Chapter 59: Nasal disorders

Disorders of the nose, which include the everyday problems of rhinitis, postnasal drip, epistaxis, folliculitis and disorders of smell, are very common in everyday general practice.

The main functions of the nose are:

• airflow

• filtration—of dust, organisms and other air-borne particles

• olfaction (smell)

• self-cleansing and moisturising of the mucous membrane

• humidification and warming of air in its passage to the lungs

• vocal resonance

The main symptoms of nasal disorders are discharge, blockage, sneezing, anosmia, itching, postnasal drip, bleeding and snoring (see TABLE 59.1).¹

Nasal discharge is a common and important symptom to evaluate. The characteristics of nasal discharge are summarised in TABLE 59.2.

A major presenting problem is nasal obstruction with the complaint of a blocked or ‘stuffy’ nose. Common causes are physiological (the nasal cycle), rhinosinusitis (allergic or non-allergic), polyps, adenoid hypertrophy and mechanical such as septal deformity.

The basic sense of smell is detected in the olfactory region by the olfactory nerve (cranial nerve I) while irritant sensors in the nose, mediated by the maxillary branch of the trigeminal nerve (cranial nerve V), detect some noxious odours.

The disorders can be classified as:³

• anosmia—no smell

• hyposmia—reduced smell

• hyperosmia—increased sensitivity to odours

• dysosmia—distortion of smell perception

  • – cacosmia—normal odours seem foul or unpleasant

  • – parosmia—a perverse sense of smell

Disorders of smell can be caused by conductive or sensorineural disturbances or considered as idiopathic (see TABLE 59.3). Conductive disorders present as anosmia or hyposmia, while sensorineural disorders can present with all of the above disorders.³ Most cases of idiopathic anosmia are considered to be viral neuropathies and may last from a few days to several months. Head trauma, which can cause conductive or sensorineural disturbances, is considered to be caused either from a fracture of the skull involving the cribriform plate or, more commonly, by posterior head trauma. Some patients will never recover their sense of smell. Patients with anosmia lack flavour discrimination and often have accompanying loss of sense of taste. They are also vulnerable to an unawareness of smoke, gas, dangerous chemicals and unhealthy food.

• History: head injury or surgery, recent URTI, drugs, occupation including chemical exposure

• Physical examination, including inspection via a Thudicum nasal speculum

• Sniff test—qualitative and quantitative odours (e.g. coffee, cloves, lemon, peppermint, water placebo). Ammonia (for irritant sensation)

• Investigations (e.g. CT scan for sinus disease, nasal polyps)

Treatment^2,4

• Explanation and reassurance

• Education about smoke detectors, caution about chemicals including gas, excessive perfume, food safety including milk and meat contamination

• Consider dietary supplement with daily zinc sulphate, vitamin A and thiamine

• For chronic anosmia following an URTI: prescribe a nasal decongestant such as Spray-Tish Menthol for 5–7 days

Rhinitis

Rhinitis is inflammation of the nose causing sneezing, nasal discharge or blockage for more than an hour during the day. Rhinitis is subdivided into various types:

• According to time span:

  • – seasonal rhinitis: occurs only during a limited period, usually springtime

  • – perennial rhinitis: present throughout the year

• According to pathophysiology:

  • – allergic rhinitis: an IgE-mediated atopic disorder

  • – vasomotor rhinitis: due to parasympathetic overactivity

Both allergic and vasomotor rhinitis have a strong association with asthma.

The classification can be summarised as:

• seasonal allergic rhinoconjunctivitis = hay fever

• perennial rhinitis

  • – allergic (usually due to house dust mites)

  • – non-allergic = vasomotor: eosinophilic, non-eosinophilic

Note: allergic rhinitis (hay fever) is presented in detail in CHAPTER 80.

Clinical features

Nasal symptoms:

• sneezing

• nasal obstruction and congestion

• hypersecretion—watery rhinorrhoea, postnasal drip

• reduced sense of smell

• itching nose (usually allergic)

Throat symptoms:

• dry and sore throat

• itching throat

Irritated eyes (allergic)

Abnormal nasal mucous membrane—pale, boggy, mucoid discharge. A transverse nasal crease indicates nasal allergy, especially in a child.

