INTRODUCTION — Nasal and sinus complaints are among the most common reasons for visits to primary care clinicians, otolaryngologists, and allergists. Although some clinicians consider nasal obstruction to imply a blockage within the nasal cavity, nasal obstruction is most commonly defined as a patient symptom manifested as a sensation of insufficient airflow through the nose . Nasal obstruction may be the cardinal presenting symptom of many common disease processes, such as rhinitis, sinusitis, septal deviation, adenoid hypertrophy, and nasal trauma.
This topic will focus on the clinical manifestations, evaluation, and treatment of nasal obstruction in adults. Specific etiologies of nasal symptoms and other conditions associated with symptomatic nasal obstruction are discussed separately:
●(See "An overview of rhinitis".)
●(See "Tumors of the nasal cavity".)
●(See "Cancer of the nasal vestibule".)
RISK FACTORS — The risk factors for nasal obstruction relate directly to the underlying etiology. Several common risk factors for nasal obstruction include a history of atopy, recurrent sinusitis, nasal trauma, nasal surgery, having household pets, exposure to poor air quality, and a family history of nasal polyposis [2-4]. Nasal obstruction commonly accompanies many other comorbid conditions including asthma and obstructive sleep apnea .
PATHOGENESIS — The pathogenesis of nasal obstruction may be related to abnormalities occurring with any of the anatomic structures and functions within the nose. Normal nasal anatomy and function are discussed elsewhere. (See "Etiologies of nasal obstruction: An overview", section on 'Nasal anatomy and function'.)
Nasal obstruction may be generally divided into mucosal and structural causes (table 1). The nasal mucosa is a complex tissue that is subject to local and systemic insults, leading to nasal obstruction. Examples of mucosal causes of nasal obstruction include bacterial sinusitis, nasal polyps, and soft tissue turbinate hypertrophy due to allergic rhinitis. There is also a normal, cyclical pattern of turbinate mucosal swelling, which alternates between sides of the nasal septum at intervals of two to five hours, referred to as the nasal cycle . Disruption of the nasal cycle can contribute to nasal obstruction.
Airflow through the nose is limited structurally by the width of the nasal cavity. The nasal cavity includes the anterior nasal cartilaginous structures as well as the borders of the bony piriform aperture (figure 1 and figure 2). The nasal valve is the narrowest portion of the human airway (figure 3) . Collapse of any of the structures making up the nasal cavity can lead to nasal obstruction. Examples of other structural causes include nasal septal deviation (cartilaginous or bony), bony inferior turbinate hypertrophy, concha bullosa formation (air in the middle turbinate), benign and malignant tumors, and choanal atresia or stenosis.
The underlying pathogenesis of nasal obstruction may be multifactorial. As an example, it is common to have compensatory mucosal hypertrophy of the inferior turbinate on the side opposite a deviated nasal septum [8,9].
CLINICAL MANIFESTATIONS — The most common clinical manifestations of nasal obstruction are the subjective sensation of congestion, stuffiness, fullness, or blockage within the nose. Of note, patients often use the term “congestion” to describe a variety of nasal symptoms, and it is important to distinguish nasal congestion from symptoms such as excessive mucus or sinus pressure or fullness .
It is common for symptoms of nasal etiology to wax and wane with respect to daily time course, body position, seasonality, and exposures to environmental stimuli. For example, difficulty sleeping due to nasal obstruction symptoms is a common complaint, as the inferior turbinates may engorge in the supine position. Patients may report being able to sleep on one side only, as contralateral sleeping causes increased nasal obstruction. In fact, nasal obstruction is a risk factor for poor sleep quality, independent of obstructive sleep apnea [11,12]. Difficulty breathing is a less common complaint, which can occur due to nasal disease on one or both sides of the nose.
Patients will often report additional symptoms that may suggest the underlying etiology of nasal obstruction. In the case of rhinosinusitis, these symptoms include facial congestion, facial pain or pressure, dysosmia, anterior rhinorrhea, postnasal discharge, cough, pruritic conjunctivitis, sneezing, or throat irritation/itching. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis", section on 'Clinical manifestations'.)
The degree of nasal obstruction, as measured objectively by acoustic rhinometry, peak nasal airflow, or rhinomanometry, may not correlate with the patient's subjective degree of nasal obstruction . As an example, minimal changes in objectively measured nasal patency may be experienced as substantially bothersome for an individual patient. (See 'Other testing' below.)
