Stuffy Nose and Nasal Obstruction

Nasal obstruction is one of the most common complaints encountered in primary care. A congested (stuffy) nose is caused when the membranes lining the nose become swollen as a result of inflamed blood vessels, rather than from too much thick mucus. Causes of nasal congestion include upper respiratory tract infections, such as the common cold and influenza, allergies and overuse of some nasal sprays or drops.

Newborn infants must breathe through the nose and so nasal congestion may cause severe difficulties, especially when feeding. Prolonged nasal congestion in older children can interfere with hearing and speech development. Significant congestion may also cause snoring and episodes of sleep apnoea.

• A chronic stuffy nose can impair normal breathing, force patients to breathe through the mouth, or cause a persistent cough, headaches and a feeling of fullness in the face.
• Simple tasks such as eating, drinking and speaking may become difficult and uncomfortable.

Acute and chronic rhinitis may produce nasal obstruction of varying degrees, characterised by swelling of the nasal mucosa, increased volume and viscosity of nasal secretions and impairment of normal ciliary function.

• Allergic rhinitis (seasonal and perennial).
• Infectious rhinitis:
  • Viral rhinitis is one of the most frequent causes of nasal obstruction. Rhinoviruses, respiratory syncytial virus, parainfluenza and influenza viruses, and adenoviruses are among the viruses most commonly identified.
  • Bacterial rhinitis may begin spontaneously or as a sequel to viral rhinitis. It causes a mucopurulent nasal discharge. Bacteria most often implicated are Streptococcus pneumoniae, group A beta-hemolytic streptococci and Haemophilus influenzae.
  • Fungal rhinitis is most often found in immunocompromised patients. Candida, Aspergillus, Nocardia, Cryptococcus, and Phycomycetes are most often implicated.
• Vasomotor rhinitis:
  • Excessive engorgement of the nasal mucosa and profuse, watery rhinorrhoea secondary to autonomic dysfunction.
  • Can be triggered by chemical irritants, changes in weather or humidity, and stress.
  • The obstruction occurs in the absence of allergy.
  • Ipratropium bromide nasal spray can be helpful in controlling rhinorrhoea.
• Atrophic rhinitis:
  • Atrophy of the nasal mucosa and turbinates.
  • The aetiology is largely unknown.
  • Nasal obstruction is caused by turbulent airflow and crusting in the nasal passages.
• Iatrogenic:
  • Rhinitis medicamentosa: prolonged use of topical nasal decongestants may result in rebound congestion of the nasal mucosa.
  • This congestion may encourage further use of the decongestant, which may exacerbate nasal obstruction.
  • Other iatrogenic causes include alcohol (engorgement of nasal membrane), oestrogen (engorgement of nasal mucosa), tobacco (irritation of mucous membranes and impairment of ciliary action).
  • Post-operative, e.g. post septo-rhinoplasty.¹
• Chronic sinusitis:
  • Nasal obstruction and discharge that are present for more than 6 weeks.
  • Obstruction is often correlated with nasal discharge and postnasal drip.
  • Sinusitis may be caused by anomalies that are physical (e.g. nasal polyps, septal deviation, foreign bodies) or systemic (e.g. immunodeficiency, cystic fibrosis, ciliary motile dysfunction).
• Foreign bodies in the nose:
  • Most commonly seen in patients aged 6 months to 5 years.
  • Persistent unilateral nasal obstruction and discharge, which may be bloody and accompanied by an offensive odour.
  • Serous otitis media on the same side often accompanies the nasal obstruction when the foreign material has been present for any length of time.
  • Nasal radiography may be required.
• Nasal septum abnormalities:
  • Nasal septal deviation (congenital or acquired), haematoma (trauma) or perforation (e.g. trauma, nose-picking, cocaine abuse).
• Occlusion of nasal valve:
  • The valve is at the narrowest part of the nose and is the apex where the septum and the upper lateral cartilage meet.
  • Causes of occlusion include septal deviation, aging and nasal valve scarring after nasal surgery.²
• Turbinate hypertrophy:
  • May be idiopathic or caused by long-standing allergic rhinitis (seasonal and perennial), inflammation (e.g. rhinitis caused by the common cold) and long-term use of over-the-counter vasoconstrictive nasal sprays.
