Margaret A. Bayard, MD, Improving your approach MPH, FAAFP; Paul Algra, DO; L. Jared Hyman, DO; Chadwick Donaldson, MD to nasal obstruction Naval Hospital Camp Pendleton, Calif margaret.a.bayard.mil@ The causes are diverse—from rhinitis and rhinosinusitis mail.mil to drugs and structural/mechanical abnormalities. The views expressed in this article are those of the authors and do not Here’s how to provide patients with relief. necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. The authors reported no potential conflict of interest asal obstruction is one of the most common reasons relevant to this article. PRACTICE that patients visit their primary care providers.1,2 RECOMMENDATIONS Often described by patients as nasal congestion or the ❯ Consider intranasal N inability to adequately breathe out of one or both nostrils dur- corticosteroids for patients ing the day and/or night, nasal obstruction commonly inter- with nasal polyps, as they are effective at reducing the size feres with a patient’s ability to eat, sleep, and function, thereby of the polyps and associated significantly impacting quality of life. Overlapping presenta- symptoms of obstruction, tions can make discerning the exact cause of nasal obstruction rhinorrhea, and rhinitis. A difficult. ❯ Prescribe intranasal To improve diagnosis and treatment, we review here the corticosteroids for patients evidence-based recommendations for the most common with adenoid hypertrophy. A causes of nasal obstruction: rhinitis, rhinosinusitis (RS), drug- induced nasal obstruction, and mechanical/structural abnor- ❯ Refer patients with chronic malities (TABLE 13-14). refractory rhinosinusitis for functional endoscopic sinus surgery. B Rhinitis/rhinosinusitis: Strength of recommendation (SOR) It all begins with inflammation A Good-quality patient-oriented evidence Sneezing, rhinorrhea, nasal congestion, and nasal itching are B Inconsistent or limited-quality complaints that signal rhinitis, which affects 30 to 60 million patient-oriented evidence people in the United States annually.3 Rhinitis can be allergic, C Consensus, usual practice, opinion, disease-oriented non-allergic, infectious, hormonal, or occupational in nature. evidence, case series All forms of rhinitis share inflammation as the cause of the nasal obstruction. The most common form is allergic rhinitis (AR), which includes seasonal AR and perennial AR. Seasonal AR is typically caused by outdoor allergens and waxes and wanes with pollen seasons. Perennial AR is caused mostly by indoor allergens, such as dust mites, molds, cockroaches, and pet dander; it persists all or most of the year.6 Causes of non- allergic rhinitis (NAR) include environmental irritants such as cigarette smoke, perfume, and car exhaust; medications; and hormonal changes,6 but most causes of NAR are unknown.3,6 While AR can begin at any age, most people develop symp- toms in childhood or as young adults, whereas NAR tends to begin later in life. Nasal itching can help to distinguish AR JFPONLINE.COM VOL 65, NO 12 | DECEMBER 2016 | THE JOURNAL OF FAMILY PRACTICE 889 TABLE 1 Common causes of nasal obstruction—and how to treat them* Condition Characteristics Causes Treatments Comments Allergic rhinitis3,4,6 Sneezing, nasal itching, Extrinsic allergens Allergen avoidance, Often starts in rhinorrhea, nasal intranasal corticosteroids, childhood or young congestion nasal irrigation, adulthood intranasal or oral second-generation anti- histamines, leukotriene receptor antagonists Non-allergic Nasal congestion, post- Unknown causes, Avoid known triggers; Often starts later in life rhinitis3,4,6 nasal drip, rhinorrhea environmental irritants, nasal irrigation, AR medications, hormonal treatments changes Drug-induced Nasal congestion, Use of alpha-adrenergic Discontinue offending rhinitis3,5,6 rhinorrhea nasal spray for >5-7 days, agent NSAIDS, ACE inhibitors, beta-blockers, oral contraceptives, antide- pressants, intranasal cocaine, and methamphetamines† Nasal polyps7-9,14 Nasal congestion, Idiopathic, CF, ARS, Treat overlying ARS/ - If no relief of symp- rhinorrhea NARS, AERD NARS; intranasal toms, consider referral corticosteroids for polypectomy Adenoid Nasal congestion, snoring, Adenoid tissue obstructs Intranasal corticosteroids, If no relief of symp- hypertrophy10-13 mouth breathing, airway leukotriene receptor toms, consider referral recurrent otitis media antagonists for adenoidectomy ACE, angiotensin-converting enzyme; AERD, aspirin-exacerbated respiratory disease; AR, allergic rhinitis; ARS, allergic rhinosinusitis; CF, cystic fibrosis; NARS, non- allergic rhinosinusitis; NSAIDS, nonsteroidal anti-inflammatory drugs. *Nasal obstruction presenting with atypical symptoms and/or not responding