1. KAU Rabigh School of Medicine
Department of Otolaryngology, Head and Neck Surgery

2. Tutorial 6
By Razan A. Basonbul, MBBS
Nasal obstruction

3. Objectives Definition Differential diagnosis History Examination
Investigation
Common issues:
Mucosal Swelling
Septal deviation
Collapse of nasal valves
Nasopharyngeal obstruction:
Adenoids
Choanal atresia
Nasal polyps
Cephalocele
Tumors, JNA

4. Definition
Nasal obstruction is the sensation of reduced air flow either through one nostril (unilateral) or both nostrils (bilateral). There are four main subdivisions:
Mucosal swelling
Septal deviation
Collapse of the nasal valves
Nasopharyngeal obstruction

5. Differential Diagnosis KITTENS Method
(K) congenital
Infectious & Idiopathic
Toxins & Truma
Tumor ( Neoplasia)
Neurogenic tumors.
Conginital Nasopharyngeal cysts.
Teratoma
Choanal atresia.
Nasoseptal deformaties
Infectious Rhinitis
Rhinoscleroma
Chronic Sinusitis
Adenoid Hyperplasia
Nasal & septal Fractures
Medicatios side effects ( Rhinitis medimentosa)
Synechia
Environmental irritants
Septal Hematoma
Foreign bodies
Papillomas
Nasal Polyps
Hemangiomas
Pyogenic granulomas
Juvenile nasopharyngeal angiofibromas
Malignancy
Endocrine
Neurologic
systemic
Diabetes
Hypothroidism
Pregnancy
Vasomotor rhinitis
Granulomatous diseases
Vasculitis
Allergy
Cystic fibrosis

6. History Character of Nasal Obstruction: Contributing Factors:
Onset and duration.
Constant VS intermittent.
Unilateral VS Bilateral.
Associated mouth breathing, Snoring, anosmia/hyposmia/taste disturbance
Tearing ( Nasolacrimal Duct Obstruction or Allergy).
Contributing Factors:
Toxin and Allergen exposure.
Known Drug Allergies
Medications
Hx of Asthma
Rhinosinusitis
Sleep Disturbance
Facial Trauma or Surgery
Common Drugs that cause Nasal Congestion
Antihypertensive, Asprin
OCP
Chronic Nasal Decongestants
Cocaine, Marijuan
Tobacco
Antithyroid Medication

7. Associated Symptoms and signs:
Allergic component:
H&N:
Sore throat.
Sneezing
Postnasal drip
Itching
Cough
Watery eyes
Ear complaints
Clear Rhinorrhea
Halitosis
Sinus Involvement:
Ocular pain
Facial Pain
hoarseness
Headaches
Acute Infection:
Fever
Malaise
Purulent or odorous nasal discharge
Pain

8. Examination External Nasal Exam: Anterior Rhinoscopy/ Nasal endoscopy:
External deformities: ( firmness, tenderness on palpation)
Nasal flaring
Nasal airflow
Anterior Rhinoscopy/ Nasal endoscopy:
Examine twice ( with and without topical decongestion)
Quality of turbinates ( hypertrophic, pale, blue)
Quality of nasal mucosa, Septum.
Osteometal complex obstruction
Foreign body, Nasal Masses, Choanal opening
Quality of Nasal Secretions:
Purulent and thick ( infectious)
Watery and clear ( Vasomotor rhinitis, Allergy)
Salty and clear ( CSF leak)

9. H & N exam: Facial Tenderness Tonsil and adenoid hypertrophy
Cobblestoned posterior pharynx
Cervical lymphadenopathy
Otologic exam

10. Investigations Allergy Evaluation CT/MRI of Paranasal Sinus: Biopsy:
CT is Indicated if Obstruction secondary to;
Nasal Masses
Nasal Polyps
Work up for Chronic rhinosinusitis
MRI is preferred if;
Suspected Tumors
Intracranial involvement
Complicated rhinosinusitis
Biopsy:
For any mass suspecious of malignancy, avoid biopsy of vascular neoplasms or encephaloceles.
Ciliary Biopsy and mucociliary Clearance Tests:
Electron microscopy and ciliary motility studies for ciliary defects.
Nasal secretion protien, Glucose or B2-transferrin:
For CSF leak.

