Nose Conditions

Nose conditions treated by Dr Jae Park

What is deviated septum?

The bone and cartilage that divides the inside of the nose in half is called the nasal septum. The bone and cartilage are covered by a special skin called a mucous membrane that has many blood vessels in it.

Ideally, the left and right nasal passageways are equal in size. However, it is estimated that as many as 80 percent of people have a nasal septum that is off-centre. This is called a deviated septum, which may or may not cause certain symptoms.

What Are the Symptoms of a Deviated Septum?

The most common symptom from a badly deviated or crooked septum is difficulty breathing through the nose, which is usually worse on one side. In some cases, a crooked septum can interfere with sinus drainage and cause repeated sinus infections. You may experience one or more of the following:

• Difficulty breathing through one or both nostrils

• Nosebleeds

• Sinus infections

• Noisy breathing during sleep in infants and young children

• Mouth-breathing during sleep in adults

What Causes a Deviated Septum?

Injury or trauma to the nose can cause the septum to become deviated or crooked. However, even people with normal growth and development, and without a history of injury, trauma, or broken nose, can have a deviated septum.

 What Are the Treatment Options?

Discuss your symptoms and any known nose damage or surgeries with an ENT specialist. They will examine your nose inside and out and might recommend additional tests based on your individual needs. When there is clearly a crooked/deviated septum, and the symptoms are severe enough to warrant intervention, the ENT specialist may suggest surgery as an option if medical treatment fails.

Septoplasty is the preferred surgical treatment to correct a deviated septum. This procedure is typically not performed on young children, unless the problem is severe, because facial growth and development are still occurring. Septoplasty is a surgical procedure that is usually performed through the nostrils, so there is no bruising or outward sign of surgery; however, each case is different and special techniques may be required depending on the individual patient.

Are There Related Factors or Conditions?

• Inferior turbinate hypertrophy—turbinates are finger-like structures in your nose that warm and moisten the air you breathe, and sometimes the lower ones can get too big

• Concha bullosa of the middle turbinate—this is when one of the turbinates next to your sinus openings gets a big air bubble in it

• Nasal valve collapse (internal or external)

• Sinusitis (acute, recurrent, chronic)

• Headaches (contact point)

• External nasal deformity (change in the shape of the nose)

• Decreased sense of smell

What is inferior turbinate hypertrophy?

Turbinate hypertrophy refers to an excessive growth or enlargement of the turbinates, which are bony structures located inside the nose. They are covered with a special skin called mucosa, and they help filter, warm, and humidify the air as you breathe. 

The mucosa naturally swells during the normal nasal cycle and when you lie down. They also swell in response to allergens and other stimuli.

The nasal cavity usually contains three sets of turbinates on each side of the nose: the superior turbinates, the middle turbinates, and the inferior turbinates. Most of the airflow in the nose passes between the middle and inferior turbinates. If these turbinates become enlarged, breathing can become more difficult.

What Are the Symptoms of Turbinate Hypertrophy?

The most common symptoms of turbinate hypertrophy include:

• Difficulty breathing

• Congestion in alternating sides of the nose

• Nasal stuffiness

• Nasal blockage

• Nasal congestion while lying down

• Noisy breathing or breathing through the mouth during sleep

• Increased nasal drainage

What Causes Turbinate Hypertrophy?

Turbinate hypertrophy is typically caused when the lining of the skin covering the turbinate bone becomes enlarged and swollen. This can be an acute (one time) or chronic (ongoing) problem, and can be caused by many conditions including:

• Upper respiratory infection, or the common cold

• Acute sinus infection

• Allergic rhinitis

• Non-allergic rhinitis

• Chronic rhinosinusitis

• Medications

• Hormonal changes

Other related factors or conditions that can cause nasal blockage include a deviated septum, nasal valve collapse, and external nasal deformity, or other kind of sinus disease.

What Are the Treatment Options?

Medical therapy—Medications are often suggested to help reduce symptoms. Depending on the specific cause of the turbinate hypertrophy, possible medications include:

• Nasal saline sprays or rinses

• Nasal antihistamine sprays

• Nasal steroid sprays

• Allergy immunotherapy

For an acute case of turbinate hypertrophy, nasal decongestant sprays (such as Oxymetazoline) should only be used for a very brief period. This is not an appropriate treatment for chronic turbinate hypertrophy. Using nasal decongestant sprays for longer than three days can result in additional swelling in the nasal cavity, worsening symptoms, and addiction with prolonged use.

