Nasal Disorders.

Nasal obstruction, rhinorrhea, and epistaxis are common presenting concerns in primary care clinics. Nasal disorders affect the quality of life for many children and families. Rarely, these complaints may represent a life-threatening condition among infant obligate nasal breathers or cases of unusual pathology. The most common causes of rhinorrhea and nasal obstruction vary by age and include physiologic, infectious, allergic, foreign body, irritant, and traumatic causes. Less commonly, children may have congenital malformations, sinonasal masses, or autoimmune disease. The most common causes of epistaxis are inflammatory, environmental, and traumatic causes and medication misuse, but rarely, children may have predisposing anatomic, hematologic, or vascular abnormalities or even sinonasal tumors. In this article, we provide a thorough review of the common nasal disorders treated every day in primary care clinics and mention briefly some of the rare but serious cases that may be overlooked without considering a full differential diagnosis.

Management of Mechanical Nasal Obstruction Isolated or Associated to Upper Airway Inflammatory Diseases in Real Life: Use of both Subjective and Objective Criteria.

PURPOSE OF REVIEW: Mechanical nasal obstruction (MNO) is a prevalent condition with a high impact on patient's quality-of-life (QoL) and socio-economic burden. The aim of this study was to determine the usefulness of both subjective and objective criteria in the appropriate management of MNO, either alone or associated to upper airway inflammatory diseases such as allergic rhinitis (AR) or chronic rhinosinusitis with nasal polyps (CRSwNP). RECENT FINDINGS: A long debate persists about the usefulness of subjective and objective methods for making decisions on the management of patients with nasal obstruction. Establishing standards and ranges of symptom scales and questionnaires is essential to measure the success of an intervention and its impact on QoL. To our knowledge this is the first real-life study to describe the management of MNO using both subjective and objective criteria in MNO isolated or associated to upper airway inflammatory diseases (AR or CRSwNP). Medical treatment (intranasal corticosteroids) has a minor but significant improvement in MNO subjective outcomes (NO, NOSE, and CQ7) with no changes in loss of smell and objective outcomes. After surgery, all MNO patients reported a significant improvement in both subjective and objective outcomes, this improvement being higher in CRSwNP. We concluded that in daily clinical practice, the therapeutic recommendation for MNO should be based on both subjective and objective outcomes, nasal corrective surgery being the treatment of choice in MNO, either isolated or associated to upper airway inflammatory diseases, AR or CRSwNP.

Does rapid maxillary expansion improve nasal airway obstruction? A computer fluid dynamics study in patients with nasal mucosa hypertrophy and obstructive adenoids.

INTRODUCTION: Rapid maxillary expansion (RME) expands the maxillary dentition laterally and improves nasal airway obstruction. However, the incidence of nasal airway obstruction improvement after RME is approximately 60%. This study aimed to clarify the beneficial effects of RME on nasal airway obstruction in specific pathologic nasal airway diseases (nasal mucosa hypertrophy and obstructive adenoids) using computer fluid dynamics. METHODS: Sixty subjects (21 boys; mean age 9.1 years) were divided into 3 groups according to their nasal airway condition (control, nasal mucosa hypertrophy, and obstructive adenoids), and those requiring RME had cone-beam computed tomography images taken before and after RME. These data were used to evaluate the nasal airway ventilation condition (pressure) using computer fluid dynamics and measure the cross-sectional area of the nasal airway. RESULTS: The cross-sectional area of the nasal airway significantly increased after RME in all 3 groups. The pressures in the control and nasal mucosa groups significantly reduced after RME but did not change significantly in the adenoid group. The incidence of improvement in nasal airway obstruction in the control, nasal mucosa, and adenoid groups was 90.0%, 31.6%, and 23.1%, respectively. CONCLUSIONS: The incidence of improvement in nasal airway obstruction after RME depends on the nasal airway condition (nasal mucosa hypertrophy and obstructive adenoids). In patients with nonpathologic nasal airway conditions, the obstruction may be sufficiently improved with RME. Furthermore, to some extent, RME may be effective in treating nasal mucosa hypertrophy. However, because of obstructive adenoids, RME was ineffective in patients with nasal airway obstruction.

