Nasal stuffiness is a common, uncomfortable complaint and causes mouth breathing, dry mouth and may lead to sleep disturbances.
The stuffiness may be caused by allergic or non-allergic inflammation of the nasal mucosa, infection of the sinuses or nasopharynx or an obstruction of mechanical nature associated with the external nose or the nasal septal structures. Nasal stuffiness is not a diagnosis as such and its cause should be identified.
Function of the nose
The nose acts as a filter and heat exchanger. Air travels through the nose in narrow 2-4 mm diameter channels, which warm, moisten and filter the respired air. About 20 000 litres of inspired air flows through the nose in 24 hours.
The nose protects itself against the drying effect of the airflow by continuously adapting the nasal conchae to fit the situation and by secreting mucus, which will eventually travel to the pharynx.
The nasal conchae shrink (become decongested) during exercise and can be artificially opened, for example, by dilating drops.
Fully opened nasal passages may initially give a pleasing sensation, but this is a non-physiological state and exerts a burden on the mucous membranes.
Reduced sense of smell and taste indicates mucosal oedema in the air passages of the upper parts of the nasal meatuses.
The left and right side of the nasal cavity take turns in breathing in about 3-hour cycles, whereby the side that is more congested is recovering from the strain caused by the airflow. In lateral (side) position, the lower side adjusts to be more congested. Oronasal breathing is common during sleep. Elevating the head side reduces congestion in the conchae.
Examination
The nasal cavity can usually be properly viewed only after the conchae have been shrunk (decongestion). The nasopharynx can be examined with a small mirror (posterior rhinoscopy) or endoscope.
Cotton wool pledgets (supplied with strings) are soaked in a solution of 4% lidocaine, and 4 drops of adrenaline (1 mg/ml) are added in each pledget. The pledgets are then inserted into the nasal cavity for a few minutes.
The nasal cavity can also be decongested by wiping the mucous membranes of the conchae with cotton-tipped swabs that have been soaked in adrenaline (1 mg/ml).
It is also possible to use decongestant nasal sprays.
Inflammation or vasomotor rhinitis
Allergies
Symptoms include itchy and watery eyes and sneezing.
The most common causative agents are pollen and animals.
Diagnosis is based on a careful history and allergen-specific IgE antibodies or skin-prick tests. The possibility of an occupational disease must be considered in, for example, bakery workers and farmers (e.g. wheat flour, cow), and appropriate measures regarding work-related insurances taken, as necessary.
In problematic cases the patient should be referred to a specialist: for example, for the more accurate diagnosis of a work-related allergy, allergen immunotherapy.
Eosinophilic non-allergic rhinitis and chronic sinusitis
Symptoms include a stuffy nose and mucus in the pharynx.
Tests will not show a specific allergy. May be associated with asthma or ASA intolerance.
The patient often has nasal polyps, mucosal oedema in the paranasal sinuses and nasal meatuses and, as a consequence, an impaired sense of smell.
The treatment consists of a long course of topical glucocorticoids together with appropriate instructions and monitoring, so that the mucosa in the anterior part of the nose does not suffer too much of the drying effect of the treatment.
Polypectomy if indicated and, in some cases, more extensive paranasal sinus surgery (often navigator-assisted)
Vasomotor rhinitis
A regulatory disturbance within the nose where the patient reacts too strongly to, for example, changes in the ambient temperature, odours or dust, which leads to nasal congestion or watery nasal drainage.
Findings include swollen, often bluish (livid) nasal conchae; the mucous membranes look healthy.
The sense of smell is good (may even be ”too good"). May be associated with a condition termed odour hypersensitivity (MCS, multiple chemical sensitivity), for which no diagnostic criteria have been substantiated.
Irritant rhinitis, chronic mucosal irritation
Possible causes
Impurities of the air, e.g. industrial dust containing metallic particles
Dryness of the mucosa in the anterior part of the nose, caused by a too high maintenance dose of a topical glucocorticoid, with nose bleeding and even septal perforation as complications
Drying and crusting of mucosa, caused by septal perforation, often with bloody crusts.
Smoking
Constant use of decongestants
Too wide nasal cavities (so-called empty nose) resulting from surgery
Systemic diseases, dehydration
Sequela of radiotherapy
Infections
Chronic sinusitis
Symptoms include purulent discharge into the pharynx or when blowing the nose, a feeling of pressure or pain at the area of the affected sinus and an impaired sense of smell.
Diagnosis is based on radiological imaging (plain x-rays or CT scanning).
In unilateral chronic sinusitis, a specific aetiology (e.g. of dental origin) should be considered.
Purulent lymphatic tissue or adenoids in the nasopharynx
In granulomatosis with polyangiitis, the presence of serum antineutrophil cytoplasmic antibodies (ANCA) should be determined and a mucous membrane biopsy taken, and in ozaena and mucositis, a bacterial culture of the purulent nasal discharge is indicated. A bacterial culture or a biopsy can be taken from purulent nasopharyngeal tissue, or the infected adenoid can be removed (sent for pathological examination).
A painful ulcer/scar evident on the skin inside the nostril, bacterial infection
Treatment consists of cutting off the hairs in order to expose the lesion, the patient is asked not to touch the area, an antibmicrobial(/corticosteroid) cream; a biopsy if indicated.
Mechanical occlusion
Also a nasopharyngeal examination should be performed. The cause of unilateral stuffiness should always be determined.
Nasal septal deviation
The most obstructive deviations usually occur in the anterior third of the septum; malposition of the external nose may also be present. The deviation may be the result of trauma or it may have developed during the person's growth.
The nose is examined before and after decongestion: is the septum in contact with the lateral wall? Acoustic rhinometry or rhinomanometry is used to measure nasal airflow to assist surgery planning.
Septal surgery is a common day case procedure.
Enlarged adenoids
A significant cause of nasal stuffiness and mouth breathing in children (and adolescents)
A mouth breathing child should be referred to an ear specialist.
If necessary, adenoids can be visualised with a mirror examination (posterior rhinoscopy) or nasal endoscopy.
Adenoidectomy is a simple day case surgery carried out under general anaesthesia.
Nasal polyps
Swellings of mucous membranes induced by mucosal oedema, which prolapse into the nasal meatuses.
They usually arise from ethmoidal cells or from their vicinity.
Symptoms include a blocked, stuffy nose, impaired sense of smell and mucus in the pharynx.
Anterior rhinoscopy after decongestion is a diagnostic investigation; nasal endoscopy if indicated. A biopsy should be taken particularly if the polyps are unilateral (an inverted papilloma or another tumour may resemble a polyp).
In cases of ASA triad (polyps, asthma, ASA intolerance), in particular, the condition is likely to recur.
Treated like eosinophilic non-allergic rhinitis (see above).
The cartilaginous vault of the nose or the nostril openings collapse during inspiration.
Diagnosis: examination by a specialist well familiar in rhinology. Nasal strips (Breathe Right® , 3M® ) and nasal dilators (Nozovent® ) are beneficial.
Treatment consists of a surgical repair. Surgery requires rhinologic expertise.
Nasal or nasopharyngeal tumour
Symptoms include unilateral stuffiness, sometimes bloody discharge, possibly signs suggestive of an infection and sometimes swelling of a cheek.
Clogging of the ear and, possibly, fluid retention in the middle ear if a nasopharyngeal tumour or inflammation disturbs the function of the Eustachian tube.
May be benign (e.g. inverted papilloma, juvenile angiofibroma) or malignant (e.g. esthesioneuroblastoma, adenocarcinoma, lymphoma or carcinoma of the nasopharynx)