to primary treatments should be considered for early referral to Otolaryngology. †The most common agents are listed here; other drug classes may also cause rhinitis. from NAR. NAR symptoms tend to be peren- intranasal glucocorticosteroids (INGCs) are nial and include postnasal drainage. If symp- the most effective monotherapy for AR and toms persist longer than 12 weeks despite NAR and have few adverse effects when used treatment, the condition becomes known as at prescribed doses.3,4 For mild to intermit- chronic rhinosinusitis (CRS). tent symptoms, begin with the maximum dosage of an INGC for the patient’s age and Treatment of rhinitis: proceed with incremental reductions to iden- Tiered and often continuous tify the lowest effective dose.3 If INGCs alone Treatment of AR and NAR is similar and are ineffective, studies have shown that the multitiered beginning with the avoidance of addition of an intranasal second-generation irritants and/or allergens whenever possible, antihistamine can be of some benefit.3,4 In moving on to pharmacotherapy, and, at least fact, an INGC and an intranasal antihista- for AR, ending with allergen immunother- mine—along with saline nasal irrigation—is apy. Treatment is often an ongoing process recommended for both AR and NAR resistant and typically requires continuous therapy as to single therapy.3,6,15 If intranasal antihista- opposed to treatment on an as-needed basis.3 mines are not an option, oral therapy can be It is unnecessary to perform allergy testing initiated. before making a presumed diagnosis of NAR ❚ Start with second-generation antihis- and starting treatment.6 tamines and consider LRAs. For oral therapy, ❚ Intranasal corticosteroids. Currently, start with second-generation antihistamines 890 THE JOURNAL OF FAMILY PRACTICE | DECEMBER 2016 | VOL 65, NO 12 NASAL OBSTRUCTION (loratadine, cetirizine, fexofenadine). First- >65 years of age are uncommon. Rhinitis generation antihistamines (diphenhydr- in this age group is often secondary to cho- amine, hydroxyzine, chlorpheniramine), linergic hyperactivity, alpha-adrenergic although widely available at relatively low hyperactivity, or rhinosinusitis. Given cost, can cause several significant adverse elderly patients’ increased susceptibility to effects including sedation, impaired cogni- the potential adverse central nervous system tive function, and agitation in children.3,4 (CNS) and anticholinergic effects of antihis- Because second-generation antihistamines tamines, non-sedating medications are rec- have fewer adverse effects, they are recom- ommended. Oral decongestants also should mended as first-line therapy when oral anti- be used with caution in this population, not histamine therapy is desired, such as for nasal only because of CNS effects, but also because congestion, sneezing, and itchy, watery eyes. of heart and bladder effects3 (TABLE 218). Of note: A 2014 meta-analysis found that a leukotriene receptor antagonist (LRA) For drug-induced rhinitis, stop (montelukast) had efficacy similar to oral the offending drug and consider an INGC antihistamines for symptom relief in AR, Several types of medications, both oral and and that LRAs may be better suited to night- inhaled, are known to cause rhinitis. The use time symptoms (difficulty falling asleep, of alpha-adrenergic decongestant sprays for nighttime awakenings, congestion on awak- more than 5 to 7 days can induce rebound ening), while antihistamines may provide congestion on withdrawal, known as rhinitis When better relief of daytime symptoms (pruritus, medicamentosa.3 Repeated use of intranasal prescribing rhinorrhea, sneezing).16 Although further cocaine and methamphetamines can also intranasal head-to-head, double-blind randomized result in rebound congestion. Oral medica- corticosteroids controlled trials (RCTs) are needed to con- tions that can result in rhinitis or conges- for allergic firm the results and investigate possible tion include angiotensin-converting enzyme and nonallergic gender differences in symptom response, (ACE) inhibitors, beta-blockers, nonsteroidal rhinitis, begin consider an LRA for first-line therapy in anti-inflammatory drugs (NSAIDS), oral con- with the patients with AR who have predominantly traceptives, and even antidepressants.3 maximum nighttime symptoms. The treatment for drug-induced rhinitis dosage and then is termination of the offending agent. INGCs incrementally What about pregnant women can be used to help decrease inflammation reduce and the elderly? and control symptoms once the offending the amount It is important to consider teratogenicity agent is discontinued. to identify when selecting medications for pregnant the lowest patients, especially during the first trimester.3