OTO-ENT • OTORHINOLARYNGOLOGY

SHIFT
NASAL OBSTRUCTION
1
Jose A. Romualdez, MD, FPSOHNS; Ma. Clarissa S. Fortuna, MD March 1, 2023 LEC #5

LECTURE OUTLINE
I. Recap of Physiology V. Structural (Anatomic) Causes
II. Nasal Obstruction A. Unilateral
A. Definition B. Bilateral
B. Causes C. Unilateral/Bilateral
C. Clinical Approach VI. Approach To Patient With Nasal
III. Mucosal Inflammatory Disease Obstruction
A. Etiology A. Physical Examination
B. Acute Infectious VII. Imaging
Rhinosinusitis A. CT Scan
C. Allergic Rhinitis B. MRI
D. Non-Allergic Non-Infectious VIII. Medical Management
Rhinitis IX. Surgical Management
E. Chronic Rhinosinusitis with X. References
Nasal Polyps
IV. Neoplastic Causes
A. Benign
B. Malignant Figure 3. Nasal mucosa.

👉
important/must
📕
book
📑
previous trans
🩺
lecturer’s key
🎉
updates
● Humidification (90% relative humidity) accomplished by secretion
from mucus glands and goblet cells inside the nasal cavity through
know points the mucosa.
● Temperature regulation (30C) controlled by the intranasal vascular
I. 🎉 RECAP OF ANATOMY system (venous erectile tissue).

II. RECAP OF PHYSIOLOGY

● Functions: humidification, temperature regulation, protection from
pollution, pathogens, and aeroallergens
● Nasal breathing is critical especially for babies who must breathe
through the nose almost all the time

Figure 1. Sagittal section of nasal cavity.

● The internal nasal valve (limen nasi) is the narrowest portion of the
upper respiratory tract and, has a major bearing on the
aerodynamics of nasal airflow.
● The turbinates (conchae) are covered with mucous membrane and
have the ability to change temperature and humidity of inhaled air.
🎉 Figure 4. Autonomic Nervous System in Nasal Physiology
● During parasympathetic nasal stimulation, venous capacitance
becomes dilated. So, neurogenic inflammation happens.
● When there’s inflammation going on, glands hypersecrete and
become edematous and then they secrete secretions.Thus, the nose
becomes congested.
● When the nasal area is obstructed, we also experience rhinorrhoea.

Figure 2. Coronal cut of nasal cavity

● Anterior group (middle meatus): maxillary, frontal and anterior

ethmoid sinuses
● Posterior group (superior meatus): posterior ethmoid and

●
sphenoid sinuses
The meatus serves as a passageway for the opening of the
paranasal sinuses (ostium).
🎉 Figure 5. Mucocilliary clearance
○ Apparent in the coronal view of CT-Scan ● Cilia beat in a coordinated pattern in the sol layer, transports
particles in the gel layer.
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 ● Movements of cilia affected by humidity, temperature, drugs, C. CLINICAL APPROACH
pollutants, smoking, infection, and nasal pathologies.
● Clinical History → Physical Examination → Diagnostic Procedures (if
warranted) → Management

Table 3. Clinical History.

● Acute or chronic
Onset
● Symptom progression
● Unilateral
○ suggests structural causes, foreign body (in
Laterality children), tumors (in adults)
● Bilateral
○ suggests mucosal inflammatory disease
● Intermittent or persistent
● Assess

🎉 Figure 6. Mucociliary flow patterns

○ alternation
○ annual seasonality
Duration ○ diurnal variability: worsens at work, home, or
● Mucociliary blanket traps pathogens and particles (>0.5 μm) and during physical activity
transports them to nasopharynx. ○ nocturnal variability: worsens in decubitus or