Impact of antiallergy agents on CPAP therapy and sleep quality with spring pollinosis in Japanese.

PURPOSE: Allergic rhinitis (AR) is associated with obstructive sleep apnea (OSA) and nasal obstruction causes decreased adherence to continuous positive airway pressure (CPAP). The purpose is to evaluate the effects of antiallergic agents on CPAP adherence and sleep quality. METHODS: A longitudinal study was made of patients who use CPAP for OSA and treated with antiallergy agents for spring pollinosis. We compared the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), nasal symptoms scores (NSS), and data from CPAP before and after treatment. Then, we classified the subjects into two groups based on the baseline PSQI score: one group without a decreased sleep quality (PSQI < 6) and the other group with decreased sleep quality (PSQI ≥ 6). RESULTS: Of 28 subjects enrolled, 13 had good sleep quality and 15 had poor sleep quality. PSQI showed significant improvements after medication (p = 0.046). ESS showed no significant differences after AR medication (p = 0.565). Significant improvement was observed after the prescription of antiallergy agents in all items of NSS (sneezing, p < 0.05; rhinorrhea, p < 0.01; nasal obstruction, p < 0.01; QOL, p < 0.01). The percentage of days with CPAP use more than 4 h increased significantly after the administration of rhinitis medication (p = 0.022). In the intragroup comparisons of PSQI ≥ 6 group, PSQI decreased significantly (p < 0.05). For the NSS in intragroup comparisons of PSQI ≥ 6 group, all parameters showed significant improvement (sneezing, p = 0.016; rhinorrhea, p = 0.005; nasal obstruction, p < 0.005; QOL, p < 0.005). CONCLUSION: The use of antiallergy agents can improve CPAP adherence and sleep quality in patients with OSA on CPAP.

A Randomized Controlled Trial on Facial Muscle Therapy in Nasal Obstruction.

Background: Muscular exercises of the lateral nasal wall have been described as a potential treatment of nasal valve obstruction. The objective of this study was to compare whether nasal exercises improve nasal obstruction, using a randomized controlled model. Methods: Participants were randomized into groups performing exercises targeting nasal (group A) or facial (group B) muscles. Nasal obstruction was measured using a validated standardized patient-reported outcome measure (PROM) questionnaire (Standardized Cosmesis and Health Nasal Outcomes Survey [SCHNOS]) at enrolment and at the end of the 8 weeks program. Results: Fifty-six patients completed the study. Upon completion of the programs, a three-point SCHNOC-C score improvement (95% [confidence interval, CI] = [-9 to 2]) was seen in Group A, whereas an eight-point score improvement (95% [CI] = [-15 to -0.4]) was observed in Group B. A seven-point SCHNOS-O score difference (95% [CI] = [-13 to -1]) was observed in Group A, whereas a difference of 15 points was seen in Group B (95% [CI] = [-22 to -8]). No significant difference was found between group A and B (p = 0.373 and p = 0.065, respectively). Conclusion: This randomized controlled trial suggested that nasal muscle exercises show no improvement on nasal obstruction.

Impact of Treatment for Nasal Cavity Disorders on Sleep Quality: Systematic Review and Meta-analysis.

OBJECTIVE: To determine the impact of treatment for patients with nasal obstruction secondary to allergic rhinitis (AR) and nasal septal deviation (NSD) on sleep quality. DATA SOURCES: Primary studies were identified though PubMed, Scopus, Cochrane Library, and Web of Science. REVIEW METHODS: A systematic review was performed by querying databases for articles published through August 2020. Studies were included that reported on objective sleep parameters (apnea-hypopnea index) and sinonasal and sleep-specific patient-reported outcome measures: Rhinoconjunctivitis Quality of Life Questionnaire, Nasal Obstruction Symptom Evaluation, Epworth Sleepiness Scale (EpSS), and Pittsburgh Sleep Quality Index (PSQI). RESULTS: The database search yielded 1414 unique articles, of which 28 AR and 7 NSD studies were utilized for meta-analysis. A total of 9037 patients (8515 with AR, 522 with NSD) were identified with a mean age of 35.0 years (35.3 for AR, 34.0 for NSD). Treatment for AR and NSD significantly improved subjective sleep quality. For AR, the EpSS mean difference was -1.5 (95% CI, -2.4 to -0.5; P = .002) and for the PSQI, -1.7 (95% CI, -2.1 to -1.2; P < .00001). For NSD, the EpSS mean difference was -3.2 (95% CI, -4.2 to -2.2; P < .00001) and for the PSQI, -3.4 (95% CI, -6.1 to -0.6; P = .02). CONCLUSION: Subjective sleep quality significantly improved following treatment for AR and NSD. There were insufficient data to demonstrate that objective metrics of sleep quality similarly improved.