11. Culture and Sensitivity:
Direct Nasal Swabs or Surgically obtained cultures may be indicated of r complicated acute rhinosinusitis and resistant chronic rhinosinusitis.
Pulmonary Function test:
Considered if suspected coexisting reactive airway disease process.

12. Nasal obstruction Adults Children *Deviated Nasal Septum
*Large Adenoids
*Choanal Atresia
*Rhinitis
*Postnasal space tumors (angiofibroma)
*Foreign body
Refer to ORL in the same day if: Unilateral obstruction ± foul or bloody discharge.
Adults
*Deviated Nasal Septum
*Rhinitis, Sinusitis
*Polyps
*Granuloma ( wegner’s)
*Topical vasoconstrictors
Refer to ORL urgently:
Numbness, tooth pain, bleeding, unilateral obstruction, tumor suspected

13. Mucosal swelling Autonomic rhinitis Rhinitis medicamentosa
Clear mucus production is the primary problem with less nasal obstruction. This is due to over activity of the glands in the nose. It is not common and usually occurs in the over 60s.
Rhinitis medicamentosa
Overuse of some decongestant nasal sprays (Otrivine, Sinex).
These can help decongest the nose for a few hours if you have a cold but should not be taken for more than a 5 days as they damage the lining of the nose.
Chronic infection
It is associated with a mucky discolored production of green mucus through the day.
Idiopathic rhinitis
Where neither allergy nor infection can be found yet the lining of the nose is swollen.

14. Turbinate Hypertrophy

15. Turbinate Hypertrophy
With lower two showing management with coblation

16. Septal deviation
Septum is bent or deviated over to one side and this blocks the air passage of the nose.
Septal deviation may be associated with a visibly deformed nose and a history of nasal trauma although it is not necessary as the cartilage may bend and deform as the nose grows.
Nasal obstruction is the predominant symptom, usually on one side. However, if other symptoms are present other disease processes must be excluded.
Management depends on the severity of nasal obstruction. Surgery to correct the deformity can be undertaken if the nose is blocked or unsightly.

17. Deviated nasal septum

18. Septal Hematoma Occurs following Trauma, Drugs as ASA or Idiopathic.
Management by: Drainage and pressure Dressing..

19. Collapse of the nasal valves
Normally on breathing in through the nostrils there is a small amount of collapse of the nostrils. Often this collapse stops if the mucosal swelling is treated.
Occasionally the problem is primarily due to a ‘floppy’ valve or side wall of the nose collapsing.
Treatment using external nasal splints can sometimes be help at night. Surgery is an option in case of bothersome issue.

20. Nasopharyngeal obstruction
Adenoids :
Most common cause of nasal obstruction in children
reaching maximum size between the age of 3-5 years old and then reduce in size often by the age of 7 and can hardly be seen by the late teens.
Snoring alone is not an indication for adenoid removal but if the child also develops apnea (stops breathing for more than 10 seconds regularly without a cold) then adenoidectomy and tonsillectomy may be helpful.

21. Choanal atresia
Incidence of 1 in 5000 to 1 in 10,000 births and is more often unilateral than bilateral.
The atresia is bony in 90% of cases and membranous in only 10%.
The choana develop between the 3rd and 7th embryonic weeks.
Symptoms:
Bilateral choanal atresia is an acutely life threatening emergency! The resulting hypoxia is manifested by cyanosis that is present at rest and improves with exertion is called paradoxical cyanosis.
Unilateral choanal atresia may be manifested by a purulent nasal discharge on the affected side.

22. Diagnosis: Treatment:
Both choanae in newborns should be routinely catheterized in the immediate postnatal period (e.g., with the suction catheter) to exclude choanal atresia.
Rigid or flexible endoscope.
Treatment:
Bilateral: intubation followed by perforation of the atresia plate.
Recurrent: stenosis is prevented by inserting a stent and securing it with a suture (to prevent aspiration).
The definitive surgical repair of bilateral choanal atresia is performed during the first weeks or months of life.
Unilateral: Surgery can be postponed until school age.