🎉 Table 1.TYPE
The nose and its defenses against disease.
OF IMMUNE RESPONSE
○
sleeping on one particular side
suggests inflammatory or functional causes
● Allergic, physical, or chemical stimuli, infections,
NON-SPECIFIC SPECIFIC surgery, injury, environmental, occupational, use of
● Mechanical Defenses ● Humoral Immune Response medications or illicit drugs, hormonal, or medical
○ E.g. vibrissae, mucociliary ○ Antibodies are formed from Triggers
conditions (especially those that lead to
blanket the paraglandular plasma predominance of parasympathetic system),
○ Vibrissae (“nose hair”) cells (IgE mediates allergic pregnancy
■ Don’t remove your nose rhinitis) ● Effect on quality of life, specific questionnaires are
hair because it serves available (e.g., Rhinoconjunctivitis Quality of Life
to protect your nose
Questionnaire, Sinonasal Outcome Test or
from foreign bodies Severity
SNOT-22),
and dust
○ predictors of proposed interventional
● Non-specific Protective Factors ● Cellular Immune Response
○ Present in mucous blanket of ○ Mast cells, macrophages, improvement in patients with chronic sinusitis
nasal mucosa neutrophils, basophils, ● Suggests allergic: pruritus, sneezing, rhinorrhea
Nasal
■ E.i. interferon, eosinophils, lymphocytes, ● Suggests infectious: facial pain, fever, anosmia
symptoms
proteases, protease dendritic or Langerhans cells ● Suggests a more aggressive etiology: epistaxis
inhibitors, lysozyme, ■ Clinical correlation: ● Asthma, conjunctivitis, chronic rhinosinusitis,
antioxidants That’s why it’s also pharyngeal symptoms, snoring, visual
important to ask for a disturbances, CNS dysfunctions, systemic
CBC as part of the lab symptoms (e.g. vasculitis, hypothyroidism)
work up ● History of atopy, exposures, trauma, previous
● Cellular Defenses Comorbidities
nasal surgery, obstructive sleep apnea, cystic
○ Cells in nasal mucosa
fibrosis, chronic infections (ex. syphilis, TB,
■ Phagocytic cells and
leprosy), or even systemic diseases like
natural killer cells
Wegener’s disease or Churg-Strauss syndrome
should be ruled out
III. NASAL OBSTRUCTION
● Intranasal decongestants, anti-thyroid drugs,
antipsychotics, anti-hypertensives, oral
Drugs
A. DEFINITION contraceptives, antidepressants, cocaine,
● Subjective perception of discomfort or difficulty in the passage of air methamphetamine, tobacco

●
through the nostrils.
Symptom and not a diagnosis
● The terms “obstruction” and “nasal congestion” can be used
synonymously
○ Obstruction is used more to refer to the subjective sensation of
irreversible blockage
● Common symptom, and a common reason for consult
○ Up to 1/3 of the adult population have some degree of nasal
obstruction
○ ¼ of these patients seek intervention to improve quality of life
○ Nasal cycle: physiological phenomenon of periodic cycles of
vascular engorgement on the nasal cavity mucosa that
alternate between left and right
📑 Laterality - may indicate urgency of the condition
📑 ○ Allergic rhinitis, systemic conditions - usually bilateral
Triggers - usually allergic
○ If non-allergic, there may be exposure to physical or chemical
stimuli
📑 ○ Ask onset to narrow down exposure
Hormonal state (e.g. congestion in a pregnant woman)
○ occurs especially during the last trimester
○ manifests from uterine congestion to Eustachian tube
📑 dysfunction because of hormonal stimulation
Drugs – 1 month history of nasal decongestants without response:
patient may be experiencing rebound congestion

B. CAUSES

Table 2. Causes of Nasal Obstruction

Inflammatory Congenital
Neoplastic Structural/Anatomic
Drug-Induced Neurogenic
Metabolic Systemic

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 IV. RHINITIS / MUCOSAL INFLAMMATORY DISEASE ○ But in the Philippines, it’s usually all-year round due to the
presence of dust in the environment
● Clinical manifestations:
A. OVERVIEW ○ Sneezing
○ Itching
○ Nasal congestion
○ Watery rhinorrhea
○ Ocular symptoms

3. NON-ALLERGIC, NON-INFECTIOUS RHINITIS

● No clinical signs of infection and sensitization
○ Heterogenous group of nasal conditions with rhinitis symptoms
● Manifest with nasal congestion and rhinorrhea

✓ NOTE: Different forms of rhinitis may co-exist (Mixed Rhinitis)

B. ACUTE INFECTIOUS RHINOSINUSITIS

● Acute: < 12 weeks
● Inflammation of the nose and the paranasal sinuses
Figure 7. Etiologies of Mucosal Inflammatory Disease (from Dr. Romualdez’s
● Most common cause: Viral or Bacterial
slides)
● Sudden onset of 2 or more symptoms:
○ One of which should be either:
■ Nasal blockage
■ Nasal obstruction
■ Nasal congestion
■ Nasal discharge (anterior/posterior nasal drip)
○ May or may not be associated with:
■ Facial pain/pressure
■ Reduction or loss of smell
● If chronic rhinosinusitis: > 12 weeks

🎉
○ CRS with or without nasal polyps
Polyp: lesion/clear mass that grows into the nasal cavity; seen
in untreated chronic rhinosinusitis

1. COMMON COLD (RHINOVIRUS)

● Most common cause of acute infectious rhinosinusitis

🎉Figure 8. Subtypes of Rhinitis (from Dra. Fortuna’s slides)