• Pollens from trees (spring) and grass (in summer)

• Moulds

• House dust mites (perennial rhinitis)

• Hair, fur, feathers (from cats, dogs, horses, birds)

• Some foods (e.g. cow’s milk, eggs, peanuts, peanut butter)

Diagnosis

Allergic rhinitis—nasal allergy:

• detection of allergen-specific IgE antibodies (not specific)

• RAST test or skin testing for specific allergens (can get false negatives)

Vasomotor rhinitis—a diagnosis of exclusion.

Other causes of rhinitis

• Chronic infection (viral, bacterial, fungal)

• Rhinitis of pregnancy

• Rhinitis medicamentosa—following overuse of OTC decongestant nasal drops or oxymetazoline sprays

• Drug-induced rhinitis:

  • – various antihypertensives

  • – aspirin

  • – phenothiazines

  • – oral contraceptives

  • – cocaine, marijuana

• Chemical or environmental irritants (vasomotor rhinitis):

  • – smoke and other noxious fumes

  • – paints and sprays

  • – cosmetics

Factors aggravating rhinitis (vasomotor)

• Emotional upsets

• Fatigue

• Alcohol

• Chilly damp weather

• Air-conditioning

• Sudden changes in temperature and humidity

Acute sinusitis

Acute sinusitis is acute inflammation in the mucous membranes of the paranasal sinuses. About 5% of URTIs are complicated by an acute sinusitis,⁴ which is mainly viral initially while secondary bacterial infection commonly follows. Any factor that narrows the sinus openings into the nasal cavity (the ostia) will predispose to acute sinusitis.

The two prime clinical presentations are:

1. an URTI persisting for longer than 10 days

2. an URTI that is unusually severe with pyrexia and a purulent nasal discharge

Refer to CHAPTER 52 for features of acute maxillary sinusitis.

Chronic sinusitis

Chronic sinusitis is the most common complication of acute sinusitis. In chronic sinusitis, the symptoms and signs of inflammation persist for more than 8–12 weeks and are more likely to be associated with factors that impair drainage via the osteomeatal complex, including nasal polyps.

Treatment

• Amoxycillin 500 mg (o) 8-hourly for 10–14 days, possibly for longer periods of 3–6 weeks⁵

• Consider decongestant spray (e.g. xylometazoline) for maximum of 5 days and intranasal steroids

• Steam inhalations three times daily

• Nasal saline sprays

If the above therapies are ineffective, a mechanical saline sinus irrigation procedure to remove stagnant mucus is beneficial.⁶

Refer urgently:

• for surgical drainage if there is no response to the above regimen

• those with orbital or facial cellulitis

Nasal polyps

Nasal polyps are round, soft, pale, pedunculated outgrowths arising from the nasal or sinus mucosa. They are basically prolapsed, congested, oedematous mucosa, described by some as ‘bags of water’ (see FIG 59.1). They occur in patients with all types of rhinitis, but especially in allergic rhinitis (see FIG. 59.2). Polyps usually arise from the middle meatus and turbinates.

Symptoms include nasal obstruction, watery discharge, postnasal drip and loss of smell.

Note:

• Nasal polyps may be associated with asthma and aspirin sensitivity.

• Cystic fibrosis should be considered in any child with nasal polyps.

• A polyp that does not have the typical smooth, pale appearance may be malignant.

• A unilateral ‘polyp’ may be a neoplasm.

• If there is a purulent discharge, swab and give antibiotics.

Treatment

The initial treatment should be medical.⁷ A medical ‘polypectomy’ can be achieved with oral steroids, for example, prednisolone 50 mg daily for 7 days. Supplement this with a corticosteroid spray such as betamethasone, starting simultaneously and continuing for at least 3 months.⁸ Give antibiotics for any purulent nasal discharge.

Simple polyps can be readily snared and removed, but referral to a specialist surgeon is advisable for surgical intervention since the aim is to remove the polyp with the mucosa of the sinuses (often ethmoidal cells) from which it arises. This complex procedure reduces the incidence of recurrence.

