Blocked Nose That Won’t Go Away? An ENT Surgeon Explains Why

A constantly blocked nose can be frustrating, but what causes it, and when should you seek help? An ENT surgeon breaks down the common reasons for this issue and what you can do for lasting relief.

WORDS DR HARDIP SINGH GENDEH

FEATURED EXPERT DR HARDIP SINGH GENDEH Lecturer and Specialist Ear, Nose & Throat Surgeon Department of Otorhinolaryngology, Head and Neck Surgery Faculty of Medicine Universiti Kebangsaan Malaysia

EXPLAINING RHINOSINUSITIS

• Chronic rhinosinusitis (CRS) is a condition whereby there is prolonged inflammation of the nose (rhino) and its surrounding air spaces within the face (sinuses) for more than 3 months.
• Acute rhinosinusitis is one with a duration of symptoms that is less than 3 months or 12 weeks.

The Doctor Will Diagnose You with CRS if You Have 2 or More of the Following:

• Nasal blockage in one or both nostrils
• Nasal discharge, usually yellowish or greenish
• Pain around the face, especially at the forehead, cheeks, and between the eyes
• Decreased or loss of sense of smell

CRS CAN BE CLASSIFIED INTO TWO TYPES

CRS with Nasal Polyps

• Prolonged inflammation of the sinuses may cause swelling of the sinus lining. Over time, outpunching akin to grapes may form on the sinus lining.
• These ‘grapes’, nasal polyps, are often glistening and pale and can be present in one or both nostrils.
• When these nasal polyps are sufficiently large, they may occupy a significant amount of space in the nose, obstruct air flow, and result in persistent nasal blockage.
• This may disturb one’s breathing and may result in snoring or even sleep disturbances.

CRS without Nasal Polyps

• The inner nose lining still undergoes inflammation, appearing swollen and red.
• Quite often, thick mucus or pus exits from the sinuses into the nasal cavity, which can lead to the affected person complaining of a foul odour in their breath.
• They may also complain of frequent throat clearing due to backflow of secretions into the throat from the nose.
• Sometimes, if this CRS is left untreated, the affected person may develop nasal polyps over time.

POSSIBLE CAUSES OF CRS

• Up to 30% are due to prolonged nose allergies (allergic rhinitis)
• Allergies to fungal spores in the air, common in a country with high humidity such as Malaysia
• Primary ciliary dyskinesia, a condition in which one has impaired clearing of mucus in the upper and lower airways
• Side effect of certain medications

A referral to an ENT specialist is necessary to determine the cause(s) of one’s CRS and the best course of treatment.

MEDICAL TREATMENT FOR CRS

Salt Nasal Rinse

• Help with washing away thick mucus within the nose.

Nasal Steroid Spray

• Applied into the affected nostril.
• Helps to reduce inflammation and shrink polyps.

Antihistamines

• For those with allergies.
• Decrease the amount of nasal secretion.

Oral Steroids

• Occasionally, a course or several courses can be prescribed.
• Help shrink the polyps and reduce inflammation.

Antibiotics

• Evidence has shown that the use of macrolides, a type of antibiotics, for 4 to 6 weeks may help reduce the size of nasal polyps.

HOW ABOUT SURGERY?

Should medical treatments mentioned earlier fail, then the ENT surgeon will consider surgery.

Preliminary Investigations

The patient often undergoes a computed tomography (CT) scan of the nose and the sinuses.

This allows for the:

• Identification of the origins of the polyps
• Assessment of the condition of the sinuses
• Identification of any abnormalities within the nose and the sinuses

The ENT surgeon may also consider performing a biopsy of the polyp—that is, taking a small amount of tissue from the polyp and sending the tissue to the laboratory for further investigation. This is to confirm whether it is indeed a polyp and identify inflammatory markers within the polyp.

Functional Sinus Surgery

• This surgery, performed on the patient under general anesthesia, ventilates and drains the sinuses as well as removes the polyps.
• A well-ventilated sinus has less inflammation and trapped mucus, thereby decreasing the number of future recurrent infections.
• The surgery also allows for better reach of nasal spray medications into the nose and the lining of the surrounding sinuses.

Note that the patient will still need to continue using medications such as steroid nasal sprays after surgery.

WHAT IF THE POLYPS COME BACK AFTER TREATMENT OR SURGERY?

• A small number of people may experience a recurrence of polyps after some time.
• This is due to the persistent factors such as exposure to allergens that cannot be completely avoided or eliminated, such as those in the air, or immunological problems within the body.

What the ENT Surgeon Can Do in This Situation

The ENT surgeon will reassess the patient and consider whether to continue with medical therapy or to perform another surgery to remove the polyps.

Another option is to consider the use of biologics, which is a fairly new treatment for patients that continue to have recurrent polyps despite receiving adequate medical and surgical treatments.

• Besides nasal polyps, biologics are indicated in the treatment of urticaria and asthma, conditions that may be related to CRS.
• However, patients will have to take these biologics for a lengthy period, and they may not work on all types of polyps.