1. Dr Deborah Amott ENT Surgeon dhamott@hotmail.com
Nasal Congestion
Dr Deborah Amott
ENT Surgeon

2. Core Presentations
By the end of this year, you should be able to perform a competent medical interview, physical examination and suggest a basic investigational plan for a patient presenting with this symptom.

3. An accurate diagnosis is:
90% History
9% Examination
1% Investigations

4. Nasal Anatomy

5. Sinus Anatomy

6. Function of the Nose 5

7. Airway Filtration Humidification Warming Smell
Function of the Nose
Airway Filtration Humidification Warming Smell

8. What are the symptoms patients will complain of?6

9. What are the symptoms patients will complain of?
Block: congestion vs. total obstruction
uni vs. bilateral
Run (‘rhinorrhoea’)
React to irritation: itching, sneezing, pain
Change in smell (+taste): decreased/absent, foul
Facial pressure/pain
Bleed (‘epistaxis’)

10. Each of these can be fixed or variable over time…

11. General Pathological Processes
VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid-base imbalance/auto-immune T-trauma/toxins E-ethyl alcohol, endocrine
Genetic: too much vs. too little of an otherwise good thing

12. Nasal Congestion: DDx Anatomical: Functional
Deviation of the nasal septum, hypertrophy of turbinates
Choanal atresia
Space Occupying Lesions
Polyps
Tumours: benign vs. malignant
Foreign Body
Congenital: Meningocoele/menigoencephalocoele, dermoids
Functional
Infection
Rhinitis
Sinusitis: acute vs. chronic
Facial pain syndromes: migraine, midfacial pain syndrome, paroxysmal hemicrania etc

13. Anatomy Doesn’t Change…

14. Anatomical Causes

15. Septal Deviation

16. Choanal Atresia

17. Space Occupying Lesions

18. Functional Causes

19. Infections

20. Rhinitis Nasal congestion Rhinorrhoea Irritation
Atopic/Allergic Infectious Irritation Vasomotor Atrophic Medication ….VINDICATE away
Rhinitis
Rhinorrhoea
Irritation

21. Rhinitis

22. RhinoSinusitis Acute Bacterial RS Chronic RS
Bacterial infection of the paranasal sinuses
Symptoms for days
P Facial Pain/pressure/fullness
O Nasal Obstruction
D Purulent nasal Discharge
S Smell: hyposmia/anosmia
Ditto, but symptoms lasting for 8-12 weeks.
Lack of signs of acute inflammation
Requires clinical demonstration of sinus inflammation (endoscopy or imaging)
Multiple Causes

23. Rhinosinusitis

24. Facial Pain Syndromes If the patients main concern is pain, consider a headache syndrome.
Likely the nose?
Probably not..

25. Facial Pain Syndromes If the patients main concern is pain, consider a headache syndrome.
Likely the nose?
Probably not..
Other nasal symptoms
Ache/pressure
Location
Bilateral
Typical triggers
No nasal symptoms
Pain, not pressure
Location
Unilateral
Typical triggers

26. Context of a Symptom
Symptom itself: acuity, duration, severity, variability, progression, triggers/relievers.
Patient: age, sex, race, lifestyle (profession, hobbies, smoking, alcohol, other drugs, other carcinogens/toxins, diet), immune status (Immunosuppressed? Atopic? Autoimmune conditions?), geography.
Associated features: what else is changing?
Local, adjacent structures
Regional
Distant organ dysfunction
Systemic symptoms

27. Concerning Features?

28. Concerning Features Unilateral Symptoms Progressive symptoms
Pain is bad, BUT absence of pain ≠ absence of nasty disease
Bleeding
Crusting
Dysfunction of adjacent structures: nasolacrimal duct, orbit, facial sensation or cheek swelling, eustachian tube obstruction, brain

29. Top 3?
VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic

30. Top 3 Infectious Congenital Traumatic (foreign body)
They can’t blow their nose…
Infectious Congenital
Traumatic (foreign body)

31. Top 3?
VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic

32. Top 3
Infectious Inflammatory Trauma (foreign body, fall)

33. Top 3?
VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic

34. Top 3(ish)
Infectious Inflammatory Trauma Drugs (Auto-immune)

35. Top 3?
VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic

36. Top 3
Infectious/inflamm atory Neoplasia Degeneration

37. Examination External view: gross deviation Nasal obstruction Tilt tip
Block each nostril separately, ‘sniff in’
Tilt tip
Look in:
thudicum speculum and
pen torch

38. Investigations Know the question you want to answer.
Only order an investigation if the result will affect your management
A proper initial clinical assessment and then repeated thorough clinical assessment is always much better than multiple non-targeted tests.
Recruit help

39. Investigation For most, none needed Imaging: options? Biopsy: options?
Allergy testing:
‘short cuts’ vs. definitive testing

40. Investigations: Imaging
Plain XRs
Ultrasound
Computed Tomography
Magnetic Resonance Imaging
Positron Emission Tomography
Nuclear Medicine Scans
The weird and wonderful

42. Investigations: Biopsy Options
Fine needle aspiration
Incisional: ‘wide needle/core’, punch, shave, scalpel
Excisional biopsy
Wide local excision (“Halsteadian”, “en bloc”, “R0 resection”)

43. Intervention
Diagnosis OR Symptoms

44. What’s the Cost-Benefit ratio?
Treatment
Behavioural: avoid triggers, diet, exercise, sleep, environmental modification, mood management
Non-pharmacological treatments: hygiene measures, moisturisers, saline rinsing, dietary supplements etc
Pharmacologic: topical, enteral, transcutaneous, injections
Interventional
Minimal: endoscopic, angiography, etc
Maximal: open surgery, radiation etc
What’s the Cost-Benefit ratio?

45. ?

46. References