○ Rhinovirus – Most common cause
○
🎉
Management – Symptomatic relief

🎉
Self medicate with decongestants
● Rhinitis
○ Inflammation of the nasal mucosa causing symptoms 🎉
Nasal saline rinse to clear the nasal cavity of secretions
AVOID ANTIBIOTICS
■ Nasal congestion (stuffy nose)
■ Rhinorrhea
■ Sneezing
■ Itching
○ Duration
■ Occurring 2 or more consecutive days
– For more than 1 hr on most days
● Most common cause of bilateral nasal obstruction

1. INFECTIOUS RHINITIS
● Usually viral (especially Rhinovirus), acute and self- limiting but may
be complicated by secondary bacterial or fungal infection
○ Secondary bacterial infection
■ Usually if there is a long-standing viral infection and then
there is an exposure to bacteria
○ Secondary fungal infection
■ Common on people who are immunocompromised
(diabetes, HIV, cancer patients)
● Most common cause under mucosal inflammatory disease
● Usually occurs during the flu season and manifests with flu-like Figure 9. Clinical course of post-viral acute rhinosinusitis and signs of potential
symptoms acute bacterial rhinosinusitis.
● Clinical manifestations:
○ Headache 2. ACUTE BACTERIAL RHINOSINUSITIS
○ Facial pain ● Increase in symptoms after 5 days or persistent symptoms after 10
○ Fever days (after acute viral rhinosinusitis) with less than 12 weeks in
○ Discolored secretion duration
○ Nasal congestion ● Signs of potential acute bacterial rhinosinusitis:
○ Crusting ○ At least 3 of:
○ Sore throat ■ Fever > 38oC
■ Double sickening
2. ALLERGIC RHINITIS ■ Unilateral disease

🎉
● Caused by IgE-mediated immune response to aeroallergens ■ Severe frontonasal pain
May be caused from the allergens in the air (aeroallergens) in the ■ Increased ESR/CRP

🎉 environment or the workplace

May be seasonal especially in the Western countries (e.i. Pollen
season)

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 Common ● Rhinovirus
pathogens ● Any URTI can
present as
rhinosinusitis (e.g.,
COVID-19)
Management ● Self-education /
e-Health
● Decongestants < 10
days
● Herbal medicine
● Zinc and Vit C
● Consider nasal
saline rinses
● Avoid antibiotics
🎉 Figure 10. Diagnosis of Acute Bacterial Rhinosinusitis.
● S. pneumoniae
● H. influenzae
● M. catarrhalis
● Mild (VAS < 5): Symptomatic
therapy
● Moderate (VSA 5-7):
Intranasal corticosteroids
(INCS)
o Most efficient way to
reduce inflammation;
topical
● Severe (VAS 8-10):
Antibiotics with INCS
o 1st line: Amoxicillin

REFER TO ENT IF:

● No resolution within 72 hours
of therapy
● Alarm symptoms present
● Recurrent ABRS

C. ALLERGIC RHINITIS

🎉 Figure 11. Management of Acute Bacterial Rhinosinusitis.

● Treatment:
○ Mild ARBS
■ Symptomatic therapy
○ Moderate ARBS
■ Intranasal steroids

👉🎉
– Tell the generic name for them to find a substitute,
especially to patients who travel abroad (e.g Figure 12. Diagnostic algorithm for allergic rhinitis. The patient most
Fluticasone) likely has allergic rhinitis when there are bilateral symptoms, and there is
○ Severe ARBS pruritus, tearing and redness in the eyes. On the other hand, the patient likely
■ Antibiotics does not have allergic rhinitis when the patient has postnasal drip (patient does
– Drug of Choice: Amoxicillin not have anterior symptoms), has colored nasal discharge, and facial pain.
● Refer to otorhinolaryngology if: These symptoms point more to chronic rhinosinusitis than allergic rhinitis.
○ Recurrent ABRS - > 4 episodes per year with symptom free
intervals ✓ NOTE: A larger picture of the algorithm is located at the appendix

🎉
○ Presence of ALARM SYMPTOMS (highly suggestive of orbital
and intracranial complications): Induced after allergen exposure (IgE-mediated inflammation)

🎉
■ Periorbital edema/erythema characterized by 2 or more cardinal symptoms

🎉
■ Displaced globe Patients commonly have personal and family history of atopy
■ Double vision Classic PE Findings:
■ Ophthalmoplegia ○ Mouth breathing
■ Reduced visual acuity ○ Allergic salute
■ Severe headache ○ Transverse nasal crease

🩺
■ Frontal swelling ○ Allergic shiners
■ Signs of sepsis Most patients aren’t able to sleep very well, so they usually have