Balloon dilation and rapid maxillary expansion: a novel combination treatment for congenital nasal pyriform aperture stenosis in an infant.

BACKGROUND: Congenital nasal pyriform aperture stenosis (CNPAS) is a rare condition that may occur alone or as part of a multi-formative syndrome. Management remains difficult. There is no specific treatment protocol. Traditional surgery would be anachronistic; a non-invasive or minimally invasive therapeutic option is required. However, the rarity of the disease and the infantile context render randomised clinical trials difficult. CASE PRESENTATION: We present the case of a one-month-old Caucasian boy with CNPAS. He presented to the Emergency Department of the Bambino Gesù Pediatric Hospital with nasal obstruction, noisy breathing, feeding difficulties, and suspected sleep apnoea. During hospitalisation, he underwent overnight pulse oximetry, airway endoscopy, and maxillofacial computed tomography (CT); the final diagnosis was CNPAS with moderate obstructive sleep apnoea syndrome. We successfully treated the patient using an innovative strategy that involved collaboration between ear-nose-and-throat surgeons and orthodontists. CONCLUSIONS: A combination of minimally invasive balloon surgery and placement of a palatal device may successfully treat CNPAS; it may also treat other types of nasal bone stenosis. Future studies may allow the development of practice consensus treatment strategies.

Diagnosis and management of nasal obstruction in the athlete. A narrative review by subgroup B of the IOC Consensus Group on "Acute Respiratory Illness in the Athlete".

Protection of the health of the athlete is required for high level sporting performance. Acute respiratory illness is the leading cause of illness and can compromise training and competition in athletes. To date the focus on respiratory health in athletes has largely been on acute upper respiratory infections and asthma/exercise induced bronchoconstriction (EIB), while nasal conditions have received less attention. The nose has several important physiological functions for the athlete. Nasal conditions causing obstruction to airflow can compromise respiratory health in the athlete, negatively affect quality of life and sleep, cause mouth breathing and ultimately leading to inadequate recovery and reduced exercise performance. Nasal obstruction can be broadly classified as structural (static or dynamic) or mucosal. Mucosal inflammation in the nose (rhinitis) is the most frequent cause of nasal obstruction and is reported to be higher in athletes (21-74%) than in the general population (20-25%). This narrative review provides the sport and exercise medicine physician with a clinical approach to the diagnosis and management of common nasal conditions that can cause nasal obstruction, ultimately leading to improved athlete health and better sports performance.

Platelet-Rich Plasma Injection in Patients with Atrophic Rhinitis.

OBJECTIVE: To investigate the effect of platelet-rich plasma (PRP) injection in patients with atrophic rhinitis. METHODS: Prepared PRP was injected into the inferior turbinate bilaterally, and nasal bacterial cultures were conducted. Improvement of symptoms was assessed with the Nasal Obstruction Symptom Evaluation (NOSE) and the Sino-Nasal Outcome Test-22 (SNOT-22). Nasal mucociliary clearance was assessed using the saccharin transit time (STT). RESULTS: In the PRP-injected group (group A), NOSE (throughout the study) and SNOT-22 (1 month after injection) scores were significantly decreased during the study. However, the saline spray group (group B) showed no significant nasal symptom improvement during the study period. In group A, the STT was improved until 3 months after the injection. In contrast, group B showed STT improvement after 2 months that was maintained throughout the study. CONCLUSION: PRP injections can improve nasal symptoms and nasal mucociliary function in patients with atrophic rhinitis.

Spontaneous Abscess of the Posterior Nasal Septum: An Unusual Cause of Nasal Obstruction in Children.