Epistaxis⁹

This common emergency should, in some instances, be treated as a life-threatening problem. The common situation is intermittent anterior bleeding from Little area, seen in children and the young adult (90% of episodes), while posterior epistaxis (10%) is more common in the older hypertensive patient. It has a strong association with higher URTI (rhinitis, sinusitis), hot dry climates and trauma. Neoplasms should be kept in mind. Bleeding often occurs at night due to vascular vasodilation. Causes of epistaxis are presented in the diagnostic strategy model in TABLE 59.4). The secret of good management is to have the right equipment, good lighting and effective local anaesthesia.

Diagnostic tips

• Recent onset of persistent bleeding in elderly points to carcinoma.

• Severe epistaxis is often caused by liver disease coagulopathy.

• Difficult-to-control posterior bleeding is a feature of the hypertensive elderly.

Ideal equipment

Head light, Thudicum nasal speculum, Tilley nasal packing forceps, suction cannula and tubing, Co-Phenylcaine forte spray ± 5% cocaine solution.

Merocel expandable pack, Kaltostat, BIPP (bismuth iodoform paraffin paste) with ribbon gauze, Foley catheter (no. 12, 14 or 16) with a 30 mL balloon and self-sealing rubber stopper, anterior/posterior balloon, Epistat catheter with or without Kaltostat.

Treatment

Simple tamponade:

• Pinch ‘soft’ part of nose below the nasal septum between thumb and finger for 5 minutes

• Apply ice packs to bridge of nose

Simple cautery of Little area (see FIG. 59.3) (under local anaesthetic e.g. Co-Phenylcaine forte nasal spray ± 5% cocaine solution):

• use one of three methods: electrocautery trichloracetic acid or silver nitrate stick (preferred)

Merocel (surgical sponge) nasal tampon or Kaltostat pack

‘Trick of the trade’ for intermittent minor anterior epistaxis:

• topical antibiotic (e.g. Aureomycin ointment) bd or tds for 10 days

• or (better option)

• Nasalate nasal cream tds for 7–10 days

• or

• Rectinol ointment or Vaseline

Avoid digital trauma and nose blowing.

Use a Foley catheter or an Epistat catheter plus anterior pack.

Nasal vestibulitis

Infection of the nasal vestibule can cause a tender, irritating, crusty problem. Low-grade infections and folliculitis, which are evident on inspection, cause localised pain, crusts and bleeding, especially if picked from habit. Treatment is with bacitracin or preferably mupirocin (intranasal) ointment topically for 5–7 days.

Furunculosis of the nasal vestibule is usually due to Staphylococcus aureus. It starts as a small superficial abscess in the skin or the mucous membrane and may develop into a spreading cellulitis of the tip of the nose. The affected area becomes tender, red and swollen. It is best treated by avoiding touching it, hot soaks and systemic antibiotics such as dicloxacillin or as determined by culture from swabs of the vestibule.

Tip: Staphylococcus aureus colonises the nose of 20–30% of the population.⁸ Carriers are prone to transmit nosocomial infection and have an increased risk of serious infections in the presence of serious medical disorders. Treatment includes strict hygiene and eradication with an agent such as mupirocin ointment (match-head size) 2–3 times daily for 5–7 days (max. 10 days).⁶

Fissure: Painful fissures often develop at the mucocutaneous junction. They may become crusted and chronic. Fissures can be treated by keeping the area moist with petroleum jelly (Vaseline) or saline gel, using hot compresses and the use of an antibiotic or antiseptic ointment if necessary.

Offensive smell from nose

This may be caused by vestibulitis but ensure no foreign body is present.

Treatment

• Take nasal swab for culture.

  consider mupirocin 2% nasal ointment, instilled 2–3 times a day for 10 days

  or

  Kenacomb ointment, instil 2–3 times a day

Rhinophyma

This disfiguring swelling of the nose is due to hypertrophy of the nasal sebaceous glands. There is no specific association with alcohol. It is almost exclusive to men over the age of 40 years. Rhinophyma may be associated with rosacea.

Treatment

• Good control of rosacea may reduce the risk (see CHAPTER 121).

• If surgical correction is warranted, refer to a specialist.

• Carbon dioxide laser therapy is the treatment of choice.

• Shave excision is another effective therapy.

Nasal septal deviation

This causes blockage as a solitary symptom. Mild septal deviation tends to cause alternating blockage while severe deviation causes persistent blockage on one side.

