Nose & Sinus Problems

Nasal drip is an annoying symptom that irritates the front of the nose and requires constant attention from the patient. When the drip is further back in the nose it is often referred to as post nasal drip. This results in throat clearing and cough. The causes range from upper respiratory infection to allergy. Non specific environmental irritants such as air pollution and temperature change may be the source in certain individuals. Neurologic imbalance within the nasal mucosa creates a condition known as vasomotor rhinitis, which is most common in the elderly. Thick and colored mucous may indicate infection and sinusitis but not always. The history and exam will help determine the cause and the appropriate treatment. Newer prescription sprays, decongestants, and antihistamines may be recommended. Office procedures are possible for those who fail medical therapy. These techniques are aimed at reducing the tissues within the nose which are producing the drip.

Nasal obstruction which persists is often due to several common factors. A deviated septum is a condition where the wall separating the two sides of the nose internally is crooked, resulting in narrowing and blockage. Some individuals are born with this and others injure their nose from trauma as a toddler or later in life. Since it is an anatomical obstruction, it will not respond to decongestants or nasal sprays. Septoplasty or nasal-septal reconstruction to correct this is very effective and typically accomplished as an out-patient with only a few days needed to get back to work or school. Other sources of obstruction are enlarged nasal turbinates or nasal polyps. These can present by themselves or in conjunction with a deviated septum and can be addressed at the same time the septum is corrected.

Sinusitis occurs when the sinuses that surround the nose become inflamed and infected. This is often triggered by allergy or upper respiratory infection which congests the nose and blocks the sinuses from draining. A deviated nasal septum or polyps may also interfere with sinus drainage and lead to sinusitis. When this condition is acute, treatment with antibiotics, pain medication, and decongestants may resolve the infection. At times, oral steroids such as prednisone, are added to the treatment to reduce sinus and nasal swelling and promote drainage.

Chronic sinusitis is sinusitis that persists for many weeks or months. In addition to the history and exam, imaging studies such as a CAT scan are very helpful to confirm the diagnosis and reveal the extent of the disease. Treatment consists of longer antibiotic therapy, sometimes for several weeks. Reducing persistent inflammation is often needed to reverse this process. Medications such as nasal steroid sprays, antihistamine sprays, Singulair, and oral steroids (prednisone), all have a role in treating chronic sinusitis. Allergy evaluation and treatment may be indicated.

Endoscopic sinus surgery is reserved for those who fail conservative medical management. This technique has been evolving over the last 15 years. Specialized sinus instruments and endoscopes are introduced through the nostrils. Enlargement of the natural drainage openings of the sinuses is then performed. Balloon sinuplasty is a recent development where a narrow catheter is introduced into a narrowed sinus passage and a balloon attached to the catheter is inflated. This dilates the natural opening and makes it permanently wider and better able to drain. Balloon sinuplasty is only necessary with certain sinuses, typically the frontal sinus.

Anosmia, or poor sense of smell, is a very distressing complaint. In order to appreciate the subtle flavor of a cheese or pastry, it is necessary for the molecules of food to migrate up to the top of the nasal vault and stimulate the olfactory nerve. Nasal obstruction from a head cold, nasal polyps, or septal deviation, will block this process. However, there may not be obstruction at all. Viral injury to the olfactory nerve and surrounding tissue may be the source of the anosmia. Rarely, the problem lies within the base of the brain where the nerve function is blocked, sometimes by a tumor. A thorough exam and endoscopic visualization of the nasal interior is an important part of the evaluation. This will determine possible therapy.

Contributing factors for bleeding from the nose include dry home heating in the winter, a deviated nasal septum, and a variety of medications such as aspirin, Plavix, and Coumadin. These medications reduce the ability of the blood to coagulate and can prolong nose bleeds and make them more difficult to treat. Bleeding usually occurs from the front of the nose along the nasal septum however occasionally the source is much further back. Evaluation can usually determine the exact site of the bleeding. Treatment then involves cauterization with chemicals or electro-cautery. At times packing is necessary to apply pressure to the bleeding blood vessel. If the source of the bleeding is posterior, a specialized type of pack is placed and the patient may need to be hospitalized.