Surgery

If medications do not help improve your symptoms, your ENT specialist may offer a surgical procedure to decrease the size of the turbinates. This procedure is usually performed through the nostrils and does not result in bruising or an outward sign of surgery.

The goal of surgery is to decrease the size of the turbinate to improve airflow through the nose while preserving the function of the turbinate. There are many different types of surgical procedures to reduce the size of the turbinates, and will depend on your specific diagnosis, the severity of the turbinate hypertrophy, and your ENT specialist’s recommendation.

What is Sinusitis?

Sinuses are hollow spaces in the bones around the nose that connect to the nose through small, narrow channels. Sinusitis, also called rhinosinusitis because the symptoms involve both the nose and the sinuses, affects about one in eight adults annually. For many, the inflammation starts when viruses or bacteria infect your sinuses (often during a cold) and begin to multiply. Part of the body’s reaction to the infection causes the sinus lining to swell, blocking the channels that drain the sinuses. This causes mucus and pus to fill up the nose and sinus cavities. For others, the symptoms and inflammation may be the result of the nose and sinuses reacting to other things in the environment, but not be an infection.

Acute vs. Chronic Sinusitis

Because sinusitis simply means inflammation of the sinuses, the word alone includes a variety of similar problems. Acute sinusitis is when the symptoms occur for less than four weeks. A diagnosis of chronic sinusitis requires that the symptoms last longer than 12 weeks. Sometimes these are caused by the same thing, but often chronic and acute sinusitis are very different from each other. Recurrent acute sinusitis is when someone has four or more sinus infections (acute sinusitis) in one year but does not have symptoms in between those infections.

What Are the Symptoms of Sinusitis?

You have acute sinusitis when you have had cloudy or coloured drainage from your nose for up to four weeks, plus one or more of the following symptoms:

• Stuffy, congested, or blocked nose

• Pain, pressure, or fullness in the face, head, or around the eyes

• Long-lasting cold symptoms

• Symptoms that do not improve within 10 days of getting sick, or initially get better then worsen again

You might have chronic sinusitis if you have at least two of the four symptoms note below for at least 12 weeks. An ENT specialist would also need to see polyps, pus, or thickened mucous in nose, or get a CT scan, to fully diagnose chronic sinusitis. Possible symptoms include:

• Stuff congested, or blocked nose

• Pain, pressure or fullness in the face, head or around the eyes

• Thickened nasal drainage

• Loss of smell

What Causes Sinusitis?

Viruses or bacteria usually cause acute sinusitis. Acute viral sinusitis is likely if you have been sick for less than 10 days and are not getting worse. Acute bacterial sinusitis is when you do not improve at all within 10 days of getting sick, or when you get worse within 10 days after beginning to get better.

Chronic sinusitis, however, is usually caused by prolonged inflammation, instead of a long infection. Infection can be a part of chronic sinusitis, especially when it worsens from time to time, but is not usually the main cause. The exact cause cannot always be determined; for some reason the nose and sinuses are overreacting to what they think is an infection.

Are There Any Related Conditions or Complications?

Migraine headaches or tension headaches can cause symptoms of sinus pain or pressure. If you have sinus headaches without discoloured drainage, talk to your primary care provider, or an ENT specialist, about the possibility of migraine headaches causing sinus pain or pressure and medications options for migraine treatment. Sometimes inflammation of the nasal cavity can also cause drainage and nasal congestion, but not involve your sinuses. 

What Are the Treatment Options?

Sinusitis is treated differently based on the cause. Most cases of acute sinusitis, about 98 percent, are caused by a virus, not bacteria, and should not be treated with antibiotics. Acute viral sinusitis may be treated using pain relievers such as acetaminophen or ibuprofen, steroid nasal sprays, or salt water irrigation in the nose. These treatments are also good options for acute bacterial sinusitis. Most people get better naturally from acute bacterial sinusitis, called “watchful waiting,” but some patients with acute bacterial sinusitis may get better faster with an antibiotic.

Chronic sinusitis is treated differently than acute sinusitis. Because chronic sinusitis is caused more by inflammation than infection, the treatments for chronic sinusitis aim to control the inflammation. Salt water nasal irrigation and/or nasal steroid sprays are the main treatments for the symptoms of chronic sinusitis. Antibiotics may sometimes be helpful but not always.

Other factors, including allergies, nasal polyps, asthma, and problems with the body’s ability to fight infections, can go along with sinusitis and make it worse unless they are also treated.

Surgery

Surgery is not recommended for acute sinusitis except in rare circumstances. Sometimes the sinus infection can spread to the eye, face, or brain; this would be considered an emergency, and surgery may be needed to reverse the infection and keep it from spreading.

