When does my blocked nose need treatment? 

  • We all have a blocked nose from time to time, but we don’t all need specific treatment for this.

  • If you feel your blocked nose is a persistent problem, and is lowering your quality of life it can almost always be improved.

What problems can I have with my nose?

  • We ask the following questions:
    • Do you suffer from nasal congestion or stuffiness?
    • Do you suffer from nasal blockage or obstruction?
    •  Do you have trouble breathing through your nose?
    • Do you have trouble sleeping, or snoring?
    • Do you have trouble with exercise because of your nose?
  •  The more of these questions to which you answer yes, the more likely that you will benefit from targeted treatment to improve your nasal airflow

What are the causes of a blocked nose?

(1) inferior turbinate swelling/ allergy

  • The inferior turbinates are a normal structure in the nose designed to warm and moisten the air we breathe.
  • If they are too big or if they swell too much with allergy, infection or other inflammation, the nose will be blocked.
  • While the turbinates can cause blockage of both sides of the nose at the same time, a common history is of a blocked nose which keeps on changing sides.
  • The effect of a cold and flu spray (eg Drixine, Otrivine, Vicks) is to clear the nasal airway by shrinking the turbinates- this will give a short term improvement for many issues, but unfortunately cannot be maintained in the long term.
  • A lot of treatment for blocked nose is aimed to reduced the size of the inferior turbinates (eg nasal allergy spray, allergy desensitisation, surgery).
Figure 1  Left: a swollen allergic inferior turbinate causing complet obstruction  Right: the same nose five minutes after a decongestant spray with a dramatically improved nasal airway  Many treatments for nasal obstruction aim to recreate this improvement in a lasting way.

Figure 1

Left: a swollen allergic inferior turbinate causing complet obstruction

Right: the same nose five minutes after a decongestant spray with a dramatically improved nasal airway

Many treatments for nasal obstruction aim to recreate this improvement in a lasting way.

(2) nasal septal deviation

  • The nasal septum is the wall between the left and right nasal airways.
  • If it is bent, it can cause a blockage of one or both sides of the nose.
  •  A bent septum may interact with other causes of blockage including enlarged inferior turbinates, or sinusitis.
  •  If a bend of the septum is a major cause of your nasal obstruction, surgery is necessary to get a satisfactory improvement in symptoms
Figure 2: A coronal CT scan which shows a significant bend of the nasal septum to the right with a reduction in the nasal airway.

Figure 2: A coronal CT scan which shows a significant bend of the nasal septum to the right with a reduction in the nasal airway.

(3) External deformity of the nose

  • In some cases, a severe bend of the nose, asymmetry of the nostrils or collapse of the nostrils are major causes of nasal obstruction
  • These factors are likely to require structural treatment with external rhinoseptoplasty.

 

Figure 3: A bent nose with severe nasal obstruction.  Function and appearance were dramatically improved by  external rhinoseptoplasty  with Dr Smith

Figure 3: A bent nose with severe nasal obstruction.

Function and appearance were dramatically improved by external rhinoseptoplasty with Dr Smith

Figure 4: Severe narrowing and asymmetry of the nasal tip with obstruction, corrected by external rhinoplasty with Dr Smith

Figure 4: Severe narrowing and asymmetry of the nasal tip with obstruction, corrected by external rhinoplasty with Dr Smith

Figure 5: A nose with severe sidewall collapse, requiring external rhinoseptoplasty with Dr Smith, gaining a major improvement in breathing and appearance

Figure 5: A nose with severe sidewall collapse, requiring external rhinoseptoplasty with Dr Smith, gaining a major improvement in breathing and appearance

(4) Sinusitis  

  • One of the key symptoms of sinusitis is nasal blockage
  • Other symptoms may include:
    • facial pain/ headache
    • nasal mucus discharge
    • post nasal drip
    • reduced sense of smell
  • The diagnosis is suggested by:
    • the history from the patient (“more than just a blocked nose”)
    •  the view on nasal endoscopy
    •  CT scan
Figure 6: A nasal polyp arising from the ethmoid sinus

Figure 6: A nasal polyp arising from the ethmoid sinus

Figure 7: A CT scan showing significant sinus thickening

Figure 7: A CT scan showing significant sinus thickening

 

(5) Adenoid enlargement

  •  Enlarged adenoids can cause nasal blockage, snoring and excessive nasal mucus
  • It is a lot more common in children than adults, but is sometimes seen in older age-groups 
  •  The diagnosis is made on nasal endoscopy
  • The only successful treatment is surgery (adenoidectomy)
Figure 8: Very large adenoids completely blocking the back of the nose

Figure 8: Very large adenoids completely blocking the back of the nose

What symptoms tell me that I should seek treatment for my blocked nose?

