

Anatomical narrowing

• Surgery

Slight narrowing

• INCS

• +/- Surgery

Normal opening

• Severe inflammation

• Usually medical treatment

• INCS

Workup

• CT scan prior to treatment

  • Preferably when symptomatic

• Then

  • Dexamethasone 8mg daily for 5 days

    • Prednisolone fine

  • Augmentin (or Rulide) for 10 days

  • INCS for 3 months

  • Nasal douche BD for 3 months

• ENT review at 3 months

  • If response INCS and nasal douche long-term

  • If there is no response, consider surgery

Things we could do better before referring

• INCS 2 spray twice easily for 3 months, 1 spray daily not enough, needs loading

• CT before referral

• ABx and INCs at same time, needed to break cycle

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