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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 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 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 , 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 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 (AR), which includes seasonal AR and perennial AR. Seasonal AR is typically caused by outdoor 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 avoidance, Often starts in rhinorrhea, nasal intranasal corticosteroids, childhood or young congestion nasal irrigation, adulthood intranasal or oral second-generation anti- , 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 for >5-7 days, agent NSAIDS, ACE inhibitors, beta-blockers, oral contraceptives, antide- pressants, intranasal , 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, , Adenoid tissue obstructs Intranasal corticosteroids, If no relief of symp- hypertrophy10-13 mouth , airway leukotriene receptor toms, consider referral recurrent media antagonists for ACE, angiotensin-converting enzyme; AERD, aspirin-exacerbated ; AR, allergic rhinitis; ARS, allergic rhinosinusitis; CF, ; 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, 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 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 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

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(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 also should mended as first-line therapy when oral anti- be used with caution in this population, not 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 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 effective dose. Nasal cromolyn has the most reassuring safety Mechanical/structural causes profile in pregnancy. Cetirizine, chlorpheni- of obstruction are wide-ranging ramine, loratadine, diphenhydramine, and Mechanical/structural causes of nasal tripelennamine may be used in pregnancy. obstruction range from foreign bodies to ana- The US Food and Drug Administration con- tomical variations including nasal polyps, a siders them to have a low risk of fetal harm, deviated septum, adenoidal hypertrophy, for- based on human data, whereas it views many eign bodies, and tumors. Because more than other antihistamines as probably safe, based one etiology may be at work, it is best to first on limited or no human data. Most INGCs are treat any non-mechanical causes of obstruc- not expected to cause fetal harm, but limited tion, such as ARS or NARS. human data are available. Avoid prescribing oral decongestants to women who are in the Nasal polyposis often requires first trimester of pregnancy due to the risk of both a medical and surgical approach gastroschisis in newborns.17 Nasal polyps are benign growths arising from Elderly patients represent another pop- the mucosa of the nasal sinuses and nasal ulation for which adverse effects must be cavities and affecting up to 4% of the popu- carefully considered. in individuals lation.7 Their etiology is unclear, but we do

JFPONLINE.COM VOL 65, NO 12 | DECEMBER 2016 | THE JOURNAL OF FAMILY PRACTICE 891 TABLE 2 Commonly used medications for nasal obstruction

Category Medication Adult dose18 Intranasal antihistamine 1-2 sprays BID olopatadine 2 sprays BID Oral antihistamine First generation diphenhydramine 25-50 mg q4-6 hours hydroxyzine 25-50 mg q6 hours chlorpheniramine 4 mg q4-6 hours Second generation loratadine 10 mg once daily cetirizine 10 mg once daily fexofenadine 180 mg once daily Intranasal glucocorticoids flunisolide 2 sprays once daily triamcinolone 2 sprays once daily Leukotriene budesonide 1 spray once daily receptor beclomethasone 1-2 sprays twice daily antagonists may fluticasone 2 sprays once daily be better suited 2 sprays once daily to nighttime symptoms Leukotriene receptor antagonists of nasal montelukast 10 mg once daily obstruction, while oral antihistamines know that nasal polyps result from underlying curs with INGCs) include systemic (oral) cor- may be better inflammation.7 Uncommon in children outside ticosteroids, intra-polyp steroid injections, suited to of those affected by cystic fibrosis,7 - macrolide antibiotics, and nasal washes.7,14 daytime osis can be associated with disease processes When symptoms of polyposis are refrac- symptoms. such as AR and . Polyps are also asso- tory to medical management, functional ciated with clinical syndromes such as aspirin- endoscopic sinus surgery (FESS) is the surgi- exacerbated respiratory disease (AERD) syn- cal procedure of choice.3 In addition to refrac- drome, which involves upper and lower respi- tory symptoms, indications for FESS include ratory tract symptoms in patients with the need to correct anatomic deformities who have taken aspirin or other NSAIDs.9 believed to be contributing to the persistence Symptoms vary with the location and of disease and the need to debulk advanced size of the polyps, but generally include nasal nasal polyposis.3 The principal goal is to congestion, alteration in smell, and rhinor- restore patency to the ostiomeatal unit.3 rhea. The goals of treatment are to restore or Several studies have reported a high suc- improve nasal breathing and olfaction and cess rate for FESS in improving the symptoms prevent recurrence.8 This often requires both of CRS.3,19-23 In a 1992 study, for example, 98% a medical and surgical approach. of patients reported improvement following Topical corticosteroids are effective at surgery,19 and in a follow-up report approxi- reducing both the size of polyps and associ- mately 6 years later, 98% of patients contin- ated symptoms (rhinorrhea, rhinitis).8 And ued to report subjective improvement.22 research has shown that steroids reduce the need for both primary and repeat surgical For septal etiologies, polypectomies.4 Other treatments to consider consider septoplasty prior to surgery (if no symptom reduction oc- Deviation of the is a common