The natural history of nasal obstruction may vary based upon the underlying etiology. As examples, structural abnormalities such as nasal septal deviation or bony inferior turbinate hypertrophy typically worsen slowly over time. Mucosal abnormalities, such as those caused by seasonal allergies or noxious stimuli, typically fluctuate in duration and severity . (See "Etiologies of nasal obstruction: An overview" and "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis", section on 'Clinical manifestations'.)
DIAGNOSIS — The evaluation of a patient with nasal symptoms involves a detailed history and physical examination. Some patients may require further evaluation involving nasal endoscopy or diagnostic imaging.
This section provides a general approach to the patient with nasal obstruction. The differential diagnosis of nasal obstruction is broad and includes both structural causes (congenital abnormalities, acquired diseases, tumors) and mucosal causes (medication-induced, infectious, and inflammatory conditions) (table 1). Diagnostic criteria for specific etiologies of nasal obstruction are discussed elsewhere. (See "Allergic rhinitis: Clinical manifestations, epidemiology, and diagnosis" and "Chronic nonallergic rhinitis", section on 'Diagnosis' and "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Diagnosis and evaluation' and "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis", section on 'Diagnosis' and "Etiologies of nasal obstruction: An overview" and "Congenital anomalies of the nose".)
History — Clinicians should focus on several key features of the clinical history:
●Location – Whether symptoms are unilateral (suggesting structural causes) or bilateral (suggesting mucosal causes)
●Time course – Temporal course of the nasal symptoms, including diurnal and seasonal variation suggesting an allergic process
●Triggers – Allergic stimuli and airborne exposures (eg, cigarette smoke, particulate matter, pets, chemicals)
●Symptoms of rhinosinusitis – Facial pain or pressure, nasal congestion, dysosmia, headache, purulent nasal discharge
●Symptoms suggesting malignancy – Facial deformity, cranial nerve dysfunction (eg, facial numbness), and unexplained epistaxis
●Oral medications – Oral contraceptives, antithyroid medication, antihypertensive medication, antidepressants, and benzodiazepines
●Trauma – History of nasal trauma or previous nasal surgery, particularly rhinoplasty
●Medical history – Granulomatosis with polyangiitis, cystic fibrosis (associated with nasal polyposis), sarcoidosis, syphilis, and asthma
Physical examination — The physical examination of the nose is of primary importance in identifying or confirming the cause of nasal obstruction . Most of the underlying causes of nasal obstruction can be determined based on a thorough examination of the nose, nasal cavity, and the nasopharynx .
External examination — The external nasal contour is examined with close attention to any bony and cartilaginous deformities, looking for evidence of prior trauma, the structural integrity of the nasal tip, and indentation or depression of the surrounding nasal bones. In older patients, deterioration or hypertrophy of the cartilage in the nasal tip may contribute to nasal obstruction. The examiner should manually elevate the nasal tip to a neutral (rather than exaggerated) position and assess for improvement of nasal airflow. Airflow improvement suggests disease of the cartilage of the nasal tip. The clinician should also examine airflow both during shallow and deep inspiration. Early collapse of nasal patency suggests nasal valve incompetence.
The Cottle maneuver is an additional physical examination maneuver to assess nasal valve competency . The Cottle maneuver is performed by retracting the cheek laterally, which pulls the upper lateral cartilage away from the septum and widens the internal nasal valve angle. If the patient’s symptoms are relieved with this maneuver, the cause of nasal obstruction is likely related to the nasal valve.
Palpation of the neck is also important to detect cervical lymphadenopathy, particularly if nasal malignancy is suspected.
Anterior rhinoscopy — Anterior rhinoscopy can be performed with a nasal speculum or with an otoscope, along with a bright light source to improve visualization. Examination of the nose is conducted with the patient's head tilted back and the clinician sitting directly opposite. To reduce patient discomfort and steady the head, the examiner should position the outer ulnar aspect of the palm not holding an instrument against the patient's forehead; the thumb of that hand is used to elevate the tip of the nose. This procedure allows for optimal visualization of each vestibule, the nasal turbinates, septum, and mucosal surfaces (picture 1).