INTRODUCTION: Nasal septal abscess is a rare disorder in pediatric patients and is mostly diagnosed as a complication of trauma or secondary to dental or sinonasal infection. CASE PRESENTATION: A 10-year-old girl presented with acute nasal obstruction, otalgia, and headache. Medical history was negative; physical examination and anterior rhinoscopy did not reveal signs of acute rhinosinusitis or septal abscess. MANAGEMENT AND OUTCOME: A thorough nasal endoscopy was performed to rule out a posterior nasal infection, revealing a bilateral posterior septal bulging, in the absence of purulent discharge. CT scan and contrast-enhanced MRI were performed, confirming the diagnosis of a spontaneous posterior septal abscess. Trans-nasal endoscopic-assisted drainage was conducted under general anesthesia. Haemophilus influenzae was detected on culture. DISCUSSION: Although rare, nasal septal abscess in the pediatric age is typically anterior and secondary to local trauma or infection. Accurate medical history and anterior rhinoscopy are usually sufficient to make the diagnosis. In cases where the clinical presentation is consistent with a nasal septal abscess, with no history of recent local trauma or infection, or signs of anterior septal bulging, nasal endoscopy should be performed to rule out spontaneous posterior septal abscess. Delay in diagnosis and treatment could potentially cause the rapid onset of life-threatening complications, including intracranial abscess, meningitis, and cavernous sinus thrombosis.

The effect of steam inhalation on nasal obstruction in patients with allergic rhinitis.

BACKGROUND: Nasal obstruction is often impact on quality of life in allergic rhinitis (AR). The steam inhalation is one of widely used home remedies to soothe and open the nasal passages. Furthermore, steam inhalation may provide change in objective nasal airway assessment. OBJECTIVE: To compare the effect of steam inhalation on nasal obstruction between patients with AR and normal individuals, as well as the change in the cross-sectional area of the nasal cavity and in nasal airway resistance (NAR) between 2 groups. METHODS: A prospective comparative, parallel group study was conducted in AR and normal individuals. Steam with the temperature of 42-44°C was inhaled. Variables obtained before and after steam inhalation were compared. RESULTS: After steam inhalation, nasal symptom score, combined global symptoms, and Visual Analog scale (VAS) of combined global symptoms of AR patients showed statistically significant improvement. Whereas, normal individuals, there was statistically significant improvement only in sneezing and combined global symptoms. Meanwhile, the change of each measurement score, combined global symptoms, and VAS of the symptoms in those with AR were significantly higher than those of normal individuals. Total nasal airflow, NAR, volume, and mean minimal cross-sectional area of AR patients tended to better improve after steam inhalation. CONCLUSIONS: The steam inhalation significantly improved nasal obstruction in AR patients, but no statistical significant difference between both groups for any parameters. The different response between the 2 groups may be due to different nasal mucosa sensitivity to stimuli.

Use of Nonmedicated Control Substances in Randomized Clinical Trials of Patients With Chronic Rhinosinusitis: A Systematic Review and Single-Arm Meta-analysis.