  • a feeling of blockage, congestion or stuffiness
  • a significant difference in the airflow between the two sides of the nose
  •  difficulty eating because of blocked nose
  •  blocked nose when sleeping, especially with snoring/ sleep apnoea (stopping breathing)
  •  difficulty managing nasal mucous
  • trouble with physical exertion because of a blocked nose

 IF YOU SUFFER FROM MORE THAN ONE OF THE ABOVE SYMPTOMS, AND FEEL THAT YOUR QUALITY OF LIFE IS SUFFERING, THEN TREATMENT OF THE NOSE IS LIKELY TO HELP

What are the consequences of not treating your blocked nose?

  • Treating a blocked nose is rarely medically essential
  • Severe nasal blockage with poor sleep quality can be a problem for your overall well being

How can my blocked nose be assessed?

History

  • A detailed history is taken of the nature and duration of nasal symptoms, and the impact on your quality of life
  • What treatments have you had so far ? (eg nasal sprays, antibiotics, prior surgery)
  • Allergy
  • Asthma
  • Smoking history
  • General medical and social history

Examination

  • External nasal deformity?
  • Septal deviation?
  • Prominent inferior turbinates?
  • Nasal endoscopy:
    • Cophenylcaine (a local anaesthetic/ decongestant) is squirted in the nose
    • The spray has a bitter taste, and makes the mouth and throat numb for about half an hour.
    • A fine, soft and flexible telescope is passed into the nose, and allows a detailed view of the sinus and adenoid areas.
    • Photos/ videos are taken of any abnormal findings, and can be shared with you by email/ USB drive if you wish
    • There is no typically no pain with this examination
    •  If the nose feels a lot clearer after cophenylcaine, it is likely that enlarged turbinates are a significant cause of the blockage

Further Investigation

  • CT scan of the sinuses tells confirms whether or not sinusitis is contributing
  • Allergy testing – blood test (RAST) or skin prick testing may be arranged

What are the treatments for a blocked nose?

Nasal Sprays

  • salt water such as FESS spray, SINUS RINSE or FLO may help to clear any thick mucus blocking the airway
  • corticosteroid nasal sprays eg NASONEX, AVAMYS, OMNARIS

 Oral medications

  • antibiotics or strong anti-inflammatories (eg prednisone)may tried if there is information to suggest sinusitis

Allergy desensitisation

  • With regular and increasing exposure to an allergen through injections under the skin, or drops under the tongue, it is possible to dampen the strength of a patient’s allergic response
  • this is rarely a first line treatment for a blocked nose, but may be used if the main issue is secretory symptoms (eg sneezing, itchy eyes, clear nasal mucous).

Surgery

(1) Septoplasty

  • A bent septum (wall between the two sides of the nose) can be straightened through an operation inside the nose (septoplasty).
  • The lining is lifted off the bone and cartilage of the septum in both sides of the nose.
  • Bends of the cartilage and bone at the back of the nose can removed from the nose.
  • A bend at the front of the septum is fixed by separating the cartilage from it’s attachement to the upper jaw (maxilla).
  • This cartilage is remodelled, and sometimes reinforced with a cartilage of bone graft before reattaching it to the maxilla
  • The lining is then replaced with dissolving sutures

 

Figure 9: A severe bend of the nasal septal cartilage during septoplasty, and after reattachment to the maxilla

Figure 9: A severe bend of the nasal septal cartilage during septoplasty, and after reattachment to the maxilla

(2) Turbinoplasty

  • If enlarged turbinates do not reduce with simple treatment such as nasal spray, surgery will help the nasal airway.
  • In this operation, a portion of turbinate bone, and the overlying nasal lining is removed
  • Turbinoplasty gives a stable, prolonged reduction in the size of the inferior turbinates, and a markedly improved nasal airway

 

 

(3) Rhinoseptoplasty 

(4) Endoscopic sinus surgery 

(5) ADENOIDECTOMY

 

WHAT IS THE PREPARATION FOR NASAL SURGERY?

