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Vincent’s S.C.A.N.S 
Ear, Nose and Throat (ENT), Head and Neck Surgery
Specialist Clinic
“DOCTOR,  I CAN’T BREATHE THROUGH MY NOSE !” Nose   block   or   obstruction   remains   one   of   the   commonest   symptoms   that   brings   the   patient   to   a   general   practitioner   (GP)   or   ear,   nose   and   throat   (ENT) surgeon.      It   refers   to   the   subjective   sensation   of   reduced   airflow   through   the   nose,   either   one-sided   or   in   both   nostrils.   It   can   be   a   troublesome   symptom affecting   both   the   children   and   adults.   However   in   a   child   who   may   not   complain,   the   parents   may   notice   the   child   frequently   breathing   through   the mouth or snoring during sleep. The nasal blockage may only be of a recent onset or has been persistent for some time. A   “nasal   cycle”   is   a   normal   (known   as   “physiological”   in   medical   terminology)   phenomenon   where   each   nostril   alternate   with   the   other   to   undergo cyclical congestion and shrinkage. Each cycle lasts between one to four hours. While it is hardly noticeable at rest in a normal person, common factors below can aggravate the nasal obstruction (of which many, fortunately, are treatable): Allergies (allergic rhinitis) Nasal infection (acute and chronic rhinosinusitis) Structural deformity (eg. deviated nasal septum, enlarged turbinates) Adenoids Nasal polyps, tumours and cancers in the nose Foreign body in the nose Medication (eg. high blood pressure pills, abuse of nasal decongestant spray) Some of these conditions may coexist worsening the nasal blockage. Allergic rhinitis (AR) The   incidence   of   allergy   in   the   modern   communities   is   increasing   steadily   indeed.   Allergy   is   a   general   phenomenon   encompassing   many   forms including asthma, skin allergy  (eczema, urticaria), food allergy, and nose allergies. While   many   of   us   may   have   heard   about   asthma,   the   nasal   counterpart   known   as   Allergic   Rhinitis ’   (AR),   is   less   commonly   known   as   such.   In   fact, many   of   the   so-called   ‘sinusitis’   are   actually   AR   from   the   medical   perspective.      AR   is   the   inflammation   of   the   inner   lining   (‘mucosa’)   of   the   nose   that occurs   when   an   allergic   individual   encounters   an   airborne   ‘allergen’   (triggers   of   allergy)   such   as   dust   mites,   pollen,   mold,   or   animal   dander   like   dogs and   cats.   In   our   tropical   region   with   the   hot   and   humid   climate,   the   house   dust   mites   are   the   commonest   culprit.   Usually   inhaled,   these   triggers generate   allergy   symptoms   such   as   sneezing,   coughing,   runny   nose,   sore   throat   and   itchy   or   watery   eyes,   phlegm   dripping   into   the   throat   (postnasal drip), chronic cough and puffy/red itchy eyes. Those   with   positive   family   history   of   allergy   or   other   forms   of   allergy   are   also   more   likely   to   have   AR. Although   AR    can    develop    at    any    age,    it    usually    appears    in    individuals    before    the    age    of    30    years old .   Nasal infection A   nose   block   o    c    c    u    r        lasting      a few    days    as i      n        a    c    u    t    e      sinusitis        or u   p   p   e   r           The         nasal lining       is inflamed    and   leading         to n     o     s     e       block.     There   b              e                accompanying   cough,   runny   nose   with   clear   or   yellowish   discharge   and   fever.   An   acute   infection   would   normally   resolve   and   the   nasal   obstruction disappear   completely.   However,   in   chronic   infection   of   the   nose   (‘chronic   rhinosinusitis’),   these   symptoms   may   persist   or   wax   and   wane   with   periods   of resolution in between. Structural deformities The nasal septum is the midline partition which divides the nose into two halves.  One may be born with a deviated nasal septum (DNS), or may develop after injury to nose. The external nasal bridge may or may not appear normal. In some cases the DNS is severe enough to narrow or block the nasal passage. While some people naturally have large turbinates (shelf-like projection from the side wall of the nose), enlarged turbinates are more commonly found in association with AR. These structural deformities may result in nasal blockage and snoring problems. DNS and enlarged turbinates can be surgically corrected using endoscope (thus no external facial incision and scar) under general anaesthesia with good results. Adenoids Adenoids    are   lymphoid   tissue   in   the   back   space   of   the   nose,   functioning   as   part   of   the   body defence   against   local   infection .    In   a   normal   child,   the   adenoids   generally   shrink   by   about   7   years old.   However,   in   the   presence   of   recurrent   or   persistent   infection,   inflammation,   allergy   of   the nose,   the   adenoids   continue   to   persist   or   even   grow   in   size,   eventually   resulting   in   the   blockage of the nasal airway. In an adult, this has to be differentiated from other tumours. Nasal polyps, tumours and cancers in the nose ‘Tumour’ is a general term indicating a growth which can be cancerous (malignant) or non-cancerous (benign). The   commonest   nose   cancer   in   Malaysia   is   the   nasopharyngeal   carcinoma   (NPC) .    It   is   commonest   among   the   Chinese,   especially   in   those   over   50 year   old,   and   people   of   the   Iban   and   Bidayuh   ethnic   groups   in   Sarawak.   This   is   the   3 rd    commonest   cancer   in   Malaysia   (based   on   the   2006   official Malaysian   cancer   registry)   after   colorectal   (1 st    place)   and   lung   (2 nd    place)   cancers.      