Importance: The effect of nonmedicated control substances in chronic rhinosinusitis remains unclear. Objective: To assess the association of nonmedicated control substances in randomized clinical trials with disease outcomes in patients diagnosed with chronic rhinosinusitis. Data Sources and Study Selection: In this single-arm systematic review and meta-analysis, the Cochrane Library of Systematic Reviews, Ovid MEDLINE, Embase, PubMed, and ClinicalTrials.gov databases were searched for randomized clinical trials with a preintervention and postintervention design for chronic rhinosinusitis that were published between 1946 and January 23, 2019. Data Extraction and Synthesis: Paired reviewers independently extracted data. The analyses used random-effects models and the Cochrane risk of bias assessment to rate the quality of the evidence. Main Outcomes and Measures: The primary outcomes were the association of nonmedicated control substances with 22-item Sinonasal Outcome Test (SNOT-22) scores or nasal symptom scores when SNOT-22 was not available. Results: A total of 2305 abstracts were identified and screened, 725 articles were reviewed in full text, and 38 articles met the study criteria and were included in the meta-analysis. Among the 38 included studies, a total of 2258 adults (mean age range, 27-53 years; 20.0%-72.5% women) were randomized to receive nonmedicated control substances or sham interventions. Topical nonmedicated control substances were associated with significant reduction in SNOT-22 scores (mean difference [MD], -8.81; 95% CI, -12.60 to -5.03). A subgroup analysis of topical therapies, limited to saline irrigation and nasal spray diluents, found that topical diluents were associated with a greater reduction in SNOT-22 scores (MD, -11.45; 95% CI, -13.50 to -9.41) compared with saline irrigation (MD, -13.60; 95% CI, -19.95 to -7.25). Nonmedicated control substances were associated with a significant reduction in nasal obstruction scores (standardized MD [SMD], -0.42; 95% CI, -0.81 to -0.03). No significant change was found in rhinorrhea scores (SMD, -0.34; 95% CI, -1.37 to 0.69), postnasal drip scores (SMD, -0.96; 95% CI, -2.18 to 0.25), facial pain scores (SMD, -0.57; 95% CI, -1.68 to 0.55), or loss of smell scores (SMD, -0.18; 95% CI, -0.68 to 0.32). Conclusions and Relevance: This systematic review and meta-analysis of the use of nonmedicated control substances in randomized clinical trials of chronic rhinosinusitis outcomes suggests that the use of nonmedicated control substances is associated with limited improvements in SNOT-22 and nasal obstruction scores. These findings highlight potential areas of future research directions and the importance of randomized clinical trials to accurately estimate treatment effect.

Regional Peak Mucosal Cooling Predicts Radiofrequency Treatment Outcomes of Nasal Valve Obstruction.

OBJECTIVES/HYPOTHESIS: Low energy radiofrequency may offer effective treatment for narrow or obstructed nasal valve, yet its precise mechanism is not fully understood. STUDY DESIGN: Prospective, nonrandomized, case series. METHODS: Twenty prospective patients with internal nasal valve obstruction underwent office-based Vivaer treatment (Aerin Medical, Inc) under local anesthesia. Computational fluid dynamics (CFD) models were constructed based on the pre- and 90 days post-procedure computed tomography (CT) scans to identify salient changes in nasal airflow parameters. RESULTS: Patients' Nasal Obstruction Symptom Evaluation score (NOSE: pre-treatment 78.89 ± 11.57; post-treatment 31.39 ± 18.30, P = 5e-7) and Visual Analog Scale of nasal obstruction (VAS: pre-treatment 6.01 ± 1.83; post-treatment 3.44 ± 2.11, P = 1e-4) improved significantly at 90 days after the minimally invasive approach. Nasal airway volume in the treatment area increased ~7% 90 days post-treatment (pre-treatment 5.97 ± 1.20, post-treatment 6.38 ± 1.50 cm3 , P = .018), yet there were no statistically significant changes in the measured peak nasal inspiratory flowrate (PNIF, pre-treatment: 60.16 ± 34.49; post-treatment: 72.38 ± 43.66 ml/s; P = .13) and CFD computed nasal resistance (pre-treatment: 0.096 ± 0.065; post-treatment: 0.075 ± 0.026 Pa/(ml/s); P = .063). As validation, PNIF correlated significantly with nasal resistance (r = 0.47, P = .004). Among all the variables, only the peak mucosal cooling posterior to the nasal vestibule significantly correlated with the NOSE at baseline (r = -0.531, P = .023) and with post-treatment improvement (r = 0.659, P = .003). CONCLUSION: Minimal remodeling of the nasal valve (7% in this study) may have a profound effect on perceived nasal obstruction, despite little effect on nasal resistance, or PNIF. The results corroborated our previous findings that subjective relief of nasal obstruction correlates with regional mucosal cooling rather than nasal resistance or peak flow rate, a potential target for future effective, personalized therapeutic approaches. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1760-E1769, 2021.

Association of Allergic Rhinitis With Change in Nasal Congestion in New Continuous Positive Airway Pressure Users.

