This is a very common symptom in the adult population. It is often difficult to tolerate for many patients, since they cannot smell, they breathe through their mouth causing excessive dryness and sometimes drooling, and the blocked feeling itself is often highly off-putting, affecting the ability to exercise and function normally. The sinuses may also be affected, with acute chronic sinusitis the result.
The causes of a blocked nose are many. They range from congenital choanal atresia (a boney plate at the back of the nose fails to dissolve during foetal development) to turbinate hypertrophy (see inferior turbinate reduction), nasal polyps (see nasal polypectomy) and a bent nasal septum (see septoplasty).
Treatment usually starts with simple application of steroid or antihistamine sprays, allergy avoidance might be helpful (see house dust mite information sheet). Following this, tablets containing antihistamines or even steroids can be given. Surgery is usually contemplated if the improvement offered by these treatments is not sufficient to cure the patient of his/her symptoms.
Major complications after surgery in this area are very uncommon, where no complications are mentioned, then the risks of surgery simply relate to infection or bleeding, both of which are rare, and usually easy to manage.
- Septoplasty
This procedure refers to “straightening the septum”. The septum is a cartilage wall, which divides the nose into left and right sides. It is relatively thin (less than 2 mm thick), but when it is bent over, it can block breathing through the nose. This can affect the sense of smell and taste, can be generally uncomfortable, and may precipitate snoring. Nose bleeds may also be caused by a bent nasal septum.
Cause
The cause of a bent septum is usually trauma of some sort, although no obvious causative incident may be recalled by the patient.
The operation
Treatment is surgical, the operation being performed as a day case under a light general anaesthetic for the majority of patients. It is standard practice to reduce back the inferior turbinate bones at the same time, since this further improves flow through the nose, and takes only a few minutes. There are no scars on the outside of the nose, and no black eyes. Surgery is performed using special, delicate nasal instruments. Lasers are not usually of value when performing this procedure.
Anaesthesia/Home
On occasion the procedure can be performed under local anaesthetic, although most people prefer general anaesthesia. Surgery time is around 30 minutes or less. On awakening, the nose feels blocked, because 2 small sponge packs are inserted into the nose at the end of the procedure. These packs are removed after 6 hours, some slight bleeding may occur at this stage. Ice packs over the nose might be used to stop the bleeding, if required. Two hours later, patients are allowed home, accompanied by family or friend. Travel home by public transport is not advised.
Postoperative care
Septoplasty and Inferior Turbinate Out Fracture, Sinus Surgery, Polypectomy
This is not generally a laser operation. However, it is sometimes part of the treatment process for snoring surgery, and is therefore an integral part of the Clinic’s work.
The post-operative care is straightforward. You will be prescribed antibiotics (usually Augmentin unless you are allergic to Penicillin), painkillers (Co-proxamol) and decongestant spray (Otrivine). Take the first two regularly from the first post-operative day.
From the 2nd post-operative day (the day of the operation is day 0), start blowing your nose one nostril at a time by gently blocking the other nostril with your knuckle. Do not blow too forcefully at the beginning.
From the 3rd post-operative day use salt water douches (½ tsp table salt dissolved in ½ cup of cooled, boiled water). Firstly, decant a small amount into the palm of your hand then sniff up one nostril at a time, like snuff. Immediately after you have sniffed up the salt water, blow it out as above, repeating until all the salt water has been used. Follow this with a steam inhalation, using Menthol and Eucalyptus, or something similar (place a large bowl of boiling water in front of you with a towel over your head, lean over the bowl and breathe in deeply). After this use Otrivine spray. Repeat this whole process 4 times per day until the nose has decongested – around day 7.
Remember that this is generally not a painful operation. A small amount of post-operative bleeding is possible for 2-3 days post-operatively. Simply dab this away when it happens. If bleeding becomes copious and persistent, contact your surgeon.
The nose will swell up between five and seven days usually and minor bleeding may occur. The nose should definitely be blown after day two, one nostril at a time to get rid of fluid from swelling, etc. There may be some slight swelling of the upper lip and even on occasion some numbness through bruising of the nerves that supply that area.