It   arises   from   the   back   portion   of   the   nose   called   the   ‘nasopharynx   and   is   silent   in   its   early   stage.   By   the   time   the   patient   complains   of   nose   block,   it   is   usually   of   a   considerable   size.   Other   sinister   symptoms   include   nose bleed,   one-sided   ear   blockage,   neck   swelling   due   to   enlarged   neck   lymph   nodes.   However,   if   detected   and   treated   early,   the   cure   rate   of   this   cancer   is good. On   the   other   hand,   non-cancerous   tumours   and   polyps   in   the   nose   can   also   obstruct   the   nose.   It   can   arise   spontaneously   and   may   be   accompanied   by o     t     h     e     r       symptoms   like runny       nose and       blood- stained discharge. Foreign body in the nose This    condition    usually    occurs    in    the    children. Parents   will   usually   notice   the   one   sided   nasal   obstruction   with   foul-smelling,   pus   discharge from   the   nose.   The   child   may   deny   or   does   not remember   the   exact   incident   when   the   foreign   material   was   inserted.   Among   the   many objects   (from   button   to   tiny   parts   of   their   toys), button    battery    (see    picture)    remains    one    of    the    commonest    item    retrieved.    In    such    a scenario,   immediate   removal   is   warranted   as   it   may   corrode   and   permanently   damage   the   inner   lining   of   the   nose.   In   an   uncooperative   child,   general anaesthesia is needed for the prompt removal. This condition is one of the commonest   ENT EMERGENCY .   At   times,   the   neglected   foreign   material   is   discovered   incidentally   or   the   child   presents   after   many   months   or   years.   A   stone,   ‘rhinolith’   (‘rhino’=nose, ‘lith’ =stones), due to chemical deposition with the foreign body at its core ,  can be found instead ! Medication Nasal   decongestant   sprays   are   easily   available   over-the-counter   medication.   The   active   ingredient,   eg.   oxymetazoline,   provides   an   immediate   relief   of nasal   blockage.   Unfortunately,   this   has   often   resulted   in   unsupervised   or   abuse   of   the   medication   beyond   the   recommended   dosage   and   duration resulting   in   a   medical   condition   called   ‘rhinitis   medicamentosa’ .   While   in   the   beginning,   the   decongestant   was   effective   in   relieving   the   blockage, continuous use has now paradoxically worsened the nasal obstruction. To   reverse   this   condition,   one   has   to   immediately   stop   using   the   medication   and   consult   your   doctor   for   a   proper   diagnosis   of   the   nasal   blockage.   It   is definitely   wiser   to   treat   the   cause   of   the   symptoms   rather   than   the   symptoms   alone!      For   people   with   high   blood   pressure,   the   hypertension   medications can also interfere with the nasal lining causing the patient to experience nasal blockage. YOUR DIAGNOSIS Through   complete   history-taking   and   examination,   your   doctor   will   be   able   to   differentiate   between   these   conditions.   Nowadays,   the   advent   of   fibreoptic
Nase Block    Nasal Obstruction EDUCATION Figure A: Moderately enlarged inferior turbinates (IT). Figure B: Very enlarged middle turbinate (MT) with normal IT.  (S=septum) S IT A B B MT IT S © Vincent Tan ENT Large adenoids: an endoscopic view of a large adenoids protruding from the back space of the nose into the nasal cavity  © Vincent Tan ENT Figure A showing a foreign body in the shape of a button battery in the nose seen on the X-ray. Figure B showing the button battery up close and personal. Figure C showing an endoscopic view of a rhinolith in the nose and Figure D showing the rhinolith up close and personal. A B C D © Vincent Tan ENT ANSWERS : All these are growth or tumours of the nose. Figure A: tumour of the blood vessel (hemangioma) arising just outside the nose and Figure B, hemangioma arising within the nasal cavity. Figure C: ‘common’ inflammatory nasal polyp and Figure D: nasopharyngeal cancer (NPC)- yes ! A real cancer! A B C D All these are growth or tumours of the nose. Guess which are the benign (non-cancerous) and malignant (cancerous) type ? Scroll down to see answers. © Vincent Tan ENT Figure A: ‘Turbinates’ are the 3 shelf-like projection from the sidewall of the nose: ST =superior turbinates,  T= middle turbinate, IT= inferior turbinate  Figure B: CT scan image showing the same turbinates (ST, T, IT) on the left side of the nose. The right side of the nose is filled with polyp (asterisk *), blocking the whole nasal airway on the right. A B right eye left eye IT T ST * © Vincent Tan ENT Acute rhinosinusitis: an endoscopic view of the nose showing yellowish pus draining from one of the sinuses © Vincent Tan ENT CT scan of the nose: Look at how bent the nasal septum is (red line) instead of the normal straight septum (blue line). © Vincent Tan ENT Septal spur is a bony protrusion arising from the nasal septum, the midline partition that divides the nose into the two nostrils. (S=septum; IT=inferior turbinate)  Endoscopic view of the right nostril:  Figure A: The arrow showing a large right nasal septal spur narrowing the right nasal airway, with the volume as occupied by the shaded area in Figure B. Compare it with the nasal airway without the large septal spur in Figure C. A normal nose: Isn’t C a wider breathing space ?  A B C © Vincent Tan ENT IT S IT S IT S
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Last update:  10/1/13 
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D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
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