The septum can be divided into anterior and posterior segments. The anterior portion is necessary to support the cartilaginous pyramid of the nose whereas the posterior portion has no supporting role and can be removed without disturbing the support of the nose. The classic submucous resection operation is therefore suitable for posterior septal deviations. Repair of anterior septal deviations is more complex.

Nasal cosmetic surgery

Rhinoplasty is undertaken to improve the function of an obstructed nasal airway or for cosmetic reasons. In counselling for rhinoplasty it is important to undertake careful planning with realistic anticipated outcomes. The GP should provide non-judgmental support for the patient’s decision on cosmetic surgery before referral to an expert in rhinoplasty. Each case has to be assessed individually and the surgery tailored to the deformity. Attention to surgery to the airway is important, otherwise the nose may become partially obstructed and stuffy after cosmetic surgery alone.

Septal perforation

A hole in the nasal septum is commonly caused by chronic infection, including tuberculosis, repeated trauma such as vigorous nose ‘picking’ or following nasal surgery. Rarely, it is encountered in syphilis and Wegener granulomatosis (see CHAPTER 32). It is a known occupational hazard, particularly among chrome workers, and is seen in drug users who sniff cocaine. In about 5–10% of cases, perforation is a result of malignant disease.⁴ The condition may be asymptomatic depending on the cause, but there is often an irritating nasal crust and a whistling sound on nasal inspiration. It can be demonstrated by looking in one nares while a light is shone in the opposite one. The cartilaginous part is usually involved.

If not due to a serious cause, treat with Vaseline or saline gel and topical antibiotics for any infection. Refer if malignancy is suspected, otherwise treat symptomatically.

Nasal fractures^2,9

Fractures of the nose can occur in isolation or combined with fractures of the maxilla or zygomatic arch. They may result in nasal bridge bruising, swelling, non-alignment and epistaxis. Always check for a compound fracture or head injury and, if present, leave alone and refer. If the patient is seen immediately (such as on a sports field) with a straightforward lateral displacement, reduction may be attempted ‘on the spot’ with digital manipulation before distortion from soft tissue swelling. This involves simply using the fingers to push laterally on the outside of the nose towards the injured side.²

Tips:

• X-rays are generally unhelpful unless excluding other facial skeletal injuries and for legal reasons.

• If a deformity is present, refer the patient within 7 days, ideally from days 3–5.

• Skin lacerations, i.e. compound fracture, usually require early repair.

• The optimal time to reduce a fractured nose is about 10 days after injury. There is a window period of 2–3 weeks before the fracture unites.

• Closed reduction under local or general anaesthetic is the preferred treatment.

• Open reduction is more suitable for bilateral fractures with significant septal deviation, bilateral fractures with major dislocations or fractures of the cartilaginous pyramid.

  Refer:

• septal haematoma

• uncontrolled epistaxis

• recurrent epistaxis

• concern about cosmetic alignment

• CSF rhinorrhoea

Haematoma of nasal septum

Septal haematoma following injury to the nose can cause total nasal obstruction. It is easily diagnosed as a marked swelling on both sides of the septum when inspected through the nose (see FIG. 59.4).

It results from haemorrhage between the two sheets of mucoperiosteum covering the septum. It may be associated with a fracture of the nasal septum.

Note: This is a most serious problem as it can develop into a septal abscess. The infection can pass readily to the orbit or the cavernous sinus through thrombosing veins and may prove fatal, especially in children. Otherwise it may lead to necrosis of the nasal septal cartilage followed by collapse and nasal deformity.

Treatment

• Remove blood clot through an incision, under local anaesthetic.

• Prescribe systemic (oral) antibiotics (e.g. penicillin or erythromycin).

• Treat as a compound fracture if X-ray reveals a fracture.

• ENT specialist advice as necessary.

Stuffy, running nose in adults

For simple post-URTI rhinitis, blow the nose hard into disposable paper tissue or a handkerchief until clear, instil a nasal decongestant for 2–3 days and also have steam inhalations with Friar’s Balsam or menthol preparations.

This can be normal or abnormal. There is a ‘nasal cycle’ in which there is nasal congestion and decongestion that alternates from side to side and leads to rhinorrhoea. Other causes of normal discharge include vasomotor reactions to external environmental stimuli, such as cold wind and irritants, and postnasal drip (2 L of mucus pass down the back of the nose each day). The diagnostic model for rhinorrhoea is presented in TABLE 59.5.

