Malady Wise

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Nasal Obstruction

Maladywise

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