892 THE JOURNAL OF FAMILY PRACTICE | DECEMBER 2016 | VOL 65, NO 12 NASAL OBSTRUCTION

structural etiology for nasal obstruction aris- clear recommendations regarding technique ing primarily from congenital, genetic, or can be made. traumatic causes.24 Turbulent airflow from the septal deviation often causes turbinate : hypertrophy, which creates (or exacerbates) Consider corticosteroid nasal drops the obstructive symptoms from the septal Adenoid hypertrophy is a common cause deviation.25 of chronic nasal obstruction in children. Septoplasty is the most common ear, Although adenoidectomy is commonly nose, and throat operation in adults.26 Reduc- performed to correct the problem, cur- tion of nasal symptoms has been reported in rent evidence regarding the efficacy of up to 89% of patients who receive this sur- the procedure is inconclusive.10 Evidence gery, according to one single-center, non- demonstrates corticosteroid nasal drops sig- randomized trial.27 Currently, at least one nificantly reduce symptoms of nasal obstruc- multicenter, randomized trial is underway tion in children and may provide an effective that aims to develop evidence-based guide- alternative to surgical resection.18 Studies lines for septoplasty.26 have also demonstrated that treatment with ❚ Septal perforation is another etiol- oral LRAs significantly reduces adenoid size ogy that can present with nasal obstruction and nasal obstruction symptoms.12,13 symptoms. Causes include traumatic perfo- ration, inflammatory or collagen vascular dis- Foreign bodies: Although eases, , overuse of vasoconstrictive Don’t forget “a mother’s kiss” adenoidectomy medications, and malignancy.28,29 A careful Foreign bodies are the most common cause of is commonly inspection of the nasal septum is necessary to nasal obstruction in the pediatric population. performed identify a perforation; this may require nasal There is a paucity of high-quality evidence on to correct . removal of these objects; however, a number adenoid Anterior, rather than posterior, perfo- of retrospective reviews and case series sup- hypertrophy rations are more likely to cause symptoms port that most objects can be removed in the in children, of nasal obstruction. Posterior perforations office or emergency department without oto- current evidence rarely require treatment unless malignancy laryngologic referral.31,32 regarding the is suspected, in which case referral for biopsy Techniques for removal include posi- efficacy of the is recommended. Anterior perforations are tive pressure, which is best used for smooth procedure is treated initially with avoidance of any caus- or soft objects. Positive pressure techniques inconclusive. ative agent if, for example, the problem is include having the patient blow their own drug- or medication-induced, and then with nose or having a parent use a mouth-to- humidification and emollients.28,29 mouth–type blowing technique (ie, the For anterior perforations, septal silicone “mother’s kiss” method).32 Refer patients to buttons can be used for recalcitrant symp- Otolaryngology if the obstruction involves:31 toms. However, observational studies indi- • objects not easily visualized by ante- cate that for long-term symptom resolution, rior rhinoscopy silicone buttons are effective in only about • chronic or impacted objects one-third of patients.29 • button batteries or magnets For patients with persistent symptoms • penetrating or hooked objects despite the above measures, surgical repair • any object that cannot be removed with various flap techniques is an option. during an initial attempt. A meta-analysis of case studies involving various techniques concluded that there is Nasal tumors: More common a wide variety of options, and that surgeons in older men must weigh factors such as the characteristics Nasal tumors occur most often in the and etiology of the perforation and their own nasal cavity itself and are more common experience and expertise when choosing in men ≥60 years.33 There is no notable from among available methods.30 Additional racial predominance.33 Other risk fac- good quality research is necessary before tors include human papillomavirus (HPV) CONTINUED