👉
■ Signs of meningitis very thick eye-bags
■ Neurological signs Nose / Anterior Rhinoscopy Findings:

🎉
○ NO RESOLUTION with antibiotic therapy within 72 hours ○ Pale boggy turbinates with clear, watery discharge
Manage allergic rhinitis (AR) by categorizing them, using the Allergic
Table 4. Acute Viral Sinusitis vs Acute Bacterial Rhinosinusitis. Rhinitis Classification and Management (ARIA Recommendations)

Duration of
symptoms
●
Acute Viral
< 10 days ●
Acute Bacterial
Increased severity of 🩺 IMPORTANT: Skin test is the standard ancillary procedure for allergic
rhinitis (AR) diagnosis because you want to identify the specific allergen of the
symptoms after 5 days OR
● Persistent symptoms after 10 patient (e.i. Dust, pollen) in order to avoid it.
days

Symptoms ● Nasal congestion ● Discolored/purulent

and/or nasal discharge
discharge ● Elevated ESR/CRP
● + Facial pain or ● Severe frontonasal pain
pressure ● Double sickening
● + Reduction or loss ● Temp > 38oC
of smell (hyposmia
or anosmia)
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 D. NON-ALLERGIC NON-INFECTIOUS RHINITIS
● Symptoms induced by exposure to nonspecific trigger, also called nasal
hyper-responsiveness

Table 5. Types of Non-allergic Non-infectious Rhinitis.

Rhinitis Trigger Mechanism
Drug-induced Medications Neuronal
(antihypertensives, imbalance
NSAIDS, antidepressants,
illicit drugs)
Hormonal Pregnancy, menstrual Neuronal
cycle, hypothyroidism imbalance
Age-related Age > 65 years old Decreased blood
flow at this age →
Mucosal and gland
atrophy
Atrophic Chronic infection, nasal Mucosal atrophy
surgery, irradiation
Irritant Chemicals, pollution, Neurogenic
Figure 13. Types of Allergic Rhinitis. smoke, strong odors inflammation
Gustatory Spicy food Neurogenic
inflammation
1. INTERMITTENT VS PERSISTENT ALLERGIC RHINITIS Idiopathic Changes in weather, Neurogenic
● Intermittent (Vasomotor) temperature inflammation
○ Symptoms happen < 4 days per week or < 4 weeks
● Persistent
○ Symptoms happen > 4 days per week and > 4 weeks

2. MILD VS MODERATE TO SEVERE ALLERGIC RHINITIS

● Mild
○ Normal: Sleep, daily activities, sports and leisure, work, and
school function
○ No troublesome symptoms; non restricted
● Moderate to Severe
○ One or more times
○ Sleep disturbance
○ Impairment of daily activities, sports or leisure, school, or work
function
○ Troublesome symptoms
● The management would depend on the classification of allergic

🎉
rhinitis
No hard and fast rule; ARIA is just a guide; need to see patient
regularly and update the outcome of management
Figure 15. Types of Non-Allergic, Non-Infectious Rhinitis.
(Obtained during SGD Session)

🎉 Gustatory Rhinitis

🎉 ○ Elicited by ingestion of spicy food

Hormonal Rhinitis
○ Pregnant patients

🎉 ■ Due to fluctuations of hormones

Rhinitis medicamentosa
○ Not all intranasal sprays can cause this
○ Decongestant: Drixine
■ Used when you can’t breathe properly through your nose
and can only breathe through your mouth
■ Don't use for more than 5 days
– Can cause rebound

🎉 –
Occupational
○
If weeks or months, won’t be effective anymore

When you get out of work, symptoms abate

○ Depending on the work place

🎉 ■ E.g carpets, aircon (dirty)

Figure 14. Management of Allergic Rhinitis.
● In general, the first step is irritant avoidance
● Next, pharmacotherapy, mostly using second-generation oral
antihistamines and intranasal corticosteroids
● For patients, who do not decrease/improve their symptoms with
avoidance and pharmacotherapy, then immunotherapy may be given
Atopic Rhinitis
○ Turbinoplasty
■ For those with increased size of turbinates wherein
medications are not effective anymore
■ Shrink with cryotherapy, cautery, radio frequency
■ If you have too much or repeated surgeries like this, this
may lead to atopic rhinitis
– Respiratory ciliated cells flatten, produces lots of
🎉 crusting due to repeated surgeries
Rhinitis of the elderly

🎉 ○ Due to multiple degenerative diseases

Vasomotor rhinitis
○ Temperature or stress related
■ E.g travel during the winter time e.g outside
■ When going back inside gets warm, symptoms relieved