Senile rhinorrhoea

This is a common, distressing problem in the elderly, caused by failure of the vasomotor control of the mucosa. It may be associated with a deviated septum and dryness of the mucosa. There are few physical signs apart from the nasal drip. The treatment is to keep the nasal passages lubricated with an oil-based preparation, e.g. insufflation with an oily mixture (a sesame oil-based preparation, e.g. Nozoil, is suitable) or petroleum jelly. Topical decongestants cause serious side effects in the elderly.

CSF rhinorrhoea

Following head injury, clear dripping fluid (+ve for glucose or beta-2 transferrin, a more specific test) may indicate a fracture of the roof of the ethmoid. A useful test is the ‘halo’ or double-ring test, where a blood-stained drop is placed on tissue paper and shows separation of blood and straw-coloured CSF. Refer for assessment, although spontaneous healing can occur.

Neoplasia

Malignant nasal disease, which is uncommon, may cause nasal discharge that may be clear at first, becoming thick and offensive. Malignancy should be suspected in the presence of blood. The growth may be in the nasal fossa, sinus or nasopharynx.

Benign tumours include papilloma, fibroma, osteoma, juvenile fibroangioma of puberty and nasal polyps. Fibroangiomas occur exclusively in males between the ages of 9 and 24. Patients present with unilateral nasal obstruction and recurrent epistaxis.

Malignant tumours include nasopharyngeal carcinoma, with the maxillary sinus being the most common site. Squamous cell carcinoma is the most common, followed by adenocarcinoma melanoma and lymphoma. Malignant or non-healing granuloma, sometimes called ‘midline granuloma’, is a slowly progressing ulceration of the face starting in the region of the nose.⁴ It may represent a form of T cell malignant lymphoma, which responds to radiotherapy. The differential diagnosis is Wegener granulomatosis (see CHAPTER 32). Diagnosis is by CT scan and biopsy. Treatment of nasopharyngeal and sinonasal carcinoma depends on the site, size and histology, but usually involves a combination of surgery and postoperative radiotherapy.

Nasal problems, especially nasal discharge (rhinorrhoea), are very common in children but the pattern of presentation is usually different from that of adults. Sinusitis is uncommon in children under the age of 10, and allergic nasal polyps are relatively rare. If a child presents with polyps, consider the possibility of cystic fibrosis or neoplasia. Rhinitis, epistaxis and nasal foreign bodies are common.

Abnormal causes

• Adenoid hypertrophy causing postnasal space obstruction

• Foreign body in nose—usually unilateral discharge

• Allergic rhinitis

• Unilateral choanal atresia

• Sinusitis (possible but rare)

• Tumour (also rare—consider fibroangioma)

Diagnosis may be enhanced by spraying with a vasoconstricting agent and getting the child to blow the nose. A tumour, foreign body or polyp may become visible.

Choanal atresia

Acute bilateral nasal obstruction may occur in newborns with congenital bilateral choanal atresia. This leads to anterior nasal discharge and to acute respiratory distress. Immediate investigation and relief are essential and a finger in the corner of the mouth can be life-saving as can passing a nasal probe down one nostril and perforating the membrane.

Sinusitis

Although rare, sinusitis can represent a serious emergency. Red flags requiring consideration include a sick child, pyrexia, rapid onset, unilateral and deteriorating airway obstruction.

Blocked nose and snoring

The above causes of nasal blockage may lead to snoring, mouth breathing, reduced sense of smell, dribbling and possibly obstructive sleep apnoea.

Nasal trauma and fractures¹⁰

Areas of concern associated with nasal fractures, which are uncommon, are possible child abuse, open fracture, septal haematoma or abscess and eye or facial changes. If a fracture is undisplaced, the treatment is pain relief, ice compresses and rest. If displaced, refer for closed reduction under general anaesthetic within 1–2 weeks (ideally at 10 days).¹⁰ If associated epistaxis does not settle with pressure, temporary packing may be required.

Epistaxis

Epistaxis is usually intermittent anterior bleeding from Little area and may follow trauma including nose picking. Bleeding often occurs at night due to vascular vasodilatation. At first, try correction with simple measures (see earlier in chapter) such as pinching below the nasal septum for 5 minutes, supplemented by cold packs. Vaseline applied in the nose at night tends to prevent bleeding, while an antibiotic ointment twice daily for 7–10 days may help.

