NASAL OBSTRUCTION

Differential diagnosis 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 nars. Nasal vestibule and nasal fossae: Due to septal or lateral wall deformity. Nasopharynx : as in adenoids, cysts, or tumors of nasopharynx The degree of obstruction can be : Bilateral ( fixed or alternating sometimes right sided and sometimes left),or unilateral. Persistent or intermittent. Partial or complete. Nasal obstruction is rare to be the only nasal symptom of the patient and commonly is associated with other symptoms. The most important causes of nasal obstruction are: Congenital: as congenital choanal atresia. Traumatic: Foreign body in the nose. Deviated nose and septum. Inflammatory: Acute and Chronic rhinosinusitis. Allergic and vasomotor rhinitis. Neoplasm and masses in the nose and nasopharynx.

CONGENITAL ATRESIA OF THE CHOANAE

This uncommon condition affects the posterior choanae and rarely the anterior choanae. In the posterior type there is failure of the nasobuccal or the buccopharyngeal membrane to absorb during fetal life. It is usually unilateral and commonly passes unnoticed for many years. Bilateral cases almost always present as neonatal emergency with asphyxia either cyclically or during suckling. Rapid relief is urgently needed and can be easily achieved by insertion of an oral (oropharyngeal) airway which is fixed in place with adhesive tap until curative surgery can be undertaken. Diagnosis is confirmed by total absence of nasal airflow (could mirror test), inability to pass a fine plastic catheter or colored nasal drops to the nasopharynx. Confirma-tion is by nasal endoscopy, contrast radiography with arrest of the radio-opaque dye -lipidol- in the nose, or CT scanning. Patients suffering from partial unilateral or bilateral posterior choanal atresia are difficult to diagnosed except by nasal endoscopy. Treatment is by excision of the plate of atresia (bony membranous or mixed) transplatally or endonasally.

NASAL TRAUMA
The nose is commonly traumatized by direct external trauma, operative trauma, or by foreign bodies. Direct external trauma usually causes nasal bone fractures. Severer forms of trauma may cause different types of middle third facial fractures and in such instances, attention should be taken to watch for involvement of the important nearby structures like 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. Displaced structures should be repositioned and septal hematomas evacuated. Care of the airway and ofany associated injuries is to be over empathized.

NASAL FOREIGN BODIES

Young children may push foreign bodies into the nose. 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 blood-tinged discharge. The object is seen easily in the affected nostril in early stages. In neglected cases, it may move backward into the nasal cavity and may become covered by mucus and granulation tissue causing difficulties in diagnosis and removal. a rhinolith (nasal stone) may develop around it. The treatment is by removal of the foreign body cautiously if failed removal under general anesthesia is safer. DEVIATED NOSE AND SEPTUM Deviation of the nose and septum presents mainly with obstruction which may be unilateral or bilateral. 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. Correction requires septoplasty, and if associated with external nasal deformity septo-rhinoplasty is done . Partial reduction of the hypertrophied turbinates is also indicated. ACUTE RHINITIS AND SINUSITIS All acute nasal, and paranasal sinus inflammations cause rapid onset or nasal obstruction followed by rhinorrhea. The course of illness should be less than 10 days. If more, a subacute stage of the disease is suspected. Acute rhinitis: It can be specific or nonspeific . Specific acute rhinitis is like diphtheria. It is rare nowadays after vaccination. Acute non specific is like common cold. Common cold: It is caused by rhini virus and commonly followed by secondary bacterial infection. 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. The treatment is by 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. Treatment is by antibiotic and the other measured used in acute nonspecific rhinitis. Surgical treament (drainage) is indicated if medical treatment fails and there are impending complications. CHRONIC RHHNOSINUSITIS (NONSPECIFIC AND SPECIFIC) 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. In addition, the patient commonly presents with other stigmata of the disease. Rhinoscleroma is the most important of this group as it is endemic in Egypt. It is caused by bacillus rhinoscleromatous. and can affect the nose, larynx or larynx. The disease passes in the following stages. -Catarrh stage: with thickened granular mucosa and thick discharge. -Atrophic stage : with roomy nose, glaze mucosa, and crustations. -Hypertrophic stage: with granulations, crustations, and external swelling.

-Fibrotic stage: with dense fibrosis and nasal deformity. Treatment of scleroma is by antibiotics: Combination of Ampicillin and septrin ( trimethoprim and cotrimoxazol), or rifampicin ( cosider hepatptoxicity) . 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. The nasal mucosa in nasal allergy and vasomotor rhinitis is edematous pale and bluish with varying degree of venous congestion. It is more reddish in color in acute episodes of the disease or if secondary viral or bacterial infection supervenes. Treatment of allergy: the best is by avoidance of the causative allergens.Mecical treatment is by antihistamines, decngestant, sodium chromoglycate (mast cell stabilizer), or corticosteroid ( systemic or local nasal spray). Hyposensitization is an other mode of treatment that sometimes gives results.It is by vaccination with increasing dose of the causative antigen. 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. Treatment is by polypectomy, better together with endoscopic ethmoidectomy.