The assessment should start at the level of the naris, looking for mucosal abnormalities, patency, and collapse of the soft tissues with respiration (figure 4) . Normal mucosal surfaces are pink, and the vestibules are patent and easily visible to the level of the middle turbinates (picture 2). The septum should be midline, although a slight deviation may be normal. Anterior rhinoscopy provides assessment of the size and caliber of the inferior turbinates and the position of the anterior to mid-nasal septum. Although there are no strict definitions for normal size of the nasal cavity, clinicians should assess the overall dimensions of the nasal cavity relative to the septum and the turbinates while identifying septal deviation, significant inferior turbinate hypertrophy, and possible contact between mucosal surfaces (picture 3).
Occluded nasal passageways caused by boggy, red nasal mucosa may develop as a result of allergies, nonallergic rhinitis, or overuse of nasal decongestants. Ulcerated, friable mucosa may indicate granulomatous disease. Polyps at the level of the middle turbinate or mid-nasal cavity may be visible (picture 4). Identification of purulent nasal discharge is helpful in identifying cases of rhinosinusitis .
Nasal endoscopy — Posterior nasal structures are best visualized with nasal endoscopy. Fiberoptic nasal endoscopy is a diagnostic tool with a high diagnostic yield but is typically available only to otolaryngologists. Patients in whom the etiology of nasal obstructive symptoms is unclear after initial evaluation, or in whom symptoms persist after initial treatment for a presumptive cause, should be referred for endoscopy.
After preparation of the nose with topical decongestant and/or topical anesthetic spray, a rigid or flexible endoscope is used to directly examine the middle meatus, posterior aspects of the nasal cavity, and the nasopharynx to identify polyps, posterior turbinate hypertrophy, middle and posterior nasal septal deviations, adenoid hypertrophy, nasal tumors, choanal atresia, and purulent discharge draining posteriorly in rhinosinusitis (picture 5 and picture 6) .
Diagnostic imaging — Diagnostic imaging to assess both mucosal disorders and anatomical deformities is indicated when the diagnosis is not clear based upon the history and physical examination alone. Computed tomography (CT) scan of the nose and paranasal sinuses is the primary diagnostic imaging modality . Plain film radiography lacks the sensitivity and specificity required in the diagnostic evaluation of nasal obstruction . Magnetic resonance imaging (MRI), which allows for more detailed soft tissue assessment compared with CT, is generally a secondary study and is indicated for better characterization of nasal tumors .
Examples of abnormal CT findings include air-fluid levels in acute bacterial rhinosinusitis (image 1), bony narrowing in choanal atresia (image 2), stenosis of the pyriform aperture (image 3), and nasal septal deformities (image 4). Although an anatomic abnormality may be seen on CT scan, the etiology of obstruction may not be apparent. As an example, any cause of inferior turbinate hypertrophy can lead to nasal obstruction, including allergic rhinitis (both seasonal and perennial), nonallergic rhinitis, rhinitis medicamentosa, and other medication-induced rhinitis. In general, more useful clinical information is obtained from the history, physical exam, and, in certain cases, fiber-optic nasal endoscopy than imaging . In general, imaging is not recommended as a first-line diagnostic intervention in most cases of clinically diagnosed allergic rhinitis or septal deviation [19,20].
Other testing — Several other tests can be performed to help characterize nasal obstruction. The data supporting the use of these measurements are somewhat controversial and results can be less than definitive. Thus, these tests are usually ordered under select clinical situations after specialist evaluation.
●Allergy testing should be considered in patients with chronic and/or seasonal symptoms, given the high prevalence of allergic rhinitis and its contribution to nasal obstruction. It should be particularly considered in patients with concurrent asthma.
●Acoustic rhinometry is a simple, noninvasive measure of cross-sectional area of the nasal cavity longitudinally along the nasal passageway.
●Peak nasal airflow is a noninvasive measure indicating peak nasal airflow in liters per minute achieved during maximal forced nasal inspiration.
●Rhinomanometry is a computerized, functional assessment of airflow.
●Mucosal biopsy is indicated for cases of suspected malignancy and may be helpful in the diagnosis of infection or inflammatory disease.
●The presence of nasal polyps in children should raise the consideration of cystic fibrosis.