If problematic, refer for an ENT appointment.

Tip: Think of a bleeding disorder or a tumour, e.g. juvenile angiofibroma.

Snoring and obstructive sleep apnoea

Generally, these problems in children are almost always due to adenotonsillar hypertrophy and most cases are relieved by surgery; CPAP is rarely necessary. Sleep studies are performed to confirm clinical features and allay parental concerns. See CHAPTER 71.

The snuffling infant

Snuffling in infants is usually caused by rhinitis due to an intercurrent viral infection. The presence of yellow or green mucus should not usually be a cause for concern.

Treatment

Reassure the parents.

• Paracetamol mixture or drops for significant discomfort.

• Get the parents to perform nasal toilet with a salt solution (1 teaspoon of salt dissolved in some boiled water); using a cotton bud, gently clear out nasal secretions every 2 waking hours.

• Once the nose is clean, saline nose drops or spray (e.g. Narium nasal mist) can be instilled.

• Stronger decongestant preparations are not advised unless the obstruction is causing a significant feeding problem, when they can be used for up to 4–5 days.

Foreign bodies in the nose

The golden rule is ‘a child with unilateral nasal discharge has a foreign body (FB) until proved otherwise’. Such foreign bodies usually consist of beads, pebbles, peas, pieces of rubber, plastic and paper or other small objects handled by the child. A rhinolith may develop in time on the foreign body. In adults, foreign bodies are often rhinoliths, which are sometimes calcium deposits on pieces of gauze or other material that has been used to pack the nose.

Removal of foreign bodies

Removal of FBs from the nose in children is a relatively urgent procedure because of the risks of aspiration. A disc/button battery such as a hearing aid battery in the nose is a medical emergency requiring urgent removal under anaesthetic.¹⁰

The nose should be examined using a nasal speculum under good illumination. The tip of the nose should be raised and pressed with the tip of a thumb. At first, spray a topical decongestant into the nose and see if the child can blow it out after waiting 10 minutes. Do not attempt to remove FBs from the nose by grasping with ‘ordinary forceps’.

1. Spray with decongestant, wait 10 minutes, then ask the child to blow out the FB.

2. It is best to pass an instrument behind the FB and pull or lever it forward.

   Examples of instruments are:

   • a Eustachian catheter

   • a probe to roll out the FB

   • a bent hairpin

   • a bent paperclip

3. Snaring the FB

   This is the appropriate method for soft, irregular FBs such as paper, foam rubber and cotton wool that are clearly visible. Examples of instruments are:

   • a foreign-body remover

   • crocodile forceps

   • fine nasal forceps

4. Glue on a stick

   Apply SuperGlue to the plastic end of a swab stick. Apply it to the FB, wait about 1 minute and then gently extract the FB.

5. Rubber catheter suction technique

   The only equipment required is a straight rubber catheter (large type) and perhaps a suction pump. This method involves cutting the end of the catheter at right angles, smearing the rim of the cut end with petroleum jelly and applying this end to the FB, then providing suction. Oral suction may be applied for a recently placed or ‘clean’ object, but gentle pump suction, if available, is preferred.

6. Irritation of the nose

   Some practitioners sprinkle white pepper into the nose to induce sneezing.

7. The ‘kiss and blow’ technique

   This mouth-to-mouth method is used for a cooperative child with a firm, round foreign body such as a bead impacted in the anterior nares. It is best to supervise the child’s mother to perform the technique, but the practitioner or practice nurse can perform it.

• Use a nasal decongestant spray.

• After 20 minutes lay the child on an examination couch with a pillow under the head.

• Obstruct the normal nostril with a finger from the side.

• Place the mouth over the child’s mouth, blowing into it until a slight resistance is felt (this indicates that the glottis is closed).

• Then blow hard with a high-velocity puff to cause the FB to ‘pop out’.

To encourage cooperation with the technique, the child can be asked to give mother (or other) a ‘kiss’. More than one attempt may be needed, but it is usually very successful and avoids the necessity for a general anaesthetic.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Hay fever

• Nosebleed

• Nose: stuffy, running nose

• Sinusitis