02/11/2011 in article
Included in this category are deformities of the nasal septum, the thin cartilage and bone that divide the nose into its two sides. These deformities can be congenital or can be due to an injury at some point in the patient’s life, including during birth. Deformities of the nose and nasal septum are common findings, and do not cause nasal obstruction in all patients. Surgery can correct the problem when the deviation is severe enough to produce obstruction.
One of the most common causes of nasal obstruction in children is enlargement of the adenoids, tonsil-like tissue that fills the back of the nose above the soft palate. This tissue shrinks in most children by age 12, which explains why this is a much less common problem in adults. Children with adenoidal hypertrophy are chronic mouth breathers, often breathe noisily at night and may snore. Surgery to remove the adenoids may be required in these situations.
Nasal polyps are smooth, pale, grape-like benign masses, which can grow in the nose, resulting in partial or near total nasal obstruction. Polyps are commonly associated with asthma in adults, and raise the suspicion of cystic fibrosis in children. The cause of nasal polyps is unknown, but they may be allergy related. By far, the most common cause of nasal polyps is chronic sinusitis. The lining of these cavities thickens and expands into the nose leading to partial or complete nasal obstruction. Treatment of nasal polyps often requires nasal and sinus surgery for removal.
The turbinates are small thin bones covered with mucus membrane, found on the lateral nasal wall. The inferior turbinates in particular protrude into the nasal airway, forming part of the so-called nasal valve, the primary site of nasal obstruction. Swelling or hypertrophy of the inferior turbinates is a common cause of nasal congestion. Reversible swelling of the mucous membranes often respond to intranasal steroids. When the changes are not responsive to medical therapy, a variety of procedures are used to reduce the mass of the turbinate protruding into the airway.
Children are prone to inserting a remarkable variety of objects into their nose. When unilateral foul smelling nasal discharge is present, a foreign body must be suspected. Tumors of the nasal cavity, both benign and malignant, are relatively rare, but must always be considered, particularly when the obstruction is unilateral.
Nasal congestion is a common problem caused by a large array of disorders. We will discuss allergies and vasomotor rhinitis in the next installment.
Allergic rhinitis is an exaggerated inflammatory response in the nose to a foreign substance, usually pollen, mold, animal dander, or some element of household dust. Foods can also play a role.
In the allergic patient, the release of histamine and similar substances results in congestion, sneezing and excess production of watery nasal discharge. Seasonal allergies, particularly common on Staten Island, cause problems in the spring (trees), summer (grass) and fall (weeds). Household allergies are more evident in the winter. Mold and animal allergies may cause symptoms year round.
The best treatment for allergies is avoidance of the allergen — but this is not always possible. Other options include antihistamines, decongestants and intranasal steroids.
Antihistamines help relieve the sneezing and runny nose of allergic rhinitis. Many antihistamines are now available without prescription, including Diphenhydramine, Chlortrimeton, and the non-sedating Loratidine. Newer and reportedly less sedating antihistamines, which require a prescription include Cetirizine, Fexofenadine, Desloratadine and Azelastine. Decongestants like Pseudoephedrine shrink congested nasal tissues, and are widely available without prescription.
Combinations of antihistamines and decongestants are also useful. Cortisone-like drugs are extremely potent, and are often administered as nasal sprays rather than pills to minimize the risks of side-effects associated with the systemic use of these drugs. Topical nasal decongestants may give immediate relief, but after using them for several days, severe rebound congestion will develop, making the congestion worse.
All of these preparations have potential side-effects and are contraindicated in some patients. Decongestants stimulate the heart and raise blood pressure and should not be used in patients with high blood pressure or heart disease. Antihistamines, whatever they may claim, can be sedating, and should also be avoided in patients with any difficulty in urination. Pregnant patients should always consult their obstetricians before taking medications.
Immunotheraphy (allergy shots) is the most effective treatment available for allergic rhinitis and is highly successful in treating patients with severe allergies. Skin or blood testing is done first to determine a patient’s specific allergies. Weak serums of these allergens, specifically tailored to a patient’s allergies, are then given by injection, progressively increasing the dose over a period of time from months to years. These injections work by stimulating the formation of blocking antibodies which interfere with the allergic reaction, decreasing its severity.
Patients with vasomotor rhinitis have symptoms similar to allergic patients but with no obvious cause. The nasal membranes have an abundant supply of blood vessels with a great capacity for both expansion and constriction.
When a person exercises, adrenaline is released, which results in vasoconstriction, or squeezing of the blood vessels. This vasoconstriction shrinks the nasal membranes, the air passages open up and the patient breathes more easily. The opposite takes place when an allergic reaction or cold develop. The blood vessels expand, the nasal membranes become engorged, and the nose becomes congested.
In addition to allergies and infections, other events can cause the nasal blood vessels to expand, leading to vasomotor rhinitis. These include psychological stress, an underactive thyroid, pregnancy, abuse of decongesting nasal sprays, some medications, alcohol, and irritants such as perfumes and cigarette smoke. In the early stages of these disorders, nasal stuffiness is temporary and reversible if the primary cause is corrected. However if the condition persists for long enough, the blood vessels stiffen and lose their ability to constrict. They fill up when the patient lies down and the resultant congestion can interfere with sleep.
Nasal congestion is a common problem caused by a remarkable array of disorders. The physician with expertise in nasal disorders will offer treatments based on the specific causes identified.
This column is provided by the Richmond County Medical Society. Drs. Sinnreich and Carney are members of the Society. Dr. Carney is the vice-president of RCMS. Both maintain a practice, ENT & Allergy Associates, LLP, Bulls Head.