Nasal symptoms such as runny nose (rhinorrhea), blockage, sneezing, bleeding, pain and reduce sense of smell are common. Common causes include allergy, infection and tumor.
Rhinorrhea
Discharge from the nose can present in different ways. Clear mucoid discharge in association with itchiness, sneezing and blockage is highly suggestive of nasal allergy. Yellowish, greenish discharge in the presence of pain and fever indicate possible infection (Figure 1). Bloody or blood-stained discharge may be a symptom of tumor.
Purulent discharge from one side of the nose in a child is a foreign body (FB) until otherwise proven. Clear watery discharge especially in a background of trauma is very suggestive of cerebrospinal fluid (CSF) leak from a break in the skull base.
Nasal allergy is generally treated with allergen avoidance, steroid nasal sprays and oral antihistamines. Immunotherapy also provides an alternative in the long term control. Treatment for nasal infection depends on the etiology. Viral rhinitis is self-limiting and symptomatic relief is all that is needed. Bacterial infections also involve the sinuses and should be treated with a course of oral antibiotics, in addition to symptomatic control. All patients with bloody discharge must have nasoendoscopy performed to exclude tumor. Any suspicious mass should be biopsied and sent for histology. Treatment will depend on the nature of the mass.
Children with unilateral (one-sided) nasal discharge should have a full examination of the nasal cavities to exclude an FB. This can include a lateral plain X-ray of the skull for suspected radio-opaque FBs or a nasoendoscopy. Sinusitis is best demonstrated on CT scan (Figure 2). CSF leaks can be confirmed on beta 2 transferrin test. MRI with intrathecal radio-opaque dye and CT scan imaging may also be helpful in locating the site of the leak.
Figure 2 shows that white arrow is normal, black indicates infection
Nasal Obstruction (Blockage)
Many people experience nasal blockage at some time in their life. Most are transient and resolve spontaneously. However, when nasal blockage persists, it can become quite distressing and can significantly affect quality of life.
Causes
The causes of nasal blockage can be divided into unilateral (one-sided) and bilateral (two-sided) blockage.
Unilateral Blockage
- Tumor – it is most important to exclude a nasal or sinus tumor (growth). It can be due to a benign (non-cancerous) growth such as a polyp or papilloma or malignant (cancerous) such as nose cancer. Blockage can be associated with bleeding or purulent discharge.
- Sinusitis – Although sinusitis usually affects both sides, acute sinus infections can affect only one side. The blockage is usually accompanied by purulent discharge, facial pain, fever and teethache or numbness.
- Deviated Nasal Septum – Some patients have a very bent nasal septum that narrows one side of the nasal cavity.
This can be congenital or a result of trauma.
- Foreign Body – in children, a one sided blockage associated with pus, a foreign body (eg toy) must be excluded.
Bilateral Blockage
- Turbinate Hypertrophy (swelling) – Turbinates are normal swelling in the nasal cavity that can swell as a result of inflammation. The most common cause of turbinate swelling is nasal allergy. Overuse of decongestant nose drops also causes the lining of the nose to swell (Rhinitis Medicamentosa). Turbinate hypertrophy is by far the most common reason patients experience persistent nasal blockage.
- Nasal Polyps – these are benign swellings that result from chronic sinus infections. They can growth very large and even prop out the nose.
- Chronic Sinusitis – persistent or recurrent infections of the sinuses can cause obstruction by filling the nasal cavities with discharge that is thick and viscous.
- Adenoidal Hypertrophy – adenoids are aggregations of lymphoid tissue found at the back of the nose (postnasal space). Commonly, they are large in children, especially from ages 3 to 8. When severe, the children are seen to mouth breathe and snore loudly.
Associated Problems
Nasal blockage is frequently associated with other conditions and aggravates symptoms. Patients frequently report headache, ear blockage, worsening snoring and sleep disturbances. When sleep is significant affected, children may demonstrate behavioral changes such as irritability, listlessness and poor concentration. Also, studies have shown that children who mouth breathe demonstrate poor dentition and lower jaw development.
Treatment
Treatment is aimed at the source of the problem.
- Hypertrophic Turbinates – Medications such as nasal steroid sprays (eg. Flixonase, Nasonex), decongestant sprays (Afrin, Iliadin) and oral decongestants (eg Clarinase, Zrytec-D) afford temporary relief. Permanent turbinate size reduction can be achieved in a few ways. These include using radiofrequency (see commonly performed procedures in the clinic), coblation or cutting.
- Nasal Polyps and Sinusitis – the first line treatment is antibiotics with or without steroids. Large polyps and severe chronic infections may require surgery.
- Deviated Nasal Septum – a bent nasal septum can be straightened surgically as a day surgery procedure.
- Large Adenoids – Adenoidectomy is a procedure to remove the adenoids and improve nasal patency. This is done mainly in children under general anaesthesia.
Epistaxis (Bleeding)
Bleeding from the nose is common. Most often, it results from trauma such as nose picking, rubbing or digging. Traumatic injury from sports, fights or accidents can result in profuse bleeding.
Bleeding from the nose is the second most common presenting symptom in patients with nose cancer (nasopharyngeal carcinoma, Figure 3 & 4). Nose cancer is the 5th most common cancer in Singapore and every adult patient with epistaxis, especially Chinese, should have a nasoendoscopy to exclude this cancer.
Treatments include control of primary cause (allergy control in allergic rhinitis, antibiotics in sinusitis etc), silver nitrate cautery for prominent septal blood vessels and nasal packing for more profuse bleeding.
Pain
Nasal pain can result from trauma or infection. Sinusitis can cause pain between the eyes. Vestibulitis (hair follicle infection at the nostril) causes pain at the opening of the nose. Trauma to the nasal bony structure can cause severe pain but generally subsides after 2 weeks.