For chronic sinusitis, surgery is an option when the symptoms cannot be controlled with medications and other treatments. The most common type of surgery for the sinuses is called endoscopic sinus surgery; a pencil-sized scope (endoscope) is used to see inside the nose and sinuses and guide the surgery. The surgery widens the natural drainage pathways between the sinuses and the nose, allowing mucus to get out of the sinuses and air to get in. Medications that are delivered into the nose and sinuses, like sprays and irrigations, can also get into the sinuses better after surgery.

What is rhinitis?

Rhinitis is a condition that typically involves nasal obstruction or congestion, runny nose or post-nasal drip, itchy nose, and/or sneezing.

There are various causes for these symptoms, although they are broadly divided into two types: allergic rhinitis (nasal symptoms related to allergy) and non-allergic rhinitis (nasal symptoms that are not related to allergy).

What Are the Symptoms of Rhinitis?

Symptoms of rhinitis may include:

• Nasal blockage or congestion

• Sneezing

• Runny nose or postnasal drainage

• Itchy nose

Rhinitis may occur before a case of sinusitis or with sinusitis, a condition where infection or inflammation affects the sinuses. If you have facial pressure, decreased sense of smell, or a greenish-yellow nasal drainage, you may also have sinusitis.

What Causes Rhinitis?

Allergic rhinitis, also known as hay fever, occurs when your body’s immune system over-responds to specific, non-infectious particles such as plant pollens, molds, dust mites, animal proteins, chemicals, foods, medicines, insect venom, and other triggers. During an allergic attack, a special antibody (fighting protein), called IgE, attaches to cells that release histamine and other chemicals in the lungs, skin, and the mucous linings of the body. These chemicals open the blood vessels and produce skin redness and swollen membranes. When this happens in the nose, sneezing, itching, runny nose, and congestion occur.

Seasonal allergic rhinitis depends on specific plants that are pollenating at that time. In the United States, springtime allergic rhinitis is typically due to pollinating trees. Early summer allergic rhinitis is often due to grass pollination, and allergic rhinitis in the fall is usually due to weeds pollinating. Hypersensitivity to ragweed is very common in autumn. Also in the fall, you may experience allergic symptoms from mould spores on falling leaves.

Perennial allergic rhinitis can be felt year-round and can result from sensitivity to animal proteins, mould, houseplants, and dust mites in carpeting and upholstery. When seeking a medical evaluation for suspected allergic rhinitis, it is important to be aware of the pattern of symptoms (seasonal triggers, indoor vs. outdoor, specific triggers, animal exposure, etc.).

Non-allergic rhinitis and vasomotor rhinitis (a type of non-allergic rhinitis) do not depend on the presence of IgE antibodies and is not due to an allergic reaction. You can have non-allergic rhinitis even if you test positive for allergies. Some of the causes of non-allergic rhinitis include:

• Certain infections

• Certain medications (various over the counter and prescription preparations)

• Eating and drinking (sometimes specific foods, sometimes all food/drink consumption)

• Weather or temperature changes

• Hormonal changes or pregnancy

• Consumption of alcohol, especially red wine

• Inflammation or irritation in the nose unrelated to allergy

Are There Related Factors and Conditions?

Depending on the type of rhinitis, certain conditions may be associated, such as:

• Asthma

• Acute sinusitis

• Inflammation of the eye (conjunctivitis)

• Atopic dermatitis or eczema

• Poor ventilation of the ears (or eustachian tube dysfunction)

• Laryngitis (inflammation causing hoarseness of voice)

• Eosinophilic esophagitis

• Sleep disturbance

What Are the Treatment Options?

Treating rhinitis depends on the specific cause or diagnosis. If there is a specific trigger that can be avoided, this may be a successful treatment. For example, in people with cat allergy, avoidance of cat exposure and direct contact with cats may help to control symptoms.

Often, medications are used to control symptoms. Depending on the specific cause of the rhinitis symptoms, some of the medications that may be used include:

• Intranasal saline spray or rinse

• Antihistamines (oral or intranasal)

• Corticosteroids (usually applied as an intranasal spray)

• Ipratropium bromide intranasal spray

For allergic rhinitis, allergen immunotherapy may be an option. This is most commonly provided via allergy shots or tablets or liquid drops taken under the tongue. Again, a qualified ENT specialist or allergist should assess your situation to determine whether allergen immunotherapy is an option.

