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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   can   occur   temporarily,   lasting   a   few   days   as   in   acute   sinusitis   or   upper   respiratory   tract infection.   The   nasal   lining   is   inflamed   and   congested   leading   to   nose   block.   There   may   be   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 other 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    technology    has    allowed endoscopes   to   be   introduced   into   the   nose   and   throat   to   visualize   the   problems   within   these narrow   cavities.   Even   the   patient   can   have   a   ‘live’   view   into   his/her   own   body   cavities   !      A recording   can   even   be   made,   allowing   for   repeat   viewing   in   the   comfort   of   your   own   home,   if   you fancy   that   !   Generally,   your   doctor   will   be   able   to   diagnose   your   condition   soon   after.      When masses   or   tumours   are   encountered   in   the   nose,   a   biopsy   (that   is   removal   of   part   of   the   tissue)   in the    clinic    is    necessary    to    know    its    nature,    whether    if    it    is   The    Big    ‘C’    (cancer)    or    otherwise. Sometimes ,    radiological   imaging   (eg   CT   scan,   MRI)   maybe   necessary   to   aid   in   the   diagnosis.   Once   a   definite   diagnosis   is   established,   your   doctor   will be able to advise you on the best form of treatment. Certain   conditions   are   initially   treated   with   a   non-surgical   modality   while   some   would   require   surgery   at   the   outset.   Whatever   the   decision,   it   is   best   to discuss the pros and cons with your doctor who has your best interest and clinical outcome at heart.
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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