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Course: Medical Surgical Nursing

Topic: Nasal Obstruction

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Module Goals

Learners will be able to

Describe the clinical manifestation of nasal obstruction.
Discuss the assessment and diagnostic findings of nasal obstruction.
Describe the medical management of nasal obstruction.
Discuss the post-surgical complications of nasal obstruction.
Discuss the nursing management of nasal obstruction.

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Nasal Obstruction

Subjective perception of discomfort or difficulty in the passage of air through the nostrils.

Physiological or pathological sensation generated in the trigeminal sensory receptors of the nasal mucosa.

The terms obstruction and nasal congestion are used interchangeably, although obstruction usually refers to the subjective sensation of irreversible blockage.

Valero et al., 2018

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Nasal Obstruction: Facts

It is one of the most common reasons for consultation in primary care, otorhinolaryngology, and allergology.

Annoying symptom that:

affects quality of life (QOL)
predisposes to and exacerbates lower airway diseases
alters night rest
decreases work efficiency
aggravates sleep apnea

Valero et al., 2018

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Nasal Obstruction: Clinical Manifestations

Persistent nasal obstruction
Apnea
Trouble breathing through the nose (mouth breathing)
Dry mouth
Difficulty sleeping
Facial pain and swelling
Nasal discharge
Sneezing
Cough
Headache

Sleep and Sinus Centers of GA, n.d.

UCI Head and Neck, n.d.

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Nasal Obstruction: Etiology

Caused by a variety of factors:

anatomical
inflammatory
neurological
hormonal
functional
environmental
pharmacological

Valero et al., 2018

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Nasal Obstruction: Unilateral and Bilateral Causes

Valero et al., 2018

Unilateral Causes	Bilateral Causes
Septal Deviation	Rhinitis
Unilateral Chronic Rhinosinusitis	Chronic Rhinosinusitis
Antrochoanal Polyps	Benign or malignant tumors
Benign or malignant tumors	Diseases
Concha Bullosa	Turbinate Hypertrophy
	Valvular Insufficiency
	Empty Nose Syndrome

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Nasal Obstruction: Anatomical and Physiological Causes

Valero et al., 2018

Anatomical Causes	Physiological Causes
Deviated Nasal Septum	Sinonasal Inflammatory Diseases
Nasal Valve Narrowing	Neoplasm
Middle Turbinate Concha Bullosa	Medical/Hormonal Changes
Inferior Turbinate Hypertrophy
Choanal Atresia
Pyriform Aperture Stenosis
Trauma and Previous Sinonasal Surgery

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Critical Thinking Question

The student nurse is reviewing nasal obstruction for the final exam.

Which of the following anatomical conditions might cause nasal obstruction? (Select all that apply).

Deviated nasal septum
Hormonal changes
Nasal trauma
Nasal Valve Narrowing
Rhinitis

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Nasal Obstruction: Assessment

History and Physical: thorough history should address the presence of:

nasal obstruction
sinusitis
rhinitis
inflammatory sinonasal disease
postnasal drip
chronic cough
facial pain or pressure
ear pain or pressure
loss of sense of smell or taste
hearing loss

Becker et al., 2022

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Nasal Obstruction: Assessment (Continued)

Valero et al., 2018

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Nasal Obstruction: Assessment (Continued)

Valero et al., 2018

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Nasal Obstruction: Assessment (Continued)

A history of environmental or seasonal allergies must be obtained
Prior nasal surgery must be noted, including:

sinus surgery
rhinoplasty
septoplasty
turbinate reduction
other procedures

Prior nasal trauma should also be identified.

Becker et al., 2022

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Nasal Obstruction: Assessment (Continued)

Anterior rhinoscopy is performed to visualize:

inferior turbinates
caudal nasal airway
external nasal valve

Becker et al., 2022

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Nasal Obstruction: Diagnostic Findings

Radiologic Exams

Coronal Sinus Computed Tomography (CT) scan

Objective Nasal Airway Studies

Rhinomanometry
Acoustic Rhinometry

Becker et al., 2022

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Coronal Sinus CT scan: can assist in identifying sources of nasal obstruction, such as a concha bullosa or posterior septal deviation, which may not have been appreciated on physical exam. Additionally, a coronal sinus CT may provide additional information for a patient who has had a history of chronic nasal obstruction or sinonasal inflammatory disease

The rhinomanometry is a device that functionally measures nasal airflow at a fixed pressure differential during the nasal respiratory cycle. This provides a method with which the rhinoplasty surgeon can quantitatively measure nasal resistance

Acoustic rhinometry is a complementary study to rhinomanometry, in that it assists in measuring the location of the nasal obstruction, not in determining total nasal resistance. Interestingly, acoustic rhinometry has been deemed the most accurate measurement of nasal area, especially anterior in the nose and the region of the nasal valve (Becker et al., 2022)

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Critical Thinking Question

Which of the following diagnostic findings would be indicated to confirm the diagnosis of nasal obstruction?

Acoustic Rhinometry
Computed Tomography
Bronchoscopy
Rhinomanometry
Sputum analysis

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Nasal Obstruction: Medical Treatment

Nasal decongestants
Corticosteroids
H1 Antihistamines
Intranasal formulation of fluticasone + azelastine (MP-AzeFlu)
Antileukotrienes
Intranasal chromones
Anticholinergics

Valero et al., 2018

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Nasal Decongestants: Both oral decongestants (ephedrine, phenylephrine, phenylpropanolamine, and pseudoephedrine) and intranasal decongestants (phenylephrine, naphazoline, oxymetazoline, tramazoline, xylometazoline)

Corticosteroids: Intranasal corticosteroids (INCs) (beclomethasone, budesonide, ciclesonide, fluticasone propionate, fluticasone furoate, mometasone, triamcinolone) have a potent anti inflammatory effect and have proven to be effective in treating Nasal Obstruction

H1 Antihistamines: Second-generation H1 antihistamines (anti-H1)—both oral agents (bilastine, cetirizine, desloratadine, ebastine, fexofenadine, levocetirizine, loratadine, mequitazine, mizolastine, rupatadine) and intranasal agents (azelastine, levocabastine, olopatadine)—exert their antiallergic effects as inverse agonists of the H1 receptor.

MP-AzeFlu: effect of MP-AzeFlu is based on a greater reduction in proinflammatory mediators combined with greater stimulation of anti-inflammatory genes

Antileukotrienes: these type of drugs drugs (montelukast, zafirlukast) improve Nasal Obstruction.

Intranasal chromones: Intranasal chromones (cromoglycate, nedocromil) act on sinonasal inflammation mainly by stabilizing mast cells

Anticholinergics: Activation of the parasympathetic system causes vasodilation and hypersecretion of the nasal mucosa, which is responsible in part for Nasal Obstruction. and may potentially improve with intranasal anticholinergics (ipratropium bromide) (Valero et al., 2018)

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Nasal Obstruction: Medical Treatment (Continued)

Other medications:

Capsaicin
Lysine acetylsalicylate
Saline solution (isotonic or hypertonic) for nasal wash

Valero et al., 2018

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Nasal Obstruction: Surgical Treatment

Nasal Septal Surgery
Submucous Resection (SMR)
Traditional Septoplasty
Endoscopic Septoplasty
Open Septoplasty

Becker et al., 2022

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Nasal Obstruction: Post-Surgical Complications

Complications of Septoplasty:

Hemorrhage
Cerebrospinal fluid (CSF) leak
Septal hematoma
Mucosal adhesions
Septal Perforation

Postoperative Infection

Becker et al., 2022

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Hemorrhage should be distinguished from the typical 24 to 48 hours of postoperative spotting expected. Significant perioperative hemorrhage in septoplasty ranges from 6% to 13.4% of cases.81,82 Acute bleeding during nasal surgery may occur as a result of inadequate local anesthetic, inadequate wait for the vasoconstrictive effects of the epinephrine to occur, or mucoperichondrial flap tears during elevation

CSF leak occurs when submucous resection is carried too high in the nasal cavity. A crack in the very thin bone of the anterior skull base (generally at the cribriform plate in the midline or the fovea ethmoidalis more laterally) and a concomitant tear of the dura mater on the floor of the anterior cranial fossa results in communication of the subarachnoid space and the nasal cavity

A septal hematoma occurs when significant venous oozing continues after the septal mucosa incision is closed, resulting in blood being trapped between the mucoperichondrial flaps or against the remaining cartilage. If this goes unrecognized and is not treated early, septal hematoma can be a major complication of septoplasty. An untreated septal hematoma begins a cascade of events that can lead to several other complications, including ischemia and necrosis of the septal cartilage, decreased septal support, and collapse of the middle vault. The result of this structural insufficiency is the saddle nose deformity

Mucosal adhesions: also known as synechiae, are abnormal bridges of inflamed and adherent mucosa that may cause nasal obstruction after septorhinoplasty

Septal Perforation: Perforation occurs when there are bilateral opposing tears in the mucoperichondrial flaps (Becker et al., 2022)

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Nasal Obstruction and Quality of Life

The effect of Nasal Obstruction reduces QOL and leads to structural alterations of the nasal cavity.
Deterioration of QOL affects all age groups.
Nasal Obstruction is a key factor affecting sleep quality.
Effective treatment of Nasal Obstruction can reduce the daytime sleepiness resulting from sleep disturbances.
Presenteeism (loss of productivity while in the workplace) is very high.
It also generate high costs.

Valero et al., 2018

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Critical Thinking Question

Which of the following are potential surgical complications of septoplasty? (Select all that apply).

CSF leak
Hemorrhage
Mucosal adhesions
Septal hematoma
Septal perforation

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Nasal Obstruction: Nursing Management

Monitor rate, rhythm, depth, and effort of respirations.
Note chest movement, watching for symmetry and use of accessory muscles.
Monitor for noisy respirations such as snoring.
Monitor breathing patterns.
Monitor oxygen saturation levels in sedated patients.

Ernstmeyer & Christman, 2021

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Nasal Obstruction: Nursing Management (Continued)

Auscultate lung sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds.
Monitor client’s ability to cough effectively.
Note onset, characteristics, and duration of cough.
Monitor the client’s respiratory secretions.
Provide frequent intermittent monitoring of respiratory status in at-risk clients.
Monitor for dyspnea and events that improve and worsen it.

Ernstmeyer & Christman, 2021

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Nasal Obstruction: Nursing Management (Continued)

Monitor chest X-ray reports as appropriate.
Note changes in ABG values as appropriate.
Institute resuscitation efforts as needed.
Institute respiratory therapy treatments as needed.
Provide for noninvasive continuous oxygen sensors with appropriate alarm systems in patients with risk factors per agency policy and as indicated.

Ernstmeyer & Christman, 2021

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

The client underwent surgery for septal reconstruction. Which of the following interventions should the nurse implement first?

Monitor for dyspnea
Monitor client’s ability to cough effectively
Note changes in ABG values
Provide noninvasive continuous oxygen

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Red Flags

Nasal Obstruction is one of the most common reasons for consultation in primary and specialized care.

It can be caused by drugs and by anatomical, inflammatory, neurological, hormonal, functional, and environmental factors.

Unilateral Nasal Obstruction that progresses over time may be a sign that the disorder has its origin in a tumor.

Valero et al., 2018

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures, talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures, family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

(AHRQ, 2020)

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Becker, D. et al. (2022). Surgical treatment of nasal obstruction in rhinoplasty. Aesthetic Surgery Journal. 30(3), 347–378. https://doi.org/10.1177/1090820X10373357

Ernstmeyer, K., & Christman, E. (2021). Open RN Nursing Fundamentals by Chippewa Valley Technical College. Applying the Nursing process. https://wtcs.pressbooks.pub/nursingfundamentals/chapter/8-3-applying-the-nursing-process/

Contact info: info@nursesinternational.org

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References

Sleep and Sinus Centers of Georgia. (n.d). Nasal Airway Obstruction. https://www.sleepandsinuscenters.com/conditions/nasal-airway-obstruction

UNI Head and Neck. (n.d.). Nasal Obstruction. https://naveenbhandarkarmd.com/conditions/nasal-obstruction/

Valero, A. et al. (2018). Position paper on nasal obstruction: Evaluation and treatment. Journal of Investigational Allergology and Clinical Immunology. 28(2), 67-9. DOI: 10.18176/jiaci.0232

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