TREATMENT — The treatment of nasal obstruction should target the underlying etiology. This section will focus on treatments of several causes of nasal obstruction, including nasal polyposis, nasal vestibulitis, nasal septal deviation, mucoceles, and nasal valve abnormalities. Treatments for other specific causes are discussed separately. (See "Congenital anomalies of the nose" and "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications", section on 'Nasal obstruction' and "Nasal trauma and fractures in children and adolescents", section on 'Management' and "Snoring in adults", section on 'Nasal patency' and "Cancer of the nasal vestibule", section on 'Treatment' and "Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment" and "Chronic rhinosinusitis with nasal polyposis: Management and prognosis" and "Chronic rhinosinusitis without nasal polyposis: Management and prognosis".)
Pharmacologic therapy is generally used as first-line treatment for mucosal causes of nasal obstruction. Nasal glucocorticoid sprays are first-line therapy for several mucosal etiologies of nasal obstruction (eg, rhinitis, nasal polyposis), and may often be used empirically as a trial of therapy . Topical nasal glucocorticoid sprays are strongly recommended in patients with a clinical diagnosis of allergic rhinitis . Clinicians should be alert to epistaxis occurring with topical nasal steroid sprays and consider otolaryngology referral if this persists. Some structural causes (eg, adenoidal hypertrophy) can be treated with pharmacologic therapy initially and referred for surgical treatment if medication response is inadequate. Other structural causes of nasal obstruction are less likely to respond to pharmacologic treatment, and surgery is the initial therapy [21,22]. As an example, choanal atresia usually requires transnasal puncture or palatal repair with subsequent stenting (picture 7 and picture 8). Malignancy of the nasal cavity usually requires radiation therapy in combination with surgical resection.
The etiology of nasal obstruction may be multifactorial, and treating more than one condition may be required for effective management of nasal obstruction. A combination of both nasal septal deviation and turbinate hypertrophy leading to nasal obstruction is common. Medical treatment of the turbinate hypertrophy component, possibly due to allergic rhinitis, may provide only partial relief depending on the degree of contribution of the individual elements. Similarly, surgical treatment may only provide partial relief, with pharmacologic treatment of comorbid allergic rhinitis needed to fully relieve symptoms.
The majority of cases of nasal obstruction are effectively treated with a combination of pharmacologic and surgical therapy. However, nasal symptoms may wax and wane and it is not uncommon for nasal obstruction to recur if allergic stimuli are encountered again or if structural abnormalities recur after treatment. Such failure may occur months or even years after initial therapy but generally responds well to another course of treatment.
Nasal polyps — Glucocorticoids are the mainstay of management of nasal polyposis . Additional therapies include the treatment of underlying allergies, treatment with antileukotriene agents, anti-IgE monoclonal antibody therapy, and surgery for refractory disease. The treatment of nasal polyposis is reviewed in detail elsewhere. (See "Chronic rhinosinusitis with nasal polyposis: Management and prognosis".)
Nasal vestibulitis — Treatment of nasal vestibulitis consists of the application of warm compresses and topical mupirocin ointment applied intranasally twice daily for five days, or oral antibiotics if the infection appears to be widespread . In some cases, the nasal vestibulitis may also reflect a local dermatitis, and empiric therapy with a low-potency topical nasal steroid (eg, 1% hydrocortisone ointment) in conjunction with the antibiotic ointment for a brief period may be additionally effective. (See "Etiologies of nasal obstruction: An overview", section on 'Nasal vestibulitis'.)
Rhinosinusitis — Multiple therapies are utilized in the management of acute and chronic rhinosinusitis, including intranasal saline, topical and systemic glucocorticoids, antibiotics, antileukotriene agents, and surgery. These treatments are combined in various ways to manage the different subtypes of rhinosinusitis. (See "Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment" and "Chronic rhinosinusitis with nasal polyposis: Management and prognosis" and "Chronic rhinosinusitis without nasal polyposis: Management and prognosis".)
Rhinitis — Management of allergic rhinitis combines allergen avoidance and pharmacologic therapy. Intranasal glucocorticoids are the most effective single therapy for allergic rhinitis in patients with significant or persistent symptoms. Oral antihistamines can also be helpful for nasal obstruction in patients with persistent allergic rhinitis. (See "Pharmacotherapy of allergic rhinitis".)
