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Nasal obstruction

Surgery > Ear, nose & throat

Differential Diagnosis Schema 🧠

Inflammatory Causes

  • Allergic Rhinitis: Common cause of nasal obstruction; associated with sneezing, itching, and rhinorrhea; triggered by allergens such as pollen, dust, or animal dander.
  • Non-Allergic Rhinitis: Similar symptoms to allergic rhinitis but not triggered by allergens; includes vasomotor rhinitis, often triggered by irritants, temperature changes, or strong odors.
  • Chronic Rhinosinusitis: Persistent nasal obstruction, often with facial pain, pressure, and purulent nasal discharge; may be associated with nasal polyps.
  • Nasal Polyps: Benign growths in the nasal cavity that cause chronic nasal obstruction; often associated with chronic rhinosinusitis and asthma.
  • Infective Rhinitis: Acute or chronic infection of the nasal passages; often viral but can be bacterial; presents with congestion, purulent discharge, and facial pain.

Structural Causes

  • Deviated Nasal Septum: Displacement of the nasal septum to one side; may be congenital or due to trauma; often causes unilateral nasal obstruction.
  • Nasal Valve Collapse: Weakness or collapse of the nasal valve, the narrowest part of the nasal airway; causes nasal obstruction, particularly during inspiration.
  • Adenoid Hypertrophy: Enlargement of the adenoids, typically in children; leads to nasal obstruction, mouth breathing, and snoring.
  • Foreign Body: Common in children; unilateral nasal obstruction with foul-smelling discharge; must be excluded in pediatric cases.
  • Tumors: Benign or malignant growths (e.g., nasopharyngeal carcinoma) can cause nasal obstruction; associated with epistaxis, facial pain, and sometimes cranial nerve involvement.

Other Causes

  • Pregnancy-Related Rhinitis: Hormonal changes during pregnancy can lead to nasal congestion without infection or allergy; typically resolves postpartum.
  • Medication-Induced Rhinitis: Rhinitis medicamentosa due to overuse of topical nasal decongestants; causes rebound nasal congestion and obstruction.
  • Systemic Conditions: Conditions such as sarcoidosis, granulomatosis with polyangiitis, and cystic fibrosis can present with nasal obstruction due to granulomas, polyps, or other structural changes.

Key Points in History 🥼

Symptomatology

  • Onset and Duration: Acute onset may suggest infection or foreign body; chronic symptoms often indicate structural causes or chronic rhinosinusitis.
  • Pattern of Obstruction: Unilateral obstruction suggests structural causes like a deviated septum or tumor; bilateral obstruction is more common in inflammatory or allergic conditions.
  • Associated Symptoms: Rhinorrhea, sneezing, facial pain, epistaxis, or anosmia can provide clues to the underlying cause; for example, facial pain and purulent discharge suggest sinusitis.
  • Triggers and Relievers: Allergens, irritants, or positional changes can help identify the cause; for example, symptoms worsened by lying down may suggest nasal valve collapse.
  • Impact on Quality of Life: Assess how the obstruction affects sleep, breathing, and daily activities; significant impact may warrant more aggressive treatment.

Background

  • Past Medical History: Important to note any history of nasal trauma, sinusitis, allergies, or previous surgeries.
  • Drug History: Review any use of nasal decongestants, antihistamines, or corticosteroids; ask about any recent changes in medication that might affect nasal patency.
  • Family History: Consider family history of allergies, asthma, or nasal polyps, which may predispose to similar conditions.
  • Social History: Assess for smoking, occupational exposures, or recreational drug use, particularly intranasal substances, which can affect nasal health.
  • Environmental Factors: Consider recent exposure to new environments, allergens, or irritants that could contribute to nasal obstruction.

Possible Investigations 🌡️

Initial Investigations

  • Anterior Rhinoscopy: Initial examination to assess for septal deviation, polyps, or other visible structural abnormalities.
  • Nasal Endoscopy: Provides a more detailed view of the nasal cavity and sinuses; useful for diagnosing polyps, tumors, or chronic rhinosinusitis.
  • Allergy Testing: Skin prick testing or specific IgE testing may be indicated if allergic rhinitis is suspected.
  • Nasal Swab: For microbiological analysis in cases of suspected infective rhinitis or chronic rhinosinusitis with purulent discharge.

Imaging and Specialist Tests

  • CT Scan of the Sinuses: Gold standard for evaluating chronic rhinosinusitis, structural abnormalities, or tumors; provides detailed images of the sinus anatomy.
  • MRI: May be indicated if a tumor is suspected, particularly if there is concern about intracranial extension or perineural spread.
  • Sleep Study: Consider if obstructive sleep apnea is suspected, particularly in cases of significant nasal obstruction affecting sleep.
  • Biopsy: Indicated if there is suspicion of malignancy or if nasal polyps appear atypical; performed during nasal endoscopy.
  • Peak Nasal Inspiratory Flow (PNIF): A simple, non-invasive test to assess nasal airflow and obstruction; useful in monitoring response to treatment.

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Ear, nose & throat