NASAL NEOPLASMS
Unilateral nasal neoplasms usually cause ipsilateral symptoms early in their course such as nasal obstruction, odorous and sometimes blood-tinged discharge. Later, both sides of the nose are affected. External nasal deformity may develop. In malignant lesions orbiral, facial and palatal manifestationsof local extension of the tumor, denote delay in diagnosis. Early nasal endoscopy is extremely helpful in detection of small and early lesions with better prospect of cure. In an adolescent male patient complaining of bilateral nasal obstruction with recurrent epistaxis and anemia, a nasopharyngeal angiofibroma should be suspected. Confirmation of diagnosis is achieved by nasal endoscopy. CT and MRI scanning. Angiography and immobilization is important to facilitate surgical excision.

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 involvement in the skull base in order of frequency of V, VI,IX,X,XI, and VIII produces palatopharyngo-laryngeal paralysis and paralysis of tongue, ophthalmoplegia , trigeminal neuralgia , and other manifestations of

these cranial nerves involvement.. Nasal endoscopy, CT and MRI scanning are important tools for diagnosing nasopharyngeal neoplasms. The treatment is by radiotherapy. 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.

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 obstruction. In all such cases, the nose show hypertrophy of inferior turbinates especially their posterior end. Table 1 demonstrates the mode of onset of nasal obstruction in different nasal diseases. Table 2 demonstrates the course of the obstruction in these diseases. Table3 demonstrates duration of nasal obstruction in important nasal diseases. Tables 4&5 demonstrate different nasal diseases with associated other manifestation beside the nasal obstruction Table 6 mentions some important causes of nasal obstruction at different age groups. Table 7 enumerates some important causes of unilateral nasal obstruction.

TABLE 1: ONSET OF NASAL OBSTRUCTION

I Abrupt trauma II Sudden 1. Trauma 2. Allergy & VMR III Rapid Acute infections IV Gradual chronic V Insidious Neoplasm

infections

TABLE 2: COURSE OF NASAL OBSTRUCTION

1 Progressive then regressive 1. Acute infections. 2. Trauma II Intermittent 1. Allergy & VMR.. 2. Recurrent sinusitis. III Persistent with remission &exacerbation Chronic Inflammation IV Steady progressive Neoplasms

TABLE 3: DURATION OF NASAL OBSTRUCTION

I. Hours Attacks of Allergy& Ii. Days I -Acute InflaIII. Months 1. Chronic Infl IV years 1. Chronic inf-

VMR lammations 2. Trauma .

mmations 2. Malignant 3. Attacks of allergy & VMR.

ammations . 2~ Benign neoplasms neoplasms

Table 4:Nasal obstruction with other manifestations

I. with II. with with Ext. Nasal Attacksof Ear block deformity sneezing& -age 1.Trauma discharge 2. 1. Nasal Develop allergy ment as D. 2. VMR nose & septum 3.Granuloas: a) scleroma b)syphilis c) TB 4.Tumors IV. with V. with Vi. Epistaxis Bloody Rec. I.Nasophsmelly Head aryngeal discharge ache & 1. Nasoph: fibroma 1.F.B.ina postnasal aryngeal (Adolescent child discharge causes as: male) (unilateral) 1. Sinusitis a) 2. Blood 2. Maligadenoids clots & nancy in b) cysts elderly C) polyps d) tumors mas . 3-Atrophic rhinitis. IIIwith

Table 5:Nasal obstruction with other manifestations cont

I. with Pale bluish mucosa 1. Bilateral with Re. itching & sneezing II. with Red mucosa 1. Diffuse in: Acute rhinitis 2. LocaliIII. with Glazed dry mucosa 1. Atrophic rhinitis. 2. Atrophic stage of IV. with Polyps 1. Multiple & bilateral in: a) Allergy b) VMR V. with Diffuse granulom. Vi. with Localized mass

masses 1. Neoplasm 1. Scleroma 2. Syphilis 2. Solitary 3. TB polyp.

in: allergy & VMR 2. Unilat. or bilateral without itching & sneezing in posterior Choanal Atresia

zed in: sinusitis

scleroma

2. Solitary antrochanal polyp.

3. Cyst.

Table 6:Nasal obstruction and age of patients

I II I1I IV Adults Almost all V Elderly Almost all N.B.: 1. Malignancy 2. Aging 3. Metabolic 4. Drug induced Newly borne Infants & Adolescents 1. Birth children. Almost all Trauma: 1. Adenoids N.B.: a) External 2. F.B. 1. Developtrauma 3. Trauma mental as D.S. b) Retained 4. Rhinitis & 2. Nasopharysecretion sinusitis ngeal fibroma 2. Posterior5. Rarely choanal a) Ch. diphatresia theria b) Congenital syphilis

Table 7: Unilateral Nasal Obstruction

I II Congenital Trauma 1. Unilat*F.B, posterior choan atresia 2. Unilatanterior Nasal atresia (rare) III Inflammatory 1. Nasal diphtheria 2. Unilatsinusitis 3. Antrochoanal polyp. IV Develop mental *D.S. V Cysts 1. Alveolar 2. Dental 3. Mucoceles 4. Dermoid VI Tumors 1. Benign: a) Papill oma b)Angioma 2. Malign ant.