JFPONLINE.COM VOL 65, NO 12 | DECEMBER 2016 | THE JOURNAL OF FAMILY PRACTICE 893 , tobacco smoke, and occupational rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122:S1-S84. exposure to inhaled wood dust, glues, and 5. Krouse J, Lund V, Fokkens W, et al. Diagnostic strategies in nasal adhesives.34-37 congestion. Int J Gen Med. 2010;3:59-67. 6. Skoner DP. Allergic rhinitis: definition, epidemiology, patho- ❚ Benign tumors occurring in the physiology, detection, and diagnosis. J Allergy Clin Immunol. nasal cavity are a diverse group of disorders, 2001;108:S2-S8. 7. Newton JR, Ah-See KW. A review of nasal polyposis. Ther Clin Risk including inverted papillomas, squamous Manag. 2008;4:507-512. papillomas, pyogenic granulomas, and other 8. Badia L, Lund V. Topical corticosteroids in nasal polyposis. Drugs. 2001;61:573-578. less common lesions, all of which typically 9. Fahrenholz JM. Natural history and clinical features of aspirin- present with nasal obstruction as a symp- exacerbated respiratory disease. Clin Rev Allergy Immunol. 2003;24:113-124. tom. Many of these lesions cause local tissue 10. van den Aardweg MT, Schilder AG, Herket E, et al. Adenoid- destruction or have a high incidence of recur- ectomy for recurrent or chronic nasal symptoms in children. Cochrane Database Syst Rev. 2010;CD008282. rence. These tumors are treated universally 11. Demirhan H, Aksoy F, Ozturan O, et al. Medical treatment of ad- with nasoendoscopic resection.38 enoid hypertrophy with “fluticasone propionate nasal drops”.Int ❚ J Pediatr Otorhinolaryngol. 2010;74:773-776. Malignant nasal tumors are rare but 12. Shokouhi F, Jahromi AM, Majidi MR, et al. Montelukast in ad- serious causes of nasal obstruction, mak- enoid hypertrophy: its effect on size and symptoms. Iran J Otorhi- 39 nolaryngol. 2015;27:433-448. ing up 3% of all head and cancers. 13. Goldbart AD, Greenberg-Dotan S, Tai A. Montelukast for children Most nasal cancers present when they are with obstructive sleep : a double-blind, placebo-controlled study. Pediatrics. 2012;130:e575-e580. locally advanced and cause unilateral nasal 14. Moss WJ, Kjos KB, Karnezis TT, et al. Intranasal steroid injections obstruction, lacrimation, and epistaxis. These and blindness: our personal experience and a review of the past 60 years. Laryngoscope. 2015;125:796-800. Most foreign symptoms are typically refractory to initial 15. Chusakul S, Warathanasin S, Suksangpanya N, et al. Comparison bodies can medical management and present as CRS. of buffered and nonbuffered nasal saline irrigations in treating al- lergic rhinitis. Laryngoscope. 2013;123:53-56. be removed This diagnosis should be suspected in certain 16. Xu Y, Zhang J, Wang J. 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31. Mackle T, Conlon B. Foreign bodies of the nose and ears in chil- tional exposure to formaldehyde and other substances. Int J Can- dren. Should these be managed in the accident and emergency cer. 1993;53:224-231. setting? Int J Pediatr Otorhinolaryngol. 2006;70:425-428. 36. Mayr SI, Hafizovic K, Waldfahrer F, et al. Characterization of ini- 32. Cook S, Burton M, Glasziou P. Efficacy and safety of the “mother’s tial clinical symptoms and risk factors for sinonasal adenocarci- kiss” technique: a systematic review of case reports and case se- nomas: results of a case-control study. Int Arch Occup Environ ries. CMAJ. 2012;184:E904-E912. Health. 2010;83;631-638. 33. Turner JH, Reh DD. Incidence and survival in patients with sino- 37. Syrjänen KJ. HPV infections in benign and malignant sinonasal nasal cancer: a historical analysis of population-based data. Head lesions. J Clin Pathol. 2003;56:174-181. Neck. 2012;34:877-885. 38. Wood JW, Casiano RR. Inverted papillomas and benign non- 34. Benninger MS. The impact of cigarette smoking and environmen- neoplastic lesions of the nasal cavity. Am J Rhinol Allergy. tal tobacco smoke on nasal and sinus disease: a review of the lit- 2012;26:157-163. erature. Am J Rhinol. 1999:13:435-438. 39. Eggesbø HB. Imaging of sinonasal tumours. Cancer Imaging. 35. Luce D, Gerin M, Leclerc A, et al. Sinonasal cancer and occupa- 2012;12:136-152.

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