Blocked Nose (difficulty breathing through the nose)

Rebound Nasal Congestion (Rhinitis Medicamentosa)

Nosebleeds (Epistaxis)

Nosebleeds are common in children. They are usually mild and easily treated. Sometimes bleeding can be more severe, but this is usually in older people, or in people with other medical problems such as blood disorders. Get medical help quickly if the bleeding is severe, or if it does not stop within 20-30 minutes. There are two types of nose bleeds.

Anterior Nosebleed: These are most common. They start from just inside the entrance of the nostril, on the nasal septum (the middle wall of the inside of the nose). Here the blood vessels are quite fragile and can rupture easily for no apparent reason. This happens most commonly in children. The lining of the nose can also get quite dry at the front of the nose, leading to crusting. This delicate area is also more likely to bleed with the following.

Picking the nose
Colds, and blocked stuffy noses, infections and hayfever
Blowing the nose
Minor injuries to the nose
Crusting and drying of the nose
Clotting disorders that run in families or are due to medications.
Fractures of the nose or of the base of the skull that can cause bleeding and should be regarded seriously when the bleeding follows a head injury.
Rarely, tumors (both malignant and nonmalignant) have to be considered, particularly in the older patient or in smokers
In the above situations, the bleeding tends to last only a short time and is usually easy to control.

The bleeding may last longer and be harder to stop if you have: heart failure; a blood clotting disorder; are taking 'blood thinning' drugs (anticoagulants) such as warfarin or aspirin.

Posterior Nosebleed: More rarely, a nosebleed can begin high and deep within the nose and flow down the back of the mouth and throat even if the patient is sitting or standing.

What is the treatment for nosebleeds?

For most nosebleeds, simple first aid can usually stop the bleeding.

If you are not feeling faint, sit up and lean slightly forward.
With a finger and thumb, pinch the lower soft end of the nose (see gray area) completely blocking the nostrils for 5 minutes by the clock. If it is still bleeding after this, then apply another 5 minutes by the clock!
DO NOT put pressure on the bony part of the nose. This will not apply the pressure to the bleeding point.
DO NOT put tissue in the nose. This starts the nose to bleed again, when the tissue is removed
If available, some ice to suck may be helpful (as cold helps the blood vessels to close down (constrict) and stop bleeding.
Once the nosebleed has stopped, do not pick the nose or try and blow out any of the blood remaining in the nostrils. This may cause another nosebleed.
If you feel faint it is best to lie flat on your side.

To prevent rebleeding after initial bleeding has stopped:

Do not pick or blow nose.

Do not strain or bend down to lift anything heavy.

Avoid piping hot food or fluids

Keep head higher than the heart.

Use a humidifier during dry winter months.

Some antiseptic cream, or vaseline, can be helpful to use on the nose after the bleeding has stopped. This protects the nose, helps with healing, and reduces crusting

Get medical help quickly if bleeding is heavy, or it does not stop within 20-30 minutes. Sometimes the nose needs to be packed by a doctor to stop the bleeding. Rarely, a nosebleed is so heavy that a blood transfusion is needed, and surgery may be required to stop it.

Recurring Nosebleeds

Some people have recurring nosebleeds. They may not be heavy, and soon stop, but can become distressing. In this situation you may be referred to an Ear Nose and Throat doctor. Using an endoscope (a tube with a light for seeing inside the nose) your ENT surgeon may locate the bleeding point inside your nose. He may well then cauterise ('burn') the bleeding point to seal it. . This is usually a minor procedure which is usually successful in stopping recurrent bleeds. He will give you nasal creams, as above, to help the nose heal, and prevent bleeding.

Sinuses and Sinusitis

The nasal sinuses are air-filled spaces in the bones of the face and head. They are connected to the inside of the nose through small drainage openings. The sinuses are important in the way we breathe through the nose and in the flow of mucus in the nose and throat. They help warm and humidify the air we breath in.

When the sinuses are working properly we are not aware of them. Sinusitis is caused by infection of the nose. This is often viral, but if prolonged, can be bacterial also. It commonly occurs following or with a ‘cold’. Symptoms include blocked nose, runny nose, facial congestion and pain, tender cheeks, fever and tiredness. Other symptoms include headache and loss of sense of smell. However it is unusual for headache alone to be caused by sinusitis. This is more likely simple headache. Sometimes it can be an atypical migraine.

Treatment includes antibiotics and a nasal decongestant spray such as Otrivine (Xylometazoline). It is very important not to use the Otrivine spray for longer than one week, or this can lead to rebound nasal congestion (rhinitis medicamentosa). Steroid nasal sprays are also important in the long term treatment of recurrent sinusitis. It is very important that the spray is directed in the correct direction (see diagram). Steroid or decongestant nasal drops may also be used. Again correct use is very important (see diagram).

If you suffer from several or continual episodes of sinusitis, then you may well require Functional endoscopic sinus surgery (FESS) to open up the sinus passages to reduce the frequency and severity of sinus infections. In some patients with severe sinusitis an operation may be needed. In rare cases if sinusitis is left untreated it can lead to complications with infection spreading into the nearby eye socket or into the fluid around the brain. These very rare complications are just some of the reasons that a sinus operation may become necessary.

Runny Nose and Post Nasal Drip

These symptoms often go along with a common cold, and can also occur with hayfever. Treatments involve nasal sprays such as steroid nasal drops and sprays and occasionally nasal decongestants. It is very important that nasal drops are used in the appropriate manner
(see diagram).

Correct position for application of nasal drops

Occasionally, just for runny nose, Rhinatec nasal spray can be very useful. This is used on an as required basis to treat runny nose that occurs often with eating.

