Clinical presentation, diagnosis, and treatment of nasal obstruction
- Neil Bhattacharyya, MD, FACS
Neil Bhattacharyya, MD, FACS
- Professor of Otology and Laryngology
- Brigham and Women's Hospital
- Harvard Medical School
Nasal and sinus complaints are among the most common reasons for visits to primary care clinicians, otolaryngologists, and allergists. Although some clinicians consider nasal obstruction to imply a blockage within the nasal cavity, nasal obstruction is most commonly defined as a patient symptom manifested as a sensation of insufficient airflow through the nose . Nasal obstruction may be the cardinal presenting symptom of many common disease processes, such as rhinitis, sinusitis, septal deviation, adenoid hypertrophy, and nasal trauma.
This topic will focus on the clinical manifestations, evaluation, and treatment of nasal obstruction in adults. The structural causes of nasal symptoms and other specific diseases associated with nasal obstruction are discussed separately. (See "Etiologies of nasal symptoms: An overview" and "Cancer of the nasal vestibule" and "Tumors of the nasal cavity" and "Congenital anomalies of the nose" and "Nasal trauma and fractures in children" and "An overview of rhinitis" and "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis" and "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis" and "Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment".)
The risk factors for nasal obstruction relate directly to the underlying etiology. Several common risk factors for nasal obstruction include a history of atopy, recurrent sinusitis, nasal trauma, nasal surgery, having household pets, exposure to poor air quality, and a family history of nasal polyposis [2-4]. Nasal obstruction commonly accompanies many other comorbid conditions including asthma and obstructive sleep apnea .
The pathogenesis of nasal obstruction may be related to abnormalities occurring with any of the anatomic structures and functions within the nose. Normal nasal anatomy and function are discussed elsewhere. (See "Etiologies of nasal symptoms: An overview", section on 'Nasal anatomy and function'.)
Nasal obstruction may be generally divided into mucosal and structural causes (table 1). The nasal mucosa is a complex tissue that is subject to local and systemic insults, leading to nasal obstruction. Examples of mucosal causes of nasal obstruction include bacterial sinusitis, nasal polyps, and soft tissue turbinate hypertrophy due to allergic rhinitis. There is also a normal, cyclical pattern of turbinate mucosal swelling, which alternates between sides of the nasal septum at intervals of two to five hours, referred to as the nasal cycle . Disruption of the nasal cycle can contribute to nasal obstruction.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Jessen M, Malm L. Definition, prevalence and development of nasal obstruction. Allergy 1997; 52:3.
- Becker SS, Dobratz EJ, Stowell N, et al. Revision septoplasty: review of sources of persistent nasal obstruction. Am J Rhinol 2008; 22:440.
- Bhattacharyya N. Air quality influences the prevalence of hay fever and sinusitis. Laryngoscope 2009; 119:429.
- Delagrand A, Gilbert-Dussardier B, Burg S, et al. Nasal polyposis: is there an inheritance pattern? A single family study. Rhinology 2008; 46:125.
- Bhattacharyya N, Kepnes LJ. Additional disease burden from hay fever and sinusitis accompanying asthma. Ann Otol Rhinol Laryngol 2009; 118:651.
- Baraniuk JN, Kim D. Nasonasal reflexes, the nasal cycle, and sneeze. Curr Allergy Asthma Rep 2007; 7:105.
- Chandra RK, Patadia MO, Raviv J. Diagnosis of nasal airway obstruction. Otolaryngol Clin North Am 2009; 42:207.
- Akoğlu E, Karazincir S, Balci A, et al. Evaluation of the turbinate hypertrophy by computed tomography in patients with deviated nasal septum. Otolaryngol Head Neck Surg 2007; 136:380.
- Jun BC, Kim SW, Kim SW, et al. Is turbinate surgery necessary when performing a septoplasty? Eur Arch Otorhinolaryngol 2009; 266:975.
- Storms W. Allergic rhinitis-induced nasal congestion: its impact on sleep quality. Prim Care Respir J 2008; 17:7.
- Udaka T, Suzuki H, Fujimura T, et al. Chronic nasal obstruction causes daytime sleepiness and decreased quality of life even in the absence of snoring. Am J Rhinol 2007; 21:564.
- Bellanti JA, Wallerstedt DB. Allergic rhinitis update: Epidemiology and natural history. Allergy Asthma Proc 2000; 21:367.
- Lam DJ, James KT, Weaver EM. Comparison of anatomic, physiological, and subjective measures of the nasal airway. Am J Rhinol 2006; 20:463.
