Patients often come to see me with nasal blockage. This can be caused by many different issues. I would see you and ask you about green or yellow nasal discharge, nasal injuries in the past, nose bleeds, facial pain, sneezing and sense of smell. I would then examine your throat, nose, ears and neck. I use a thin camera (nasendoscope), connected to a monitor, to have a good look deeper inside the nasal cavity to check for any deviation of the nasal septum, nasal polyps, pus, tumours or signs of allergy which might be blocking the nose.
I sometimes ask for a CT scan of nose and paranasal sinuses to check for infection deep within the sinuses.
Causes of nasal blockage:
Deviated nasal septum
The nasal septum is the partition which separates the left side of the nose from the right side of the nose. This can be bent partially or completely blocking the nose on one or both sides. It might have been bent by a previous injury, or can grow over time to become bent. Often, I would give you a trial of a steroid nasal spray to try for 6 weeks. This does not alter the septal deviation, but can shrink down the lining of the nose to make it easier to breath past the physical nasal obstruction of the bent partition. If this does not work, surgery might be worth pursuing. If there is a deviation low down in the nose, a septoplasty operation may be helpful. If the deviation is a major one, and is high up in the nose, or associated with an external deformity of the nose, a septorhinoplasty would be a better choice of operation to make the whole nose straight inside and out.
Hypertrophic turbinates
There are 3 pairs of shelves either side of the nasal septum, in the nasal cavity. These shelves are called turbinates. Their function is to humidify the air that is breathed into the nose. Sometimes, the turbinates can become swollen and boggy. This might be because of allergy. I would diagnose this problem using the nasendoscope in the clinic. A steroid spray or drop is used for 6 weeks. If medication is unsuccessful in unblocking the nose, surgery can be performed to burn the turbinates underneath their lining (submucous diathermy) which makes them swell initially and subsequently shrink down, creating more space to breathe in the nose. Alternatively, it is possible to remove part of these shelves, to reduce their size without completely removing them (turbinoplasty). Both these surgeries are performed when you are asleep (general anaesthetic) and don’t involve any external cuts or bruises.
Allergic rhinitis
Allergic rhinitis is caused by an allergy to something in your environment which can cause the lining of the nose to swell and to leak fluid. This can cause nasal blockage and sneezing. Sometimes it is possible to identify the allergen by placing the common allergens on the skin of the forearm and pricking the skin with a sterile needle. The reaction is measured. This is called skin prick testing. Alternatively, blood tests can be ordered to check for allergic response to certain common allergens (RAST blood tests). The mainstay of treatment of allergic rhinitis is allergy avoidance, washing the allergens out of the nose with a nasal rinse (Neilmed sinus rinse or sterimar), steroid nasal drops/sprays, and antihistamines. Occasionally, surgery may be advised.
Chronic rhinosinusitis with or without nasal polyps
Sinusitis causes nasal blockage, facial pain, and green and yellow nasal discharge. Nasal polyps are benign white grape like structures which can grow inside the nasal cavity, compromising breathing, causing nasal discharge and affecting the sense of smell. Once you have polyps they may be a problem forever. If they are visible on both sides of the nose they are likely to be benign (non-cancerous). If they are one sided, they may need to be biopsied to exclude cancer. Sinusitis and polyps may be treated with steroid nasal drops, sprays or tablets. Antibiotics may help. If the nose remains blocked despite maximal medical treatment, surgery may be necessary. A CT scan of nose and paranasal sinuses is ordered to check for the extent of the polyps, and to act as a road map for surgery.
I perform functional endoscopic sinus surgery (FESS). This involves coming into hospital and having a general anaesthetic. Once you are asleep, I use a camera connected to a monitor identify the polyps and remove them with special grabbing forceps. I use other instruments to open up the affected sinuses to let out the infection/pus. No external cuts are necessary as I perform the operation endoscopically. I often pack the nose with an absorbable wadding to prevent bleeding. This dissolves over a couple of weeks and aids healing. You are likely to be able to go home the same day.
Even after such surgery, it is important to continue with steroid drops and sprays to prevent regrowth of the polyps. The risks of surgery include: pain, bleeding, infection, general anaesthetic, recurrence of polyps, leak of fluid from around the brain (CSF leak) rare, meningitis (rare), double vision (rare), blindness, and persistent lack of sense of smell.
Cancers of the nose and sinuses
These are quite rare tumours. They can present with nose bleeds, nasal blockage, pain and facial swelling. One of the risk factors of developing a cancer of the sinuses is being a wood worker. Epistein-Barr virus infection can cause cancer in the back of the nose (nasopharyngeal carcinoma). I would normally examine you in clinic and check your nose with a camera (nasendoscope). Anyone with unexplained, or persistent, nose bleeds should be examined by an ENT surgeon with this camera. I would also check your neck to see if the cancer has spread to the lymph nodes.
A biopsy may be done under local anaesthetic in the clinic, or general anaesthetic in theatres. I would normally order an MRI and CT scan of the nose and sinuses to check the extent of the cancer. I may also order a CT scan of the rest of the body to make sure the cancer has not spread. Treatments include surgery, radiotherapy, and chemotherapy. These modalities can be used in isolation or in combination with one another. The treatment of such cancers is a specialist endeavour.