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 🎉 We must grade the polyp since it can be treated medically or
surgically
○ Grade 1
■ You never see the polyp with simple anterior rhinoscopy
■ Incidental finding in endoscopy
■ Purely medical in management
■ WIll only require surgery if it will not respond to complaint
treatment
○ Grade 2
■
🩺Graying area
“Halos nakikita mo nakalevel niya yung middle
turbinate” and seen by speculum
■ If 6 months to1 year using a nasal steroid but still with

🎉nasal congestion. We opt to do sinus surgery

There is a high recurrence rate in endoscopic sinus
surgical removal. That is why they still back it up with
nasal steroid after the surgery
Figure 16. Management for different types of Non-Allergic, Non-Infectious
Rhinitis. (Obtained during SGD Session).

🎉
🎉 Ipratropium bromide not always available in Philippines
○ Grade 3

🎉 Practically, all the management is AVOIDANCE of the triggers

For hormonal induced rhinitis: In reality it become bothersome to
■
🩺
This is massive and no need for examination
Patient will just say “ doc may nakikita akong parang
may sago sa may ilong ko”
some patient that why they give empirical nasal steroids ■ Warrants endoscopic surgery

E. CHRONIC RHINOSINUSITIS WITH NASAL POLYPS 2. SECONDARY CHRONIC RHINOSINUSITIS

● Refers to sinonasal inflammation caused by an underlying disease or
pathology

Table 7. Secondary Chronic Rhinosinusitis

Localize/ Odontogenic Infection
Unilateral ● An inflammatory condition of the maxillary sinuses
Figure 17. Nasal Polyps. Bilateral edematous semi-translucent glistening
inflammatory whitish masses.
1. NASAL POLYPS
● Bilateral edematous semi-translucent glistening inflammatory whitish
masses.
● Commonly originating from mucosal lining of sinonasal mucosa and
prolapsing into the nasal cavities
● Unlike turbinates, polyps are insensitive to palpation, rarely bleed,
and does not decrease in size with application of a topical
decongestant
● Associated with chronic rhinosinusitis and diagnosed through history
of slowly progressive bilateral nasal obstruction accompanied by
hyposmia
● Anterior rhinoscopy or nasal endoscopy reveal this characteristic
mass commonly occurring bilaterally
● Polyps occurring unilaterally: indicative of a neoplastic process and
further evaluation may be warranted
● Uncommon in children
○ Presence in this age group may suggest cystic fibrosis as an
because of a dental pathology or prior dental procedure.
● Maxillary molars & premolars - most common involved
teeth since the bony wall that separates the roots from the
maxillary sinuses are very thin
Fungal InfectionRadiologic evidence of sinus opacification
● Presence of cheesy mucopurulent material within the sinus
● Dense conglomeration of hyphae separate from the sinus
mucosa
● Nonspecific chronic inflammation of mucosa with no
predominance of eosinophils or granuloma
● Presence of allergic mucin
● No histopathologic evidence of fungal mucosa invasion
Tumors (discussed in Neoplastic Causes)
Foreign Body
● Common cause of unilateral obstruction in children
○ Unilateral foul-smelling rhinorrhea
○ Can be missed and remain for weeks or months
○ Some objects can cause severe damage and need to
be removed urgently (e.g. batteries & magnets)
● Considered an emergency when these objects are seen
as foreign bodies
Mechanical

🎉 underlying pathology
Nasal polyp a is clearer and translucent than the pinkish mucosa of
Diffuse/
Bilateral
● Cystic Fibrosis - causes defective ion transport
● Primary Ciliary Dyskinesia - results in abnormal ciliary

🎉 middle turbinates
If you see in the clinic a nasal polyps, just spray it with decongestant
and it will not shrink. Spraying of decongestant will help to
structure and function
● Both Cystic Fibrosis and Primary Ciliary
Dyskinesia - cause tenacious and viscous mucous
differentiate polyp from middle turbinates and recurrent infection because of impaired ciliary
movement
Table 6. Nasal Polyp Grading and Management. Inflammatory (Wegener’s Granulomatosis, Churg-
GRADE 1 GRADE 2 GRADE 3 Strauss Syndrome)
Polyps do not extend Polyps extend Polyps are massive and ● Vasculitides that cause inflammation in the blood vessels
beyond the most beyond the middle occlude the entire nasal in the nose and sinuses
anterior part of the turbinate cavity
middle turbinate Selective Immunodeficiency
Nasal endoscopy Visible with a nasal Can be seen readily ● Primary Immunodeficiencies - Inherited disorders
required for speculum (anterior ● Secondary Immunodeficiencies
visualization rhinoscopy) ○ Result of events such as a viral infection or iatrogenic
Intranasal Intranasal corticosteroids with short-term oral immunosuppression
corticosteroids; oral steroids (either concurrently or sequentially) ● IgG, IgA, IgM Deficiencies, and Common Variable
steroids if no Immunodeficiency (CVID)
resolution ○ Most frequent and clinically relevant deficiencies
If no response to medical therapy: refer for functional endoscopic sinus associated with chronic rhinosinusitis
surgery to remove polyp and aerate the sinuses so that function will be
restored

