Nasal Obstruction

Obstruction due to anatomic changes: With age, the nose gradually changes, largely because of gravitational effects. The tip of the nose droops, and the nose elongates and narrows. The angle between the columella of the nose and upper lip decreases because skin becomes lax and the cartilage of the nasal alae thins and softens. Nasal obstruction may result if the drooping is pronounced or the softened alae close against the septum during inspiration.

Obstruction due to anatomic changes is diagnosed if elevating the tip of the nose with the thumb produces immediate improvement. The nasal airway can be opened further by placing gentle lateral traction on the cheek.

Treatment may involve wearing adherent plastic strips on the nose at night to hold the collapsed nasal airway open. For severe obstruction, surgery to lift the tip, shorten the nasal septum, and tighten the skin may be indicated.

Bilateral obstruction: Seasonal or perennial nasal allergy, as well as anatomic changes, may cause bilateral obstruction. Allergic symptoms may begin when a person moves to a new region of the country. However, for many elderly persons, the symptoms of allergic rhinosinusitis seem to diminish with age.

Bilateral obstruction may also result from bilateral nasal polyps. If the obstruction is associated with unilateral or bilateral hearing loss secondary to serous otitis media, the cause may be a nasopharyngeal tumor (eg, carcinoma, lymphoma, plasmacytoma), which should be ruled out by sinus x-ray.

Occasionally, nasal congestion may be due to hypothyroidism. Nasal congestion may be caused by certain antihypertensives and tricyclic antidepressants. Overuse of nasal decongestant sprays (eg, phenylephrine, oxymetazoline) can cause chronic hypertrophic changes of the turbinates (rhinitis medicamentosa).

For patients with allergies, the mainstay of treatment is antihistamines. However, antihistamines with anticholinergic properties tend to cause sedation, dry mouth, orthostatic hypotension, constipation, urine retention, and confusion in the elderly. Only drugs without anticholinergic properties (eg, astemizole, cetirizine, fexofenadine, loratadine) should be used in the elderly.

Unilateral obstruction: Causes include nasal swelling or polyps secondary to chronic infection in the maxillary or ethmoidal sinuses, particularly in patients who have had maxillary dental abscesses or nasogastric or nasotracheal intubation. If a confused patient has an obstruction with a discharge, the cause may be a foreign body (commonly, a wad of tissue or cotton) pushed into the nose. A unilateral obstruction associated with bleeding may be due to neoplasia involving the sinuses or nose.

Evaluation involves a physical examination, sinus x-rays, and culture; biopsy is indicated if a tumor is suspected. For benign sinus disorders, limited nasal and sinus surgery is usually required. For a malignancy, radiation therapy, surgery, or both are required, depending on biopsy and x-ray findings.