- Fraser L, Kelly G. An evidence-based approach to the management of the adult with nasal obstruction. Clin Otolaryngol 2009; 34:151.
- Wittkopf M, Wittkopf J, Ries WR. The diagnosis and treatment of nasal valve collapse. Curr Opin Otolaryngol Head Neck Surg 2008; 16:10.
- Bhattacharyya N, Lee LN. Evaluating the diagnosis of chronic rhinosinusitis based on clinical guidelines and endoscopy. Otolaryngol Head Neck Surg 2010; 143:147.
- Hamdan AL, Sabra O, Hadi U. Prevalence of adenoid hypertrophy in adults with nasal obstruction. J Otolaryngol Head Neck Surg 2008; 37:469.
- Ardeshirpour F, McCarn KE, McKinney AM, et al. Computed tomography scan does not correlate with patient experience of nasal obstruction. Laryngoscope 2016; 126:820.
- Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg 2015; 152:S1.
- Corey CL, Most SP. Treatment of nasal obstruction in the posttraumatic nose. Otolaryngol Clin North Am 2009; 42:567.
- Tan BK, Lane AP. Endoscopic sinus surgery in the management of nasal obstruction. Otolaryngol Clin North Am 2009; 42:227.
- Newton JR, Ah-See KW. A review of nasal polyposis. Ther Clin Risk Manag 2008; 4:507.
- Jankowski R, Klossek JM, Attali V, et al. Long-term study of fluticasone propionate aqueous nasal spray in acute and maintenance therapy of nasal polyposis. Allergy 2009; 64:944.
- Stjärne P, Blomgren K, Cayé-Thomasen P, et al. The efficacy and safety of once-daily mometasone furoate nasal spray in nasal polyposis: a randomized, double-blind, placebo-controlled study. Acta Otolaryngol 2006; 126:606.
- Filiaci F, Passali D, Puxeddu R, Schrewelius C. A randomized controlled trial showing efficacy of once daily intranasal budesonide in nasal polyposis. Rhinology 2000; 38:185.
- Lund VJ, Flood J, Sykes AP, Richards DH. Effect of fluticasone in severe polyposis. Arch Otolaryngol Head Neck Surg 1998; 124:513.
- Becker SS. Surgical management of polyps in the treatment of nasal airway obstruction. Otolaryngol Clin North Am 2009; 42:377.
- DeConde AS, Mace JC, Levy JM, et al. Prevalence of polyp recurrence after endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis. Laryngoscope 2017; 127:550.
- Rambur B, Winbourn MW. Recognizing nasal vestibulitis in the primary care setting. Nurse Pract 1994; 19:22, 25.
- Varghese M, Glaum MC, Lockey RF. Drug-induced rhinitis. Clin Exp Allergy 2010; 40:381.
- Gandomi B, Bayat A, Kazemei T. Outcomes of septoplasty in young adults: the Nasal Obstruction Septoplasty Effectiveness study. Am J Otolaryngol 2010; 31:189.
- Caylakli F, Yavuz H, Cagici AC, Ozluoglu LN. Endoscopic sinus surgery for maxillary sinus mucoceles. Head Face Med 2006; 2:29.
- Brachlow A, Schwartz RH, Bahadori RS. Intranasal mucocele of the nasolacrimal duct: an important cause of neonatal nasal obstruction. Clin Pediatr (Phila) 2004; 43:479.
- Devars du Mayne M, Moya-Plana A, Malinvaud D, et al. Sinus mucocele: natural history and long-term recurrence rate. Eur Ann Otorhinolaryngol Head Neck Dis 2012; 129:125.
- Soon SR, Lim CM, Singh H, Sethi DS. Sphenoid sinus mucocele: 10 cases and literature review. J Laryngol Otol 2010; 124:44.
- O'Halloran LR. The lateral crural J-flap repair of nasal valve collapse. Otolaryngol Head Neck Surg 2003; 128:640.
- Kiyohara N, Badger C, Tjoa T, Wong B. A Comparison of Over-the-Counter Mechanical Nasal Dilators: A Systematic Review. JAMA Facial Plast Surg 2016; 18:385.
- RISK FACTORS
- CLINICAL MANIFESTATIONS
- Physical examination
- - External examination
- - Anterior rhinoscopy
- - Nasal endoscopy
- Diagnostic imaging
- Other testing
- Mucosal disorders
- - Nasal polyps
- - Nasal vestibulitis
- - Rhinosinusitis
- - Rhinitis
- - Medication-induced
- Structural disorders
- - Nasal septal deviation
- - Mucoceles
- - Nasal valve abnormalities
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS