EVALUATION OF NASAL OBSTRUCTION

Apr 5, 2009

History and Physical Exam

History
  • Character of Nasal Obstruction: onset and duration, constant versus intermittent, unilateral (tumors, normal nasal cycle) versus bilateral obstruction, associated mouth breathing, snoring, anosmia/hyposmia/taste disturbances, tearing (nasolacrimal duct obstruction or allergy)
  • Contributing Factors: potential toxin and allergen exposure, known drug allergies, medications (see Table 1–1), history of immunodeficiency, asthma, sinusitis, otitis media, allergy, sleep disturbances, facial trauma or surgery
  • Associated Symptoms: allergic component (sneezing, itchy and watery eyes, clear rhinorrhea), sinus involvement


  • Antihypertensives
  • Psychotropic Medications
  • Oral Contraceptives
  • Chronic Nasal Decongestants: rhinitis medicamentosa
  • Cocaine: local vasoconstriction
  • Tobacco: irritates mucosa and impairs ciliary clearance
  • Antithyroid Medication
  • Aspirin: activates peripheral chemoreceptors
  • Marijuana

headaches), acute infection (fevers, malaise, purulent or odorous nasal discharge, pain)
Other Head and Neck (H&N) Symptoms: sore throat, postnasal drip, cough, ear complaints, halitosis, ocular pain, hoarseness
Think “KITTENS” for differential diagnosis (see Table 1–2)

Physical Exam
  • External Nasal Exam: external deformities (firmness, tenderness on palpation), nasal flaring, nasal airflow
  • Anterior Rhinoscopy/Nasal Endoscopy: examine twice (with and without topical decongestion), quality of turbinates (hypertrophic, pale, blue), quality of nasal mucosa, nasal septum, osteomeatal complex obstruction, foreign bodies, nasal masses, choanal opening
  • Quality of Nasal Secretions: purulent or thick (infectious), watery and clear (vasomotor rhinitis, allergy), salty and clear (CSF leak)
  • H&N Exam: facial tenderness, tonsil and adenoid hypertrophy, cobblestoned posterior pharynx, cervical adenopathy, otologic exam

Ancillary Tests
  • Allergy Evaluation: (see below)
  • Paranasal Plain Films: may be considered for screening, largely been replaced by CT/MRI
  • CT/MRI of Paranasal Sinus: indicated if obstruction may be secondary to nasal masses, polyps, or complicated sinusitis

Tabel 1-2 Differential diagnosis of Nasal Obstruction

(K) Congenital

Infectious & Idiopathic

Toxins & Trauma

Tumor
(Neoplasia)

Endocrine

Neurologic

Systemic

Neurogenic tumors

Infectious rhinitis

Nasal and septal fractures

Papillomas

Diabetes

Vasomotor rhinitis

Granulomatous
diseases

Congenital nasopharyngeal cysts

Rhinoscleroma

Medication side effects (rhinitis medicamentosa)

Nasal Polyps

Hypothyroidism


Vasculitis

Teratoma

Chronic sinusitis

Synechia

Hemangiomas

Pregnancy


Allergy

Choanal atresia

Adenoid hyperplasia

Environmental irritants

Pyogenic granulomas



Cystic fibrosis

Nasoseptal deformities


Septal hematomas

Foreign bodies

Juvenile nasopharyngeal
angiofibromas

Malignancy






  • Biopsy: indicated for any mass suspect for malignancy, avoid biopsy of vascular neoplasms (juvenile nasopharyngeal angiofibroma, sarcomas) or encephaloceles
  • Rhinomanometry: provides an objective measurement of airway resistance, largely not utilized in clinical practice since highly time consuming, not cost effective, and inaccurate
  • Ciliary Biopsy and Mucociliary Clearance Tests: electronmicroscopy and ciliary motility studies for ciliary defects
  • Nasal Secretion Protein and Glucose: evaluate for CSF leak if suspected
  • Culture and Sensitivity: surgically obtained cultures usually indicated for complicated acute rhinosinusitis and resistant chronic sinusitis
  • Pulmonary Function Tests: suspect reactive airway disease component
  • Olfactometry: qualitative and quantitative testing of olfactory substances

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