Patients with chronic nonallergic rhinitis are less responsive to pharmacologic therapy than those with allergic rhinitis. However, intranasal glucocorticoids and the topical antihistamine azelastine are useful in treating the total symptom-complex of chronic nonallergic rhinitis. (See "Chronic nonallergic rhinitis", section on 'Management'.)
Medication-induced — Nasal obstruction caused by medication use generally resolves with termination of the offending medication (table 1) . In addition, an intranasal glucocorticoid can help reduce nasal symptoms that persist soon after discontinuation. (See "An overview of rhinitis", section on 'Nasal decongestant sprays' and "An overview of rhinitis", section on 'Systemic medications'.)
Structural disorders — In general, structural disorders are most effectively treated with surgical intervention . In addition, external nasal dilator strips may be helpful in cases in which the soft tissues around the lateral external nose collapse, either unilaterally or bilaterally, during regular or moderate inspiration.
Nasal septal deviation — Septoplasty is the definitive treatment in patients with nasal obstruction due to septal deviation. Reported rates of long-term efficacy vary, but one study reported that septoplasty was successful in reducing nasal symptoms in up to 89 percent of patients .
Mucoceles — Nasal and sinus mucoceles are effectively treated with endoscopic sinus surgery [28-31].
Nasal valve abnormalities — Nasal valve collapse generally requires surgical intervention [15,32,33]. Correction of nasal valve weakness usually involves cartilage grafts to buttress and support the existing cartilage. External nasal dilator strips and nasal clips, which are applied at night, may relieve symptoms and serve as an alternative to surgery in some patients .
REFERRAL — Patients presenting with symptoms or signs of potentially serious nasal or sinus disease should be referred to an otolaryngologist (ie, facial deformity/swelling, diplopia, ocular proptosis, facial numbness, cranial nerve dysfunction, and unexplained epistaxis). Patients with structural causes of nasal obstruction should be also referred, as these conditions generally require specialized diagnostic equipment (eg, nasal endoscopy) and surgical treatment.
Further evaluation and management of mucosal causes of nasal obstruction depend on individual clinician experience with a particular disorder. It is reasonable to start medical therapy (eg, intranasal glucocorticoids) for most mucosal disorders and refer to an allergist or otolaryngologist if nasal obstruction persists despite empiric therapy.
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SUMMARY AND RECOMMENDATIONS
●Underlying causes of nasal obstruction include both mucosal disorders (medication-induced, infectious, and inflammatory conditions) and structural abnormalities (congenital deformities, acquired diseases, tumors) (table 1). (See "Etiologies of nasal obstruction: An overview" and 'Pathogenesis' above.)
●The evaluation of a patient with nasal symptoms involves a detailed history and physical examination. Some patients may require further evaluation involving nasal endoscopy or diagnostic imaging. (See 'Diagnosis' above.)
•The history should include a description of nasal symptoms, potential triggers, intranasal drug use, oral medication use, previous trauma or surgery, and pertinent medical history. (See 'History' above.)
•Most of the underlying causes of nasal obstruction can be identified with a thorough examination of the external nose, nasal cavity, and the nasopharynx. Anterior rhinoscopy and/or nasal endoscopy should be used for better visualization of internal nasal structures. (See 'Physical examination' above.)
•In cases where the diagnosis is not clear based upon the history and physical examination, computed tomography (CT) scan may be helpful in assessing for mucosal disorders and anatomic deformities. Plain film radiography lacks the sensitivity and specificity required in the diagnostic evaluation of nasal obstruction. (See 'Diagnostic imaging' above.)
●The treatment of nasal obstruction should specifically target the underlying etiology. Pharmacologic therapy, particularly intranasal glucocorticoids, is generally used as first-line therapy for mucosal causes of nasal obstruction (eg, rhinitis, nasal polyposis). Many structural causes of nasal obstruction do not respond to medical treatment and require surgical intervention (eg, nasal septal deviation, nasal valve abnormalities). (See 'Treatment' above.)
●Patients presenting with symptoms or signs of potentially serious nasal or sinus disease should be referred to an otolaryngologist (ie, facial deformity, cranial nerve dysfunction, and unexplained epistaxis). Patients with structural causes of nasal obstruction should be also referred, as these conditions generally require surgical intervention. (See 'Referral' above.)
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