Nasal Obstruction, Congestion, and Drainage
Vishvesh M. Mehta
Frank E. Lucente
Nasal congestion, obstruction, and drainage are three of the most common symptoms that bring patients to physicians. Although they usually result from a benign condition, these symptoms may represent a serious or life-threatening problem. Any patient with one of these symptoms merits full evaluation. In the United States alone, more than $6 billion are spent annually on proprietary and prescription medications to relieve nasal obstruction.
Nasal congestion is a term used by patients to describe an unpleasant sense of fullness or heaviness in the nose and midfacial region. It is not necessarily accompanied by objective findings an examiner can observe. Nasal obstruction often causes problems in other related structures. Common nonnasal manifestations of obstruction include dry mouth; chronic sore throat; frontal, cheek, or orbital pain indicating acute or chronic sinusitis; excessive snoring; halitosis; and fullness or blockage in the ear.
MEDICAL HISTORY AND PHYSICAL EXAMINATION
The medical history should be taken as described in Chapter 3. Specific attention should be directed towards the circumstances at the onset of congestion or obstruction, exacerbating or remitting factors, temporal sequence of the obstruction, and presence of associated symptoms (e.g., pain, bleeding, watering eyes, allergic symptoms, or impairment of smell). Any history of trauma should be recorded. The drainage should be characterized as unilateral or bilateral, watery, purulent, bloody, or foul smelling. All medications taken by the patient should be recorded, including aspirin, oral contraceptives, laxatives, and other substances not usually interpreted by the patient as being medications. Attention should be paid to recent changes in the patient’s work and home environment, as well as any contact with known nasal irritants. It is particularly important to ascertain the influence of the nasal obstruction on the patient’s lifestyle and the degree of impairment of the patient’s functioning. The patient’s interpretation of the cause of the obstruction also should be determined.
A thorough physical examination is crucial in determining the cause of the congestion, obstruction, or drainage (see Chapter 4). The external part of the nose should be inspected for evidence of trauma or deviation and for congenital anomalies. Changes may be subtle and therefore, any deformity of the bones or cartilages should be recorded. Scars of the nasal skin may be evidence of nasal trauma. The external nares should be inspected for symmetry and patency. It is important to have the patient tilt the head backward so that the examiner can look for any protrusion of the septal cartilage into either naris. Gently lifting the tip of the nose with the thumb, the examiner inspects the relation of
the septum to the upper lateral cartilages on each side. Good illumination by means of headlight or flashlight is essential. The crucial relation of the lower end of the upper lateral cartilages to the septum must be examined to appreciate this “valve” area, which has the greatest airflow resistance.
the septum to the upper lateral cartilages on each side. Good illumination by means of headlight or flashlight is essential. The crucial relation of the lower end of the upper lateral cartilages to the septum must be examined to appreciate this “valve” area, which has the greatest airflow resistance.
Using a nasal speculum, the examiner inspects the septum and records its position and relation to adjacent nasal bones, ethmoidal plate, vomer, and the relation to the upper lateral cartilage. The examiner also looks for evidence of mucosal damage to the septum, including deviation, spurs, and perforation. The turbinates are inspected next. The examiner assesses the color, size, position, and presence of any edema or mucosal changes and records the location or apparent site of origin of drainage. The drainage should be characterized as watery, cloudy, bloody, or purulent. The presence of crusts, foreign material, polyps, or masses also is recorded.
Decongesting the nose allows improved visualization of the nasal septum and turbinates. The use of rigid or flexible fiberoptic nasal endoscopes improves visualization of the posterior portion of the nose and nasopharynx. The patency of the posterior choanae can be ascertained by means of direct inspection or passage of a soft rubber or plastic catheter through the nose into the pharynx. The nasopharynx also is examined. The airflow on each side of the nose is tested and recorded by means of sequentially occluding each naris and asking the patient to breathe. The technique of testing is important. The examiner places a finger gently across the opening of each naris while testing the opposite side. The side of the nose (lower lateral cartilage) should not be compressed. Displacement of the nasal tip may relieve an obstruction on the opposite side. More sophisticated tests such as rhinomanometry can be used for objective recording of nasal airflow if necessary. It is important to evaluate the nasal airway before and after decongestion. Obstruction that resolves after decongestion is caused by mucosal abnormalities.
DIFFERENTIAL DIAGNOSIS
The disorders that should be considered in the differential diagnosis of nasal congestion are listed in Table 15-1.
Viral or Bacterial Infection
Acute viral or bacterial rhinosinusitis is a common cause of nasal congestion. Numerous respiratory viruses affect the nose and cause a sense of congestion accompanied by midfacial pain and watery drainage. Excessive lacrimation and itching around the eyes may be seen. This is usually a self-limited disease, and vigorous treatment should be avoided. The supportive use of an oral decongestant or nasal decongestant (3 days maximum) may improve breathing and reduce nasal secretions. Mucolytic agents and saline irrigation are helpful to some patients when thick secretions are a problem. Antibiotics are not used unless the drainage becomes purulent or the patient has a fever. Bacterial infections of the nose and paranasal sinuses (Fig. 15-1), often are a secondary complication of viral rhinitis, treatment with an antibiotic such as amoxicillin (250 mg by mouth three times a day) or erythromycin (250 mg by mouth four times a day) is recommended.
TABLE 15-1. Differential diagnosis of nasal stuffiness based on incidence, age, and sex | ||||||||||||||||||||||||
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