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 ○ Facial and nasal swelling
○ Epiphora, diplopia, proptosis, visual disturbances
○ Palatal swelling

🎉
○ Cervical lymphadenopathy, affectation of cervical LN
Cranial nerve dysfunction

01. SQUAMOUS CELL CA

● Account for most of malignant sinonasal tumors
● Primary management: surgery

02. NASOPHARYNGEAL CA
● Common malignant tumors in the nasopharynx which commonly
present as cervical lymph node enlargement
● Manifest with unilateral middle ear effusion because of eustachian
tube dysfunction and lateral rectus palsy
🎉Figure 18. Secondary Chronic Rhinosinusitis ●
●
At later stages, may metastasize in the lungs, liver, and bones
Common among Southern Chinese descent having a diet high in salt
and cured meats such as salted fish, and infection with EBV

🎉
V. NEOPLASTIC CAUSES (COMMONLY UNILATERAL) ● Primary management: radiotherapy

🎉
🎉
You have sinusitis because you have obstruction
“Bumara kasi yung tumor kaya nag backflow yung mucus”
Some of them have nasal congestion due to tumors. The ●
○
○
No surgery
If extensive, chemotherapy can be employed
Symptoms

🎉 rhinosinusitis is only secondary infection or collateral damage.

Treatment will be directed to the management of neoplasm
○
○
Most common: Cervical lymphadenopathy
Lateral rectus palsy

03. ESTHESIONEUROBLASTOMA
● Other name: Olfactory neuroblastoma
● Rare malignant neoplasm originating from the olfactory
neuroepithelium
● Primary management: surgery

VI. STRUCTURAL (ANATOMIC) CAUSES

🎉Figure 19. Neoplastic causes of Nasal Obstruction

1. BENIGN
● Benign lesions are slow-growing lesions with insidious progression of
symptoms
● Managed by complete surgical removal either by endoscopic or a

🎉Figure 20. Structural causes of Nasal Obstruction.

wider and more invasive open approaches

01. ANTROCHOANAL POLYP

● Whitish lesion, mostly seen in the antrum; you can see it in the 1. UNILATERAL
nasopharynx
● Benign polypoid lesions arising from maxillary antrum extending into 01. SEPTAL DEVIATION
the choana
● Occur more commonly in young adults ● Common finding with most asymptomatic patients
● Some may complain of unilateral nasal obstruction
● Congenital or acquired → nasal injury
02. INVERTED PAPILLOMA
● Benign sinonasal epithelial tumor with a high rate of recurrence 02. CHOANAL BULLOSA
● Associated with HPV
● Predilection to develop to SCC in 10% of cases ● Pneumatized or air-filled cavity within a nasal turbinate which may
also block the air exchange
● One of the turbinates is enlarged
03. JUVENILE NASOANGIOFIBROMA
● Benign vascular tumor arising predominantly in the lateral wall of an 2. BILATERAL
adolescent male
● Presenting complaints:
○ Recurrent epistaxis 01. ADENOID HYPERTROPHY
○ Firm, friable violaceous mass in the nasal cavity ● Common among children
○ Bloody because of angiomatous component ● Associated symptoms: rhinorrhea, mouth breathing (chronic nasal
● Only adolescent males are affected; never reported in females airway obstruction), chronic cough, postnasal drip, snoring, anorexia,
○ Due to hormonal factors hyponasal voice (rhinophonia clausa)
● May be initially medically treated but surgically removed in the
2. MALIGNANT presence of obstructive sleep apnea
● Malignant lesions should be considered in patients with rapid
symptom progression and unilateral involvement
● Presenting symptoms:
○ Unilateral epistaxis

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 02. CHOANAL ATRESIA
● Congenital disorder in which the paired openings that connect the
nasal cavity and nasopharynx are occluded by soft tissue or bone
● Posterior choana are closed
● Due to failed recanalization during fetal development
● Unilateral
● Bilateral
○ Neonate (obligate nasal breathers) is unable to breathe
■ The infant experiences episode of asphyxia at rest when
mouth is closed
○ Considered an EMERGENCY Figure 22. Palpation maneuvers for physical examination
● Not routinely done because of COVID. Done only when the patient
3. UNILATERAL / BILATERAL complaint of of facial pain
👉 Nasal valve region is made up of the inferior turbinate, nasal septum,
and lateral wall
○ Inferior turbinate and nasal septum: rigid structures
●
🎉
Anterior rhinoscopy