A thin blue stitch is sewn into the inside of the nose during the operation; it is a self-dissolving stitch, which disappears on its own after around six weeks. Occasionally, the stitch can become loosened and slip down the nose into the nostril. If this is unsightly, it can be snipped off level with the inside of the nose. By the end of the first post-operative week, the stitch is no longer necessary.
Follow up is usually four weeks after surgery.
- Allergic Rhinitis
Allergic rhinitis is a condition that is often inherited and is characterised by nasal blockage and sneezing attacks. Hay fever is an example of allergic rhinitis. Common allergens include grass and tree pollen, house dust mites and animal fur.
The lining of the nose is sensitive in people with allergic rhinitis, and this causes swelling and increase in mucus production.
The swelling in the nose leads to nasal blockages and the excess mucus production leads to sneezing and watery discharge from the nose or eyes, as well as headaches and facial discomfort.
These symptoms can be seasonal or perennial.
One of the first steps in managing allergic rhinitis is to try and identify the allergen or substance causing the allergic reaction.
If a specific allergen is found, then steps to avoid contact with it should be taken.
Topical steroids could be prescribed and with this type of medication the symptoms may take several weeks to clear.
Antihistamines could also be prescribed and these are given in many forms to ease the symptoms of allergic rhinitis. They can be given topically (directly on the affected area) or orally.
To avoid allergic rhinitis you should try to avoid smoky environments, paints and air pollutants, reduce house dust mite by regularly vacuuming and washing furniture and toys can be helpful. Contact with pets such as cats and dogs should be avoided but if you have these as pets then weekly washing and cleaning their bedding does help. You should try to keep windows closed and wear sunglasses outside to give some protection against pollen and also avoid walking in parks in the morning and evenings when the pollen count is high.
- Nasal Polyps
This condition is often very debilitating, since the nose is usually completely blocked, with virtually no sense of smell or taste, a constantly running nose and permanent mouth breathing, with subsequent poor sleep.
Cause
It is often related to asthma, because both conditions are inflammatory allergic reactions, with the area involved, ie: nose or lungs, having the same basic lining cells. Sinusitis is a common adjunctive condition, because polyps fill up the nose sinuses, leading to recurrent infection.
Treatment
As discussed earlier, treatment is usually with a mixture of sprays and tablets in the first instance. Tablets of steroids in short bursts are often very effective, unfortunately it is undesirable to give systemic steroids for longer periods of time. Surgery involves either small operations under local anaesthetic, or longer procedures under general anaesthetic. The latter are designed to open up the sinuses from the inside, using special nasal telescopes and instruments.
Polypectomy under local anaesthetic
Anaesthesia is achieved using the application of local anaesthetic paste or solution, which is inserted into the nose on cotton wool or ribbon. It takes approximately 10 minutes to achieve the desired degree of numbness.
Polyps are removed using forceps. There is usually minimal bleeding, a short term sponge pack may be required – this stays in for around 2 hours. Discharge home occurs soon after this.
Polypectomy under general anaesthetic
This procedure involves removing polyps both from the nose, and the sinuses from where they originate. The sinuses are widely opened during this operation. The extent of surgery depends on the extent of the polyps. Specific risk during this procedure relates to damage to the eye cavity/eye, or entering the skull, damaging the lining around the brain. Both of these complications are probably not as bad as they sound, thankfully they are very rare ( less than 1:1000). Surgery time ranges from 30 – 90 minutes. Sponge packs are inserted into the nose at the end of the operation - these are usually removed after 6 hours. Discharge home is often on the same day as surgery, although occasionally, an overnight stay is required.