Importance: Nasal congestion occurring after continuous positive airway pressure (CPAP) treatment initiation impairs CPAP adherence. Allergic rhinitis is associated with worsening nasal congestion in patients who are exposed to nonallergic triggers. Use of CPAP presents potential nonallergic triggers (eg, humidity, temperature, pressure, and airflow). Objective: To compare nasal congestion among CPAP users with allergic rhinitis, nonallergic rhinitis, and no rhinitis. We hypothesize that CPAP patients with baseline allergic rhinitis are more likely to experience a worsening of nasal congestion (or less improvement in nasal congestion) compared with patients with no baseline rhinitis. Design, Setting, and Participants: This prospective cohort study included consecutive patients newly diagnosed with obstructive sleep apnea in a tertiary sleep center who were using CPAP therapy 3 months after diagnosis. Baseline rhinitis status was assigned as allergic rhinitis, nonallergic rhinitis, or no rhinitis, based on questionnaire responses and past allergy testing. Data were collected from 2004 to 2008 and analyzed from July 2019 to February 2020. Main Outcomes and Measures: At baseline before CPAP exposure and again 3 months later, subjective nasal congestion was measured with the Nasal Obstruction Symptom Evaluation (NOSE) scale and a visual analog scale (VAS), each scored from 0 to 100 (100 = worst congestion). Changes in nasal congestion were tested over 3 months for the whole cohort, within each rhinitis subgroup (paired t test), and between rhinitis subgroups (multivariate linear regression). Results: The study cohort comprised 102 participants, of whom 61 (60%) were male and the mean (SD) age was 50 (13). The study included 23 (22.5%) participants with allergic rhinitis, 67 (65.7%) with nonallergic rhinitis, and 12 (11.8%) with no rhinitis. Nasal congestion improved from baseline to 3 months in the whole cohort (mean [SD] NOSE score, 38 [26] to 27 [23], mean [SD] change, -10 [23]; 95% CI, -15 to -6; mean [SD] VAS score, 41 [27] to 32 [28]; mean [SD] change, -10 [26]; 95% CI, [-15 to -4]) and in each rhinitis subgroup. Adjusted improvement in nasal congestion at 3 months was significantly less in the allergic rhinitis subgroup compared with the no rhinitis subgroup (positive difference means less improvement) compared with baseline: NOSE score 14 (95% CI, 1 to 28) and VAS score 15 (95% CI, 0 to 30). Conclusions and Relevance: Initiation of CPAP was associated with improved subjective nasal congestion, but less improvement in patients with baseline allergic rhinitis. Baseline allergic rhinitis may predict which patients are more vulnerable to potential congestive effects of CPAP.

Physiological changes in the size of the septal swell body correlate with changes in inferior turbinate size.

OBJECTIVE: The nasal septal swell body is a normal anatomical structure located in the superior nasal septum anterior to the middle turbinate. However, the impact of the septal swell body in nasal breathing during normal function and disease remains unclear. This study aimed to establish that the septal swell body varies in size over time and correlates this with the natural variation of the inferior turbinates. METHOD: Consecutive patients who underwent at least two computed tomography scans were identified. The width and height of the septal swell body and the inferior turbinates was recorded. A correlation between the difference in septal swell body and turbinates between the two scans was performed using a Pearson's coefficient. RESULTS: A total of 34 patients (53 per cent female with a mean age of 58.3 ± 20.2 years) were included. The mean and mean difference in septal swell body width between scans for the same patient was 1.57 ± 1.00 mm. The mean difference in turbinate width between scans was 2.23 ± 2.52 mm. A statistically significant correlation was identified between the difference in septal swell body and total turbinate width (r = 0.35, p = 0.04). CONCLUSION: The septal swell body is a dynamic structure that varies in width over time in close correlation to the inferior turbinates. Further research is required to quantify its relevance as a surgical area of interest.

The Nose and Nasal Breathing in Sleep Apnea.

Assessment of the nose is critical in evaluating obstructive sleep apnea (OSA) because the nose plays an important role in the physiology of sleep by regulating nasal airway resistance and stimulating ventilation. Nasal obstruction is common in sleep apnea, contributes to OSA, and interferes with tolerance of OSA treatment with continuous positive airway pressure (CPAP) or oral appliances. Medical treatment of nasal obstruction and rhinitis with nasal corticosteroid sprays is associated with improved OSA severity and sleep symptoms. Surgery for nasal obstruction, including septoplasty, turbinate reduction, rhinoplasty, and sinus surgery, improves OSA-related quality-of-life measures and CPAP tolerance.