○
Warrant the use of speculum
Assess the anterior third of the nose (septum, nasal valve,
○
👉
Lateral wall: less rigid
Variable determinant of nasal valve instability ○
inferior turbinate, head of middle turbinate)
Nasal mucosa should be evaluated for signs like:
■ Atrophy or dryness
01. NASAL VALVE INSUFFICIENCY ■ Scabs (in vasculitis or chronic atrophic rhinitis)
● The movable part of the alae closes down during inspiration due to ■ Congestive and pale mucosa (allergic or drug-induced
airflow and may cause physiological narrowing. rhinitis)
■ Presence of septal deviation, synechia, perforations, and
rhinorrhea and their characteristics
○ Important to detect lesions of nasal passages either bilaterally
02. HYPERTROPHIC TURBINATES (polyps) or unilaterally (tumor)
● Refers to excessive enlargement of the turbinates ○ Note the appearance before and after administering a topical
● Can be caused by swelling of the mucosa due to various forms of vasoconstrictor
rhinitis (most commonly coming from allergic rhinitis)
● Managed medically or surgically (if the cause is thickened or
abnormally placed turbinate bones)

VII. APPROACH TO PATIENT WITH NASAL OBSTRUCTION

🎉 Figure 23. Anterior rhinoscopy

● Transillumination
○ Document the presence of frontal or maxillary sinusitis

🎉 Figure 21. How to recognize rhinitis symptoms and how to classify (Allergic,
Infectious, Non-infectious). Symptoms will just guide you on what type of
○
○
Important to dim the light
If light passes through the maxillary sinus, it doesn’t mean you
can rule out infectious diseases
examination you will do.

● Complete history and head and neck PE are critical to accurately

diagnose the underlying etiology of a patient’s underlying symptoms

1. PHYSICAL EXAMINATION
● Inspection
○ Appearance of the skin, protrusions, asymmetries, lateralization
of the nasal pyramid
○ Record dynamic or static nostril collapse in inspiration and
anomalies like asymmetry or location of quadrangular cartilage
over the columella
● Palpation Figure 24. Transillumination for physical examination
○ Palpate the frontal and maxillary sinus to assess whether it
triggers pain ● Complete head and neck exam
○ In the bony and cartilaginous pyramid, note for asymmetry, ○ Examination of the remaining areas of the ear, nose, throat,
crepitation, lack of support or collapse head, neck, and presence of cervical lymphadenopathy must be
○ Assessment of the alignment and consistency of the anterior done
septum should be noted ● Physical exam of other organ systems to document if there is
systemic disease

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 ● Functional maneuvers VII. IMAGING
○ Cottle’s maneuver
● Not routinely employed for the evaluation of nasal obstruction
■ To determine if the most significant site of nasal
because the cause is often evident through clinical history and
obstruction is at the nasal valve or farther inside the nasal
physical exam.
cavity
● May be indicated:
■ Cheeks on the side to be evaluated is gently pulled
○ When there is suboptimal response to medical therapy
laterally with one to two fingers to open the nasal valve,
especially for mucosal diseases
which offers the highest resistance in the airway
○ When there are red flags of orbital and intracranial
complications

A. CT SCAN
● Used to evaluate structural or bony abnormalities such as deviated
septum, nasal bone fractures, choanal atresia, mucosal sinus
disease
● May also be useful for neoplastic lesions that may reveal unexpected
findings such as concha bullosa

B. MRI
Figure 25. Cotte’s maneuver
● Because of its soft tissue detail, it is better suited for evaluating the
integrity of the dura and for further assessment of certain nasal
● Nasal endoscopy
masses such as encephalocele and glioma
○ Provides a more detailed examination of the nasal passages
● Commonly performed to assess the full extent, intracranial
○ Visualize both the anterior and posterior regions of the nasal
extension, and improve the specificity of diagnosis in the presence of
cavity (mucosa, turbinates, meati, sinus ostia, ostiomeatal unit,
aggressive neoplasms
posterior choana in the nasopharynx)
○ Present size and laterality of septal deviation should be noted
○ Any polypoid masses; if rhinorrhea is present