23. Coanal Atresia

24. Nasal Polyps
Defined as benign swelling of most commonly ethmoid sinus mucosa of unknown cause.
Histology: waterlogged stroma infiltrated with inflammatory cells and eosinophils.
They rise from each ethmoid air cells and hang down inside the nasal cavity.
Polyps can arise from other sinuses as a single large polyp arising from the maxillary sinus called antrochoanal polyp, this prolapse done the nasopharynx.
Associated with: Asthma, Aspirin Sensitivity and Cystic fibrosis.
Samter’s Triad: Nasal Polyposis, Aspirin Allergy and Asthma.

25. !! Role out Malignancy in Adults with unilateral polyp.
Hx:
Nasal obstruction,
watery rhinorrhea,
sinus infection,
anosmia.
Ex:
Pale, Semitransparent gray mass.
Mobile.
Insensitive when palpated. ( differentiate it for hypertrophied turbinate)
May prolapse out of the nose if left untreated.
!! Role out Malignancy in Adults with unilateral polyp.
!! Role out Meningocoele or encephalocoele By CT
TTT:
Topical Steroids spray
Surgery

26. Nasal polyps
ALL POLYPS SHOULD BE SENT TO HISTOPATHOLOGY!

27. Cephalpcele
Cephaloceles are herniations of intracranial contents through a bony defect in the skull.
Types:
Meningocele.
Meningoencephalocele.
Meningoencephalocystocele (meningocele + portions of the ventricular system)
Etiology:
Most cephaloceles are congenital.
Rare cases are post-traumatic (e.g., after a frontobasal fracture)
Presentation:
Closely resemble Nasal Polyp. But have to be role out in Unilateral nasal polyp in children.

28. Diagnosis:
CT or MRI can supply information on the location and extent of the mass and the associated bony defect.
Treatment:
Always surgical and consists of removing the cephalocele and repairing the dural defect

29. Tumors Of the Nasal Cavity
Unilateral nasal blockage, discharge and bleeding are often the presenting symptoms of nasal or sinus tumors.
Osteomas are often asymptomatic.
Transitional cell papilloma is the most common benign tumor ( may undergo malignant changes)
Squamous cell carcinoma is the most common malignant tumor.
50% of Sinonasal cancer arise from lateral nasal wall,
33% in Maxillary antrum.

30. Juvenile angiofibroma (JNA)
A benign tumor that arise adjacent to the sphenopalatine foramen, tends to bleed and occurs in the nasopharynx of prepubertal and adolescent males.
Epidemiology:
0.05% of all head and neck tumors.
Occurs in MALES.
Affects age 7-19 years.
Presentation:
Nasal obstruction (80-90%)
Epistaxis(45-60%) unilateral sever bleeding.
Headache (25%)

31. Diagnoosis: Treatment: Vascular unilateral nasal mass.
CT and MRI showing the extent of the tumor growth.
Angiography shows branches of external carotid that feeds the tumor.
Treatment:
Hormonal: Testosterone receptor blocker
Surgical Resection and Radiotherapy.

32. Foreign Bodies of the Nose
Mostly are self inserted by children.
Organic materials present early by Purulent Discharge
Inorganic materials may remain for ages.
Presentation:
unilateral, foul smelling nasal Discharge ± blood
Management:
Forceps: Pieces of paper or cotton swabs.
blunt hook: for Rounded objects, pass it deeper than the object then try to bring it out by dragging it over the floor of the nose.
Removal under General Anastasia might be required, make sure to protect the airway!
Complications:
Nasal infection and sinusitis.
Rhinolith formation.
Inhalation into the tracheobronchial tree.

33. Nasal Foreign body removal

34. Foreign body removal by balloon catheter

35. Be aware !
In children with a blocked nose on one side and a one sided nasal discharge, a foreign body may be in the nose.
Nasal polyps are rare in children and further tests should be done.
Nasal obstruction of one side of the nose in adults, with or without bleeding, needs to be REFERED to be examined carefully by an otolaryngologist.
Instruct the patient to Avoid the long-term use of nasal medication purchased over the counter unless specifically prescribed.

36. Thank you  References:
Clinical Otolaryngology online (COOL)
Under the American Academy of otolaryngology, Head and Neck Surgery
The British Association of Otolaryngology Head and Neck Surgery
Otolaryngology head and neck surgery by Raza Pasha,MD
Primary care otolaryngology
Bailey and Love Short practice in surgery 25th edition.
Oxford Handbook of clinical specialties.
Thank you 