Hay Fever

Hay Fever is due to allergy or other irritant which can cause inflammation of the lining of the nose. Symptoms include blocked nose, sneezing, runny nose, itchy eyes and throat. Often people can have hayfever, asthma and eczema together (atopic patients). Sometimes skin prick testing can be helpful to identify a particular irritant (allergen). Avoidance of the allergen (where possible) can be helpful. Measures would include.

Pollens

not hanging the clothes outside on the line in the pollen season
having shower on returning home
wearing sun glasses when out
closing the windows on a high pollen count day

House Dust Mite

anti-allergy bedding
avoidance of carpets and heaving drapes in the bedroom
wood flooring in the bedroom if possible.

Moulds

avoiding having house plants in the home/bedroom
having good ventilation in the bathroom
having a smaller rubbish bin in the kitchen

Pets

changing from a cat to a turpin?!

Medications:

Antihistamine tablets are useful, particularly if the problem is seasonal and short lived. They also treat the eye, throat (cough & itch) and chest problems that may occur with allergy. The majority of antihistamine tablets now used are non sedating.
Steroid nasal sprays. These are the mainstay of ‘hayfever’/allergy treatment for the nose. Most common sprays used are Flixonase (fluticasone) and Nasonex (mometasone). This is because these sprays are not only stronger in the nose, but less of the active drug is absorbed into the body (most of the drug is broken down in the nose or in the liver). There is no significant effect on bone growth in children. It is important that the sprays are used in the correct direction, one spray in the nose and toward the eye and one spray in the nose and towards the ear (see diagram)
Steroid nasal drops can also be used. It is important to use the drops in the correct position (see diagram). If you just bend your head backwards, most of the drops will go into your throat and stomach. You really need to have your head well back to get the drops into the nose.
Sodium cromoglycate and monteluckast inhibitors are also used.
Immunotherapy is now available for people with grass pollen allergies. This is called ‘Grazax’ and is an exciting addition to the treatment options available. This is given as a sublingual (under the tongue) tablet taken in the morning only. It has to be taken every day for three years. There is to be a tablet released shortly for house dust mite also.
Surgery is occasionally used to treat the swollen inferior turbinates (submucous diathermy to the inferior turbinates, or radiofrequency reduction or laser reduction or trimming) to allow better nasal breathing. It obviously does not treat the underlying allergy.

Nasal Polyps

Nasal Polyps are soft swellings that grow inside the nose. They are yellowish in colour. They are not cancerous, nor do they have any propensity to turn into cancer. They may be associated with asthma. They do cause blocked nose, reduced sense of smell, snoring and occasionally sinus infection.

In most cases the cause is not known. It is thought that ongoing (chronic) inflammation in the nose causes overgrowth of the lining of the nostril. This can sometimes lead to small polyps forming. These may then gradually grow larger. Polyps usually affect both nostrils. Certain conditions make nose inflammation and polyps more likely. These include: asthma, allergy to aspirin, cystic fibrosis, and some rare conditions of the nose.

About 1 in 100 people will develop nasal polyps at some stage in their life. They are four times more common in men than in women and are very uncommon in children. A child with nasal polyps should also be checked for cystic fibrosis as cystic fibrosis is a 'risk factor' for developing nasal polyps.

Nasal polyps are usually diagnosed by their appearance. This may require a very small telescope (endoscope) to be used inside your nose to inspect the inside of your nose. Sometimes a CT scan of the nose and sinuses is performed to assess the extent of sinus involvement.

Treatment initially includes nasal steroid drops (as above) and steroid sprays, antihistamine tablets (such as deslortadine) and occasionally a short course of oral steroids. Should this treatment not be successful, then (following a CT scan of the sinuses) an endoscopic nasal polypectomy or functional endoscopic sinus surgery (FESS) operation needs to be performed. People sometimes require more than one operation to remove nasal polyps as they can recur. This is why it is very important to continue with steroid nasal sprays after the surgery, as they prevent, or significantly delay the recurrence of nasal polyps.

Blocked Nose

Difficulty breathing through the nose) can be due to many causes. It can be due to swelling of the lining of the nose (as seen in hayfever), nasal septal deformities, nasal polyps, blockages at the back of the nose, enlarged adenoids (children), foreign bodies in the nose (children e.g. little bits of Lego!) etc. Treatment is offered after history, examination and diagnosis. If the nasal blockage is due to a deviated nasal septum then a septoplasty could be performed

Blocked Nose in Pregnancy

Click here to read more.

Rebound Nasal Congestion (Rhinitis Medicamentosa)

This is a problem where the nose gets dependant on nasal sprays such as Otrivine (Xylometazoline) or other decongestants nasal drops. This problem can arise if you use the nasal drops longer than one week. Nasal decongestants cause the blood vessels of the nose to shrink, and therefore unblock the nose. But if you use them longer than this, then the blood vessels become more resistant to the sprays, and you need to use them more frequently to get the same affect. It can even reach the stage where you use the nasal decongestant drops for years. This can be difficult to treat. It can be helped by using nasal steroid drops (see diagram), and then nasals sprays

Nasal Deformities

Outer nasal deformities can be traumatic or congenital. The nose can be bent or twisted, or prominent. A prominent nasal hump can be of concern, as can a large nasal tip. The operation on the nose to correct these problems is called a rhinoplasty. Commonly nasal septal problems are also present with external nasal deformities. Therefore a septoplasty needs to be performed also. This combined operation is called a septorhinoplasty. I would stress that this operation should be performed by a surgeon who is able to manage both the nasal septum and the outside nasal deformity.

Nasal Septal Problems

Nasal blockage can present with single sided blocked nose. This occurs when the nasal septum is bent to one side. This can occur secondary to trauma or can be congenital. It needs an operation to fix this, called a septoplasty.

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