EVALUATION OF NASAL OBSTRUCTION

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• Paranasal Plain Films: may be considered for screening, largely been replaced by CT/MRI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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