The blocked nose
The nose, apart from its important aesthetic role in the appearance of the face, is a sensitive organ, having two main missions: The conditioning of the inspired air, and the sense of smell. Behind the two nostrils, a complicated pyramid-shaped structure is hidden inside the bones of the face. A thin wall divides this pyramid into two nasal cavities. This wall, made of cartilage and bone, is the nasal septum. Three long bony shelves occupy the side walls in each nasal cavity. These are called the turbinates. All the inside walls of the nose are covered with a delicate biological tissue, called mucosa. The mucosa of the nose warms and humidifies the inspired air, while filtering it from harmful substances. During inspiration, part of the inspired air, containing diluted smells, is led to the upper (narrower) part of the nasal cavity, where the olfactory system recepts and recognizes the smells. The rest of the inspired air is led to the post-nasal space and from there to the throat, larynx and finally the lungs.
An automatic mechanism, not controlled by our will, has the ability to increase the volume of the mucosa, when the outside conditions demand it. So, if the outside temperature is low, the nose swells up, the flow of the inspired air slows down, and the mucosa has enough time to condition the cold air and bring it up to body temperature. On the contrary, if it is hot outside, the mucosa shrinks, so that the air can pass more quickly through the nose, on its way to the lungs. Unfortunately, this automatic air conditioner often malfunctions, and the mucosa swells up when it is not necessary. This is perceived by the patient as nasal obstruction.
Nasal obstruction may exist only at night, associated with snoring, or throughout the day, disturbing most activities. Nasal blockage is usually a sign of a chronic pathological condition called Chronic Rhinitis. Difficulty in breathing through the nose may force the patient to over-use nasal decongestant sprays. These sprays provide an immediate relief, but in the long term lead to drug-induced rhinitis, which develops on top of the existing inflammation of the nose, and is rather difficult to treat.
Chronic Rhinitis can generally be divided into two large categories: Allergic Rhinitis and Chronic non-Allergic Rhinitis.
In the case of Allergic Rhinitis, the cause of the mucosal malfunction is the hypersensitivity of the patient to certain, invisible by the naked eye, substances, named allergens, which induce a forceful reaction when they contact the mucosa of the sensitized patient. The various allergens may exist all year- round, such as the house dust mites and the animal dander, or they may circulate in the air during specific periods, as happens with the various pollens, which float in the air usually during springtime.
In the case of Chronic non-Allergic Rhinitis, there is no specific enemy. The mucosa over-reacts to non-specific triggers, such as temperature or humidity differences, atmospheric pollution, cigarette smoke, etc. Often, this over-reaction simply reflects malfunction of the autonomic nervous system, which regulates the condition of the mucosa.
Apart from inflammation, various anatomical variances can cause nasal blockage. Most common of all is the septal deviation, in which the dividing wall of the nose is twisted or displaced, interfering with the air flow. Other common cause of nasal obstruction is the hypertrophy of the nasal turbinates. This hypertrophy is usually not a real hyperplasia of the turbinate bone, but rather a permanent swelling of its mucosal cover, due to the existing chronic rhinitis.
The vast majority of patients who seek medical advice for a blocked nose, have a combination of anatomical obstruction (usually septal deviation) and a functional obstruction, usually caused by chronic rhinitis. Correct management in these cases must include treatment of both conditions, which contribute to the problem: The septum must be straightened surgically, and the inflammation of the chronic rhinitis must be treated medically. Both arms of the treatment are equally important, for a successful, long-lasting result.
Nowadays, surgical correction of the deviated nasal septum is a simple and painless procedure. It is done under general anaesthesia, requires one night stay in hospital, and does not require nasal packing, which has been traditionally the major complaint of the patients having nasal surgery. Instead of the disturbing gauze, we use an absorbable stitch inside the nose, which does not need to be cut postoperatively.
Reduction of the hypertrophied turbinates can be done in several ways. Recently, we are able to shrink the swollen turbinates from inside, with a special 2 mm shaver blade, which removes the excess soft tissue without disturbing the sensitive functioning mucosa on the surface of the turbinate. Other options may include Laser or Radiofrequency reduction. In persisting or recurrent cases, we can remove excess soft tissue and bone with an endoscopic procedure named submucosal turbinoplasty.
Diagnostic approach of Chronic Rhinitis includes allergy skin prick testing, sometimes combined with special blood tests (RAST), to exclude possible allergic background. Anti-inflammatory treatment follows, initially based on nasal sprays. Antiallergic or anti-inflammatory pills may be prescribed, in some cases. If one or more responsible allergens are identified by allergy tests, avoidance measures are suggested. Furthermore, if initial medical treatment fails to control symptoms, the option of de-sensitization is offered. This is a specialized treatment with either shots or sublingual drops, which typically lasts for 3 to 5 years, and aims at the elimination of the allergy.
Concluding, nasal obstruction can be caused either by anatomical abnormalities, or by functional obstruction due to rhinitis, or (most commonly) by both. The specialist will evaluate your case and suggest the appropriate management strategy. Modern surgical techniques have turned traditionally painful operations into simple, painless procedures. This significant reduction of the overall patient discomfort facilitates the decision for surgery, allowing more patients to take advantage of the scientific advances and get rid of their nasal blockage.