NASAL OBSTRUCTIONMANAGEMENT

NASAL OBSTRUCTION?
It is the subjective sensation of nasal breathing, difficulty or blockage. This subjective sensation can be measured objectively by rhinometery. The levels of obstruction are : External Nose bones or cartilage , or narrow anterior nairs. Nasal vestibule and nasal fossae. Nasopharynx .

The degree of obstruction can be : Bilateral ( fixed or alternating sometimes right sided and sometimes left(NASAL CYCLE),or unilateral Persistent or intermittent Partial or complete Acute, chronic or recurrent

Nasal obstruction is rare to be the only nasal symptom of the patient and commonly is associated with other symptoms.

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Management of Nasal Obstruction:

A.

Diagnosis: 1. History 2. Clinical examination. 3. Endoscopy 4. Assessment of nasal patency: i. Subjective (scoring

HISTORY
1. Duration and frequency of the obstruction. 2. Onset- sudden or gradual? 3. Is it intermittent or persistent? 4. Unilateral or bilateral? 5. Inquire about the presence and character of drainage. Is it watery, purulent, or bloody? 6. Does the patient have nasal or sinus pain or headaches? 7. Ask about recent travel, the use of drugs or alcohol, and previous trauma or surgery.

The presence of acute nasal obstruction should suggest acute sinusitis(U/L), acute rhinitis(B/L), a viral URI(B/L), allergic rhinitis(B/L), nasal diphtheria(B/L), cluster headache, migraine, foreign body(U/L), and trauma +/- FEVER. The presence of chronic nasal obstruction, particularly if it is unilateral, would suggest sinusitis, foreign bodies, neoplasm, deviated septum, polyps, Wegener's granulomatosis, mucormycosis, and nasal gumma. If it is bilateral, it would suggest allergic rhinitis, vasomotor rhinitis, adenoid enlargement, rhinitis medicamentosa, and ingestion of drugs such as reserpine

EXAMINATION
1. Examine the patients nose; assess airflow and the condition of the turbinates and nasal septum. 2. Evaluate the orbits for any evidence of dystopia, decreased vision, excess tearing, or abnormal appearance of the eye. 3. Palpate over the frontal and maxillary sinuses for tenderness. 4. Look for mobility or crepitus suggesting a # of the nasal pyramid. The midfacial bones (especially the bony orbital rim) are also palpated to check for step-offs indicating a fracture line 4. Examine the ears for signs of middle ear effusions.

Anterior Rhinoscopy The rhinologic examination itself begins with anterior rhinoscopy to evaluate the nasal vestibule and the anterior portions of the nasal cavity. Can be used for evaluating the nasal floor, inferior turbinate, and the anterior portions of the septum. The head is tilted backward to obtain a limited view of the middle meatus and middle turbinate. In many cases the nasal mucosa should be decongested with vasoconstrictors prior to the examination Posterior Rhinoscopy Posterior rhinoscopy was formerly done to evaluate the nasopharynx and posterior nasal cavity (choanae, posterior ends of the turbinates, posterior

Nasal Endoscopy

Nasal endoscopy has become the most important and rewarding clinical examination method in rhinologic diagnosis. The patient is seated for the examination; as in anterior rhinoscopy, the preparations include decongestion of the nasal mucosa. A topical anesthetic should also be applied. Diagnostic nasal endoscopy is performed with a 4-mm 30 telescope. The 2.8-mm scope is used only in a very narrow nasal cavity or in children.

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Posterior pharyngeal wall Eustachian tube orifice Torus tubarius

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process Middle turbinate

SPECIAL TESTS

Simple methods can be used for the preliminary assessment of nasal patency. One such method is to hold a reflective metal plate under the nose; the degree of fogging will give a crude impression of the patency of the tested nasal cavity. Nasal patency in infants can be tested subjectively by holding a wisp of cotton in front of each nostril. Today the most standardized

1. CONGENITAL ATRESIA OF THE CHOANAE(post>ant) Commonly unilateral and commonly passes unnoticed for many years. Bilateral cases almost always present as neonatal emergency with asphyxia either cyclically or during suckling. Ds-total absence of nasal airflow (could mirror test), inability to pass a fine plastic catheter or colored nasal drops to the nasopharynx. Confirmation is by nasal endoscopy, contrast radiography with arrest of the radio-opaque dye -lipidol- in the nose, or CT scanning. Mx- a. oral (oropharyngeal) airway which is fixed in place with adhesive tap until curative surgery can be undertaken b. excision of the plate of atresia (bony

2. NASAL TRAUMA Direct external trauma usually causes nasal bone fractures.in severe condn, different types of middle third facial fractures invlvin the cranium and orbits. Anterior skull base fractures cause CSF rhinorrhea possibly with epistaxis, An associated intracranial hemorrhage must be taken in consideration. Nasal fractures present with external deformity (lateral displacement and/or depression), swelling (hematoma, edema and(or) surgical emphysema), contusions and/or lacerations. The nasal fossae show septal fractures, hematomas and/or lacerations with clotted blood in the lumen. Nasal obstruction is usually severe

Mx-Displaced structures should be repositioned and septal hematomas evacuated. Care of the airway and ofany associated injuries is to be over empathized 3. NASAL FOREIGN BODIES Inorganic objects usually stay asymptomatic or produce only unilateral nasal obstruction. Organic objects produce local inflammation which may proceed to formation of granulation tissue. In such cases, unilateral nasal obstruction is rapidly followed by purulent, foul-smelling and commonly bloodtinged discharge. Compln-rhinolith (nasal stone) may develop around it. Mx- removal of the foreign body cautiously if failed removal under general anesthesia is safer.