  • The enlarged turbinates lose their ability to expand and shrink and therefore result in nasal obstruction.
  • Patients with this condition often present with complaints of continuous nasal obstruction unrelieved by nose drops, antihistamines, or allergic desensitisation.
  • Examination with a nasal speculum reveals enlargement of the inferior turbinate.
  • Treatment consists of alleviating symptoms with a steroid nasal spray and antihistamines for allergies, discontinuing habitual use of over-the-counter vasoconstrictive nasal sprays, and surgical procedures to shrink the turbinates.
• Adenoid hypertrophy:
  • More common in children than adults.
  • Occurs when excessive adenoid tissue blocks the nasopharynx and results in snoring, nasal obstruction, post-nasal drainage and infections.
  • In children, the condition can be expected to regress over time.
  • Adenoidectomy may be required for significant functional impairment (hearing and speech).
• Nasal polyps:
  • Often present as persistent obstruction of one or both nostrils.³
  • They are clear, grape-like, inflammatory swellings of the nasal and sinus linings.
  • Polyps are benign and are more often seen in adults.
  • Causes include allergy and chronic sinus infection.
  • Polyps may obstruct the sinus openings and contribute to the development of sinus infection.
  • They are atypical in children, and their occurrence in a patient younger than 16 years may indicate cystic fibrosis.
  • Nasal polyps may also be associated with asthma and also aspirin intolerance.
  • A rare type of nasal polyp is the choanal polyp. This benign lesion is single and unilateral and usually arises from the medial wall of the maxillary sinus. Most choanal polyps present in teenagers and young adults.
  • Treatment with steroid nasal sprays can alleviate some symptoms, but surgical removal of the polyp is often necessary.
• Neoplasm:
  • The possibility is suggested by unilateral epistaxis.
  • Inverted papilloma, though histologically benign, is locally invasive and may produce bone erosion.
  • Other neoplastic lesions that produce nasal obstruction include sarcoma, lymphoma and juvenile nasopharyngeal angiofibroma. Primary malignant tumours in the nasal cavity, which are relatively rare, are unilateral and are generally squamous cell carcinoma.
• Choanal atresia:
  • Congenital, may be unilateral or bilateral, and may be either membranous or bony.
  • Unilateral atresia may go undiagnosed in infants. Bilateral atresia is a medical emergency in newborns because they are obligate nasal breathers.
  • Respiratory distress in the newborn, bilateral nasal drainage and not able to place a paediatric nasal catheter should raise a high level of suspicion of bilateral choanal atresia.
  • Choanal atresia is commonly associated with CHARGE syndrome (coloboma, heart anomalies, choanal atresia, retardation of growth and development, and genital and ear anomalies).⁴
  • Computed tomography is the radiographic procedure of choice in evaluation of choanal atresia.

Not usually required but may include:

• Full blood count
• Allergy tests
• X-rays: adenoid, sinus
• CT scan
• Nasopharyngoscopy

• The management will depend on the initial diagnosis and degree of impairment.
• Indications for referral include:
  • Unilateral blood-stained discharge and nasal blockage in a middle-aged or elderly patient (urgent)
  • Soft swelling either side of septum following trauma suggests septal haematoma (urgent)
  • This may need evacuation to reduce the risk of cartilage necrosis and infection (urgent)
  • Toddler with unilateral nasal blockage and foul-smelling discharge (foreign body likely)
  • Child with persistent hearing difficulties and speech delay
  • Uncertain diagnosis
  • Failure of initial treatment, e.g. topical nasal steroids
• Apart from specific management for the assumed cause of nasal obstruction, management will include reassurance, general advice and perhaps a trial of topical cromoglycate or steroids, and/or an oral antihistamine.
• It is essential to teach and ensure correct technique when using a nasal spray (head forward, look at toes when activate the spray, breath in gently and don't take a big sniff.

• Nasal congestion and obstruction can also contribute to headaches and also sleep disorders such as snoring and obstructive sleep apnoea, with resultant daytime fatigue.