For severe runny nose or nasal obstruction/congestion that does not respond to medications, your ENT specialist may consider additional procedures or surgery appropriate to your situation.

What is epistaxis?

Nosebleeds (called epistaxis) are caused when tiny blood vessels in the nose break. Nosebleeds are very common and affect many people at some point in their lives.

In Australia, about 60 percent of people will experience a nosebleed in their lifetime. They can happen at any age but are most common in children around the ages of two to 10, and adults around the ages of 50 to 80.

What Are the Symptoms of a Nosebleed?

There are two categories of nosebleeds. Anterior nosebleeds occur when the bleeding is coming from the front of the nose and posterior nosebleeds occur when the bleeding originates from further back in the nose, often where the source of bleeding cannot be seen without examination. Common symptoms can include:

• Anterior nosebleeds begin with a flow of blood out one or both nostrils

• Posterior nosebleeds can begin further back in the nose and may flow down the throat

What Causes a Nosebleed?

Most nosebleeds are in the front part of the nose and start on the nasal septum, the wall that separates the two sides of the nose. The septum contains blood vessels that can be easily damaged. Irritation from blowing the nose or scraping with the edge of a sharp fingernail is enough to tear the vessels and cause a nosebleed. Anterior nosebleeds are also common in dry climates, or during winter months when dry, heated indoor air dehydrates the nasal membranes and makes the blood vessels more likely to rupture.

Causes of recurring or frequent nosebleeds may include:

• Allergies, infections, or dryness that cause itching and lead to picking the nose

• Vigorous nose blowing that ruptures superficial blood vessels

• Problems with bleeding caused by genetic or inherited clotting disorders (e.g., hemophilia or Von Willebrand’s disease)

• Medications that prevent blood clotting (e.g., anticoagulants like coumadin/warfarin, XARELTO®, or anti-inflammatory drugs like ibuprofen or aspirin)

• Fractures of the nose or the base of the skull (a nosebleed occurring after a head injury should raise suspicion of serious concern)

• Hereditary hemorrhagic telangiectasia, a disorder involving birthmark-like blood vessel growths inside the nose

• Tumors, both malignant (cancerous) and nonmalignant (benign), must be considered, particularly in older patients or smokers

What Are the Treatment Options?

It is important to try to determine if the nosebleed is anterior or posterior. Posterior nosebleeds are often more severe and almost always require a physician’s care.

Anterior nosebleeds

When dry air is believed to be the cause of the nosebleed, it may result in crusting, cracking, and bleeding. This can be prevented by placing a light coating of saline gel, petroleum jelly, or an antibiotic ointment on the end of a Q-tip and gently applying it inside the nose, especially on the middle portion of the nose (the septum).

Follow these steps to stop an anterior nosebleed:

1. Stay calm, or help a young child stay calm. A person who is agitated may bleed more profusely than someone who feels reassured and supported.

2. Sit up and keep the head higher than the level of the heart.

3. Lean forward slightly so the blood doesn’t drain into the back of the throat.

4. Gently blow any clotted blood out of the nose. Spray the nose with a nasal decongestant; oxymetazoline is the active ingredient in most over-the-counter sprays.

5. Using the thumb and index finger, pinch all the soft parts of the nose.

6. Hold the position for five minutes. If it’s still bleeding, hold it again for an additional 10 minutes.

Should the bleeding continue after this, you should seek medical care. Treatment administered by a medical professional at this point may include cautery (a technique in which the blood vessel is burned with an electric current, silver nitrate, or a laser to stop the blood flow) or nasal packing.

Posterior nosebleeds

More rarely, a nosebleed can begin high and deep within the nose and flow down the back of the mouth and throat, whether the patient is sitting or standing. Posterior nose bleeds differ from anterior nose bleeds because direct pressure on the outside of the nose will not stop the bleeding, and spraying the nose with a decongestant is less likely to work. It is important to seek prompt medical care if the bleeding does not stop to prevent heavy blood loss.

Posterior nosebleeds are more likely to occur in older people and people with previous nasal or sinus surgery or injury to the nose or face. Generally, treatment includes cautery and/or packing the nose. The nose may be packed with a special gauze, sponge, or an inflatable balloon to put pressure on the blood vessel; most of these need to be removed in two to three days. Sometimes the packing is an absorbable material and does not need to be removed. You should ask your provider what type of packing they used and if it will need to be removed by a professional.

Frequent nosebleeds

If frequent nosebleeds are a problem, it is important to consult an ENT specialist, who will carefully examine the nose using an endoscope to see inside the nose before making a treatment recommendation.