4. DEVIATED NOSE AND SEPTUM The obstructions caused by the deviation in the narrow side and by compensatory hypertrophy of the turbinates on the wide side and commonly fluctuates with the nasal cycle. Other symptoms are headache, recurrent nasal bleeds and discharge in addition to cosmetic deformities Mx- 1. Septoplasty, and if associated with external nasal deformity septo-rhinoplasty is done . 2. Partial reduction of the hypertrophied turbinates is also indicated

5. ACUTE RHINITIS AND SINUSITIS A/c rhinitisspecific/non-specific(commo cold) It starts by ischaemic stage, with sensation of irritation, dryness, and sneezing.This isfollowed by the hyperaemic stage ,with nasal obstruction, thin discharge, and mild constitutional manifestation. The stage of secondary infection follows with thick clored purulent discharge, more nasal obstruction, and more constitutional manifestation. Then the stage of resolution follows. Mx- rest ,excessive fluids, antihistamines, decongestants, analgesics, and antibiotics if there is secondary bacterial infection .

Acute sinusitis :can develop as complication of acute rhinitis, nasal packing, dental infection , teeth extraction, or external penetrating trauma to the sinuses. It results in facial pain and headache with tenderness over the affected sinus. condition is accompanied with nasal obstruction ,and discharge, with low grade fever and malaise. Mx-1.antibiotic and the other measured used in acute nonspecific rhinitis. 2. Surgical treament (drainage) is indicated if medical treatment fails and there are impending complications

6. C/C RHINOSINUSITIS (NONSPECIFIC AND SPECIFIC

A)

Chronic nonspecific rhinitis may be hypertrophic or atrophic. While in the former obstruction is caused by the swollen turbinates, in the later excessive crusting and altered sensation of inspired air cause a state of unsatisfaction of breathing interpreted by patients as nasal obstruction. In chronic specific rhinitis (granulomas), diffuse affection of the nasal fossae with granulomatous tissues (of scleroma, syphilitic gumma or tuberculous granulation tissues produces nasal obstruction. Obstruction is further aggravated by the secondary nasal deformities and fibrosis caused by the disease. +STIGMATA of d/s

B)

7. NASAL ALLERGY & VASOMOTOR RHINITIS Nasal allergy is an immediate type hypersensitivity reaction to allergens. Allergens may inhalants as dust and pollen, or ingestant as egg and fish. Vasomotor rhinitis is hypereactivity to non-antigenic stimuli as temperature and humidity changes. In both of them, patients present with recurrent attacks of nasal sneezing, rhinorrhea and obstruction. Nasal itching is more pronounced in allergy and is associated with itching in nasopharynx, eyes and ears. An allergic facial features may be seen especially in children with lower lid puffiness, creases and discoloration. and a transverse crease in nasal supratip area and repeated rubbing of the nose. A positive family history of allergy and a past history of infanlile eczema help in differential diagnosis of allergy

Nasal obstruction in both allergy and vasomotor rhinitis is usually intermittent especially in early stages of the disease, yet if left uncontrolled it always become persistent due to development of a state of chronic hypertrophic rhinitis and/or development of multiple bilateral ethmoidal polyps .Bronchial asthma may proceed. accompany or follow the onset of nasal allergy or vasomotor rhinitis. Hypersensitivity to aspirin(and some other non corticosteroid anti-inflammatory drugs) may be present and constitutes with bronchial asthma and nasal polyps a syndrome known as aspirin triad. Mx- Treatment of allergy: the best is by avoidance of the causative allergens.Mecical treatment is by antihistamines, decngestant,

Nasal polyps in allergy and vasomotor rhinitis: They are are multiple, bilateral, ethmoidal glistening, pale, bluish, soft and buggy. They should be differentiated by nasal endoscopy from secondary nasal polyps caused by lymphatic and venous obstruction induced by malignancy in the posterior part of the nose and from the pinkish-white, mamillated or warty, fleshy polypoidal mass of inverted papilloma. Mx- polypectomy, better together with endoscopic ethmoidectomy

8.

NASOPHARYNGIEAL MASSES

Nasopharyngeal masses cause nasal obstruction with varying degree of middle ear dysfunction or inflammation. Adenoidal hypertrophy is the commonest cause in a child while persistent adenoidal hypertrophy and nasopharyngeal cysts are common causes in adults. In an adolescent male bilateral nasal obstruction and recurrent epistaxis highly suggest nasopharyngeal angiofibroma. The treatment is by excision . In patients with nasopharyneal malignancy (commonly elderly), the first manifestation of the disease might be a unilateral secretory otitis media or an upper deep cervical lymph node metastasis even before an appreciable degree of nasal obstruction is complained of. Lower cranial nerves

An antrochoanal polyp is a solitary polyp arising from the maxillary antrum (probable of ineffective origin) and passing posteriorly blocking the ipsilateral posterior choana causing complete ipsilateral nasal obstruction and discharge. As the polyp enlarges. it may block the nasopharynx and the contraIateral posterior choana producing bilateral nasal obstruction. Nasal Endoscopy and CT scanning confirm the diagnosis. The treatment is by excision. 9. NASAL OBSTRUCTION IN JERIATRICS Senile rhinitis is a subtype of vasomotor rhinitis due to endocrine changes occurring chiefly in men. Postmenopausal changes produce similar condition in women. Many drugs likely to be consumed by the elderly produce nasal obstruction as a side effect such as some antihypertensives and coronary dilators. Many hypometabolic states can cause nasal

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