Postoperative care – local and general anaesthetic
A course of systemic steroids is usually given both before and after the operation. Blowing the nose after surgery should be avoided for the first 24 hours. After this the nose can be blown gently, and nasal salt water sniffs (eg: Sterimar – bought from the chemist) should be started, being used 4 times per day for 1 week, or longer if required. When using salt water sniffs, it is important to sniff up the salt water, then immediately blow it out into a handkerchief, one or two times per session. Follow up with the surgeon should be around 4 weeks after treatment. At this stage, a nasal steroid spray will be started, this is to be used long term to try to avoid recurrence of the polyps – which is unfortunately relatively common, even after good surgery.
- Laser reduction of the inferior turbinates
Operations Inferior Turbinate Reduction / Blocked Nose
Indications for Inferior Turbinate Reduction or Blocked Nose surgery
Blocked nose symptoms are multi-factorial. The "Nasal Cycle" always means that one side of the nose will be open, the other relatively blocked, from time to time and side to side during the day and night. Allergy, humidity, air temperature, stress etc can all be related to the symptom of blocked nose. Although Inferior Turbinate reduction with the laser is one option in the treatment of nose blockage, the London Laser Clinic surgeons are experienced in other, more common procedures that may be required. In particular, septoplasty (straightening the cartilage inside the nose), polypectomy (removal of nose polyps) and endoscopic sinus surgery (drainage of the sinuses to remove infection and reduce swelling) may all be required. Those patients with nose blockage due to swelling of the lining of the nose over structures called the Inferior Turbinates are the group that might benefit from laser surgery. Those suitable for surgery will usually have tried a variety of drug treatments, including antihistamine tablets, and nose sprays (steroid and anti histamine).
The pre-treatment diagnosis also often involves X-rays of the sinuses, and full endoscopic examination of the nose. What happens?: The procedure works by altering the function of nose breathing receptors, and reducing the size of the turbinates, thus increasing the size of the breathing channel and reducing the ability to sense blockage.
Lasers used
- The scanned Carbon Dioxide laser.
- Under general anaesthetic, the Carbon Dioxide, Holmium-YAG or Diode laser.
Anaesthetic
This operation can be performed under local or general anaesthetic. Local anaesthetic is achieved painlessly by the gentle insertion into the nose of a small amount of local anaesthetic moistened cotton wool for 10 minutes.
Post-op Instructions
Recovery is quick, such that whether under local or general anaesthetic, a day-stay procedure can be performed. Packing of the nose is not usually required. Application of antibiotic cream twice daily is necessary, for 1 week. There is little postoperative pain. A follow up appointment is made between 2 and 4 weeks postoperatively. More than one procedure may be necessary, depending on the severity of the disease. Only one side of the nose is treated at any one time.
Following the operation, your nose will feel slightly numb inside and antibiotic cream will have been applied to the inside walls of the nose. The numbness will wear off after an hour. If your operation was performed under general anaesthetic, at this stage you will feel no pain, talk normally, and will be ready to go home 4 hours after surgery. Breathing through the nose is often immediately improved. Before you leave, your surgeon will perform a postoperative examination and supply you with a prescription for painkillers and antibiotics, although there does not tend to be an uncomfortable recovery from this procedure.
You will be given a tube of antibiotic cream to apply to the inside of the nose, at home, using a cotton bud. This should be performed twice a day, usually on rising, and again in the early evening.
The inside of the nose may crust slightly for the first week, the cream also helps to prevent this. If at all worried by this you should contact your surgeon for advice, any crusting is generally innocuous and resolves over a few days.
Full recovery takes about 10 days, at which time the other side of your nose can be treated if necessary. Inferior Turbinectomy is not usually a painful procedure in the postoperative phase and incidence of bleeding, a possible complication of surgery, is less than 1%. If any bleeding does occur, apply pressure to the front of the nose by squeezing the front of the nose between the thumb and forefinger. An ice pack (or bag of frozen peas) applied to the back of the neck may help, and do not lean forward, simply sit with the head held in an upright position.
After about 10 minutes, if there is no improvement, go to your nearest Accident and Emergency department. Also call your LLC surgeon who will liase with the hospital staff.
You will be required to make an appointment for a follow up examination at around 2 weeks postoperatively.