  • Once a decision for surgery is made, Dr Smith will provide appropriate printed information, we will watch appropriate video information discuss, discuss risks and benefits of treatment, and any questions you may have will be answered.
  •  Information about expected costs are provided by the staff at the front desk, and if you wish we will put you in touch with our anaesthetist for the day of surgery.
  • The hospital will be in touch the working day prior to admission, and give information on fasting times, what to wear, what to bring and where and when to present at the hospital. Admission to hospital is usually on the morning of surgery.
  • We understand that the decision for surgery is a big one, not to be undertaken lightly.
  • You should only elect to go ahead with surgery when you are completely comfortable that it is the correct decision for you

WHAT IS THE POSTOPERATIVE CARE FOR NASAL SURGERY?

  • Your nose will feel very blocked for 3-4 days after surgery, until the first postoperative appointment
  •  There is usually not too much pain, and it is usually well controlled with a combination of paracetamol, ibuprofen and occasional endone.
  • You will be given a discharge script for antibiotics.
  • At the first review, dissolving packing will be suctioned from the nose, and it will usually feel clearer than you can remember for a long time
  • You will be encouraged to use regular saline flush (eg FLO or Sinus Rinse) for some weeks after surgery; gentle nose blowing is allowed
  • Further followups are usually at 7-10 days, 3-4 weeks and 3 months
  • There are no further out-of –pocket expenses for postoperative followups

What are the risks of nasal surgery?

  • General anaesthetic
  • Bleeding
    •  <2% needing readmission to hospital or further treatment
    • <<<1% needing blood transfusion
  •  Failure to gain the desired improvement, needing more treatment.
  •  Very small chances of chronic nasal discharge, a hole between the two sides of the nose (septal perforation) or an unfavourable change in the shape of the nose.
  • At the time of booking surgery, Dr Smith will provide appropriate printed material from the Royal Australian College of Surgeons
  • He will have a more detailed discussion with you on risks and benefits of treatment, and answer any further questions you may have.

How much time will I need off work after nasal surgery?

  • It is always good to have 2 weeks available to fully recover.
  • If you have a sedentary or office job, it is likely that you can be back to work in the first week.
  • For an active/ physical job, the full 2 weeks is likely to be required.

How much time until I can play sport after nasal surgery?

  • Three weeks is required until heavy physical exertion, because of the slight risk of bleeding.
  • Gentle exercise can commence in the first week, and gradually build to full intensity by the third week.
  •  If you are a serious sportsperson, it is best to find a 1 month window in your playing and training schedule, where you are not required to be at your best

How much time until I can fly or travel after nasal surgery?

  • You should not travel anywhere remote, or fly for 1 month after surgery

What are the results for nasal surgery adults?

  • It is most likely that you will achieve a dramatic improvement in nasal airflow, once you are recovered
  • Sometimes, further nonsurgical or surgical treatment will be required to gain a completely satisfactory result

What are the alternatives to surgery for a blocked nose?

  • If nasal sprays such as saline, or corticosteroid (eg nasonex), there is no other treatment as likely to help as surgery, if nasal blockage is the main symptom which worries you

Dr Smith’s approach to nasal airway surgery

  • I will take time to diagnose, and discuss the causes of your blocked nose. 
  • We will always consider the role, and usually try non-surgical treatment first (except in the case of severe deformity of the nose).
  •  I perform a lot of rhinoseptoplasty (surgery to the entire nasal framework), and apply the techniques learnt in major nasal reconstruction to perform very reliable, definitive septoplasty, giving the best possible internal nasal airway, with a smaller surgical approach.
  • If you have severe deformity of the outside of the nose, or are worried about the look of your nose, I have extensive experience and expertise to address these issues with rhinoseptolpasty.
  • I also have extensive experience with endoscopic sinus surgery, and am able to definitively treat any associated issues with sinusitis.
  • In the rare case that a first operation does not give a perfect functional result, I will be happy to continue further treatment of your nose without any further out-of-pocket expenses to me, and would expect a satisfactory improvement in most cases.