Figure 28. CT and MRI

Figure 26. Nasal Endoscopy. MT: Middle Turbinate; IT: Inferior Turbinate.
● Acoustic rhinomanometry
○ Evaluates the relationship between nasal cross-sectional areas,
resistances, and patencies
○ Measured before and after topical application of nasal
decongestants in patients complaining of nasal obstruction
○ Uses reflected sound signal to measure the cross-sectional
areas and volume of nasal passages
○ Gives a functional measure of the pressure-flow relationship
during the respiratory cycle
○ Adapter with a constant and preset length is placed in the nasal
vestibule which is connected to a sonic tube and the results
obtained are recorded in a graph where the areas are
highlighted according to the distance from the nasal window
■ Provides information of the nasal volume
■ Two notches can be seen in the non-congested cavity and
the narrowest area located 3 cm from the nasal window
VIII. MEDICAL MANAGEMENT
● Antihistamine & anti-leukotriene
○ For allergic rhinitis
● Intranasal corticosteroids
○ Moderate to severe and persistent types of allergic rhinitis
(immunotherapy if no response to pharmacotherapy)
○ Bacterial rhinosinusitis ± antibiotics
○ Vasomotor rhinitis – neurogenic inflammation (capsaicin can
sometimes be useful for this)
○ Chronic rhinosinusitis (± polyps)
● Nasal saline douche
○ Adjunctive therapy for any form of rhinitis; allergic, infectious,
non-allergic & noninfectious rhinitis (counseling on avoidance of
triggers)
● Decongestant
○ For those with nasal congestion as the most prominent
symptom
○ Symptomatic therapy
○ Caution for adverse events
■ Oral: hypertension, cardiovascular risks
■ Intranasal: only given for maximum of 5-7 days to prevent
rhinitis medicamentosa (rebound rhinitis) U
● Immunosuppressive
○ For Wegener’s disease & Churg-Strauss syndrome
○ Glucocorticoids, rituximab, cyclophosphamide, etc.
● Intravenous IgG
○ IgG immunodeficiency

IX. SURGICAL MANAGEMENT

● Structural (anatomic) problems
○ Indicated for patients with significant breathing and functional
problems
○ For asymptomatic and mild symptoms – monitoring &
Figure 27. Acoustic rhinomanometry. counseling only
● Chronic rhinosinusitis (CRS)
○ If with failure of maximal medical therapy (CRS ± polyps)

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 ○ Presence of complications (orbital or intracranial)
● Neoplastic
○ Main therapy for benign and malignant lesions (except
nasopharyngeal carcinoma - gold standard therapy is
radiotherapy) U
○ Malignancy supplemented by radiation and chemotherapy
depending on the disease stage
● Congenital problems
○ Choanal atresia, nasal encephalocele, glioma

Figure 29. Surgical Management

Recorded Lecture

X. REFERENCES
● Batch 2023 Nasal Obstruction Transcript
● Romualdez, J. (2022). Nasal Obstruction. [Recorded lecture
presentation]. Manila, Philippines: Faculty of Medicine and Surgery,
University of Santo Tomas, DEPARTMENT OF
OTORHINOLARYNGOLOGY

XI. REVIEW QUESTIONS

1. In patients with allergic rhinitis having troublesome symptoms, the
recommended pharmacotherapy by ARIA would be:
A. Anti-leukotriene
B. Oral antihistamine
C. Mast cell stabilizer
D. Intranasal corticosteroid
2. An intranasal benign tumor that may be locally aggressive, and is
known for its propensity to transform into malignancy
A. Nasal polyposis
B. Inverting papilloma
C. Antrochoanal polyp
D. Juvenile angiofibroma
3. A 25-year-old male consulted for bilateral nasal congestion for 3
days associated with watery rhinorrhea, low-grade fever, and facial
pain. What would be most appropriate management?
A. Cetirizine
B. Amoxicillin
C. Montelukast
D. Symptomatic therapy
4. The pathogenesis of this type of rhinitis is believed to involve
neurovascular autonomic disturbance in regulating the nasal
mucosal vessel tone
A. Allergic
B. Irritant
C. Atrophic
D. Vasomotor
5. A 40-year-old female consulted for bilateral nasal obstruction and
hyposmia. Anterior rhinoscopy revealed pale gray polypoid masses
on both nasal cavities that can only be visualized only through nasal
endoscopy. What is the primary management?
A. Intranasal decongestant
B. Endoscopic sinus surgery
C. Intranasal corticosteroids
D. Oral antihistamine + decongestant

1. Intranasal corticosteroid
2. Inverting papilloma
3. Symptomatic therapy
4. Vasomotor
5. Intranasal corticosteroids

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 VIII. APPENDIX
Appendix 1. Diagnostic algorithm for allergic rhinitis.

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 IX. FREEDOM WALL

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