The most common bone in the body to break is the nasal bone. Often the traumatic event is accompanied by pain, nose bleeds, and obstruction. The broken nose starts to swell and may bruise. Management is usually deferred until the swelling is reduced. An x-ray is not always necessary. After several days an exam will determine if the nasal bone is fractured but in good position. In this situation, the bone will heal on its own and the nose will look as it did before the accident. A displaced fracture is when the bone is out of place. It will remain movable for several weeks before it heals out of place. A decision on treatment must be made promptly. A closed reduction is performed by manipulating the nasal fracture back into place. No incisions or cuts are needed. The nose is then stabilized with tape or a cast. This can often be performed under local anesthesia in the office. For children, adolescents, or apprehensive adults, a brief general anesthetic is utilized. If the fracture is older or does not respond to a closed reduction, then an open reduction is performed. This procedure is performed under anesthesia. Incisions are made inside the nose and the nasal bones are chiseled or re-fractured to reproduce the original look of the nose. If there is trauma to the nasal septum and nasal obstruction, it can be corrected at the same time.

Nasal congestion, drip, sneezing, and itching can all be the result of allergy. The history of exposure and time of the year of symptoms are often clues that allergy is the cause. There are a variety of oral antihistamines, both prescription and over-the-counter that are helpful. More recently, topical cortisone and antihistamines sprays have become available. These provide the option of concentrating the medication right where the symptoms are, within the nose, with a minimum of side effects. Allergy testing may be indicated in some patients.

Nasal polyps present as nasal obstruction and diminished sense of smell. They are often, but not always, in patients who have nasal allergy. When they are small, it is possible to treat with topical cortisone sprays and oral cortisone to get polyps under control. Polyps usually originate from the nasal sinuses. They then block drainage from the sinuses and lead to chronic sinusitis and nasal inflammation. In patients with asthma, this can lead to increased asthmatic symptoms from release of inflammatory substances into the blood stream. When conservative medical management fails, endoscopic sinus surgery is indicated to remove the polyps and clear out sinuses.

Nasal turbinates are structures along the sides of the nasal passage. They have the function of moistening and warming the air we breathe. Dust particles and pollutants are filtered out. The structures can become swollen over time and cause nasal obstruction and excessive postnasal drip. Topical cortisone or antihistamine sprays can be helpful. When turbinate swelling (hypertrophy) is the major factor in obstruction, the structures can be reduced, often as an office procedure.

Clinical observation and research is showing similarities between asthma, inhalant allergy, and inflammatory diseases of the nose and sinuses. This has led to a concept of an interrelated or unified airway. This means that the entire respiratory system including the nose, paranasal sinuses, larynx and lungs can be thought of as one functional unit. Depending on which symptoms are most prominent, the patient may present to an ear, nose, and throat (ENT) physician, pulmonary physician, primary care physician, or allergist.

Early on it was observed that asthma patients had a high incidence of nasal symptoms. Conversely patients with allergic rhinitis and chronic sinusitis often went on to develop other respiratory problems including asthma. The more severe the nasal and sinus disease, the more likely one is to develop asthma. The unifying concept is one of chronic inflammation. Exactly what triggers certain individuals to develop allergic and other inflammatory reactions is not known.

The mucus membranes which lying the nose, sinuses, trachea and lungs are composed of similar epithelium with similar functions. On a cellular level, inflammatory cells such as eosinophils, T lymphocytes and monocytes, infiltrate the respiratory lining in all these locations causing similar changes. These immunity type cells release cytokines causing inflammation and attract other inflammatory cells to the area. These chemicals then travel through the bloodstream acting as mediators and initiating inflammation in other respiratory tissue. This is what is now called the unified airway theory.

This has led to studies which show the significance of controlling chronic sinusitis and allergic rhinitis on the management of asthma. Controlling the nasal disease results in decreased asthma medication and improved pulmonary function.

The information posted on this page is provided as general, background information in the spirit of service to the reader. In no way should it be interpreted as medical advice. While the practice of Robert Feld, MD, LLC, attempts to convey accurate and current information on this site, this information may contain typographical errors, technical errors, or may at some point become out-of-date. You are advised to confirm the accuracy of any information presented on this site before relying on it in any way.