Nosebleeds (Epistaxis) 

Sinusitis 

Runny Nose and Post Nasal Drip 

Hay Fever 

Nasal Polyps 

Blocked Nose (difficulty breathing through the nose) 

Blocked Nose in Pregnancy 

Rebound Nasal Congestion (Rhinitis Medicamentosa) 

Nasal Deformities 

Nasal Septal Problems 

Snoring and sleep apnoea 

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

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

House Dust Mite

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

Moulds

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

Pets

  1. changing from a cat to a turpin?!

Medications:

  1. 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.
  2. 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)
  3. 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.
  4. Sodium cromoglycate and monteluckast inhibitors are also used.
  5. 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.
  6. 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 dependent 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.

Snoring and Sleep Apnoea

Snoring is a very common problem. In the 30-40-age range, 20% of men and 5% of women snore. By the age of 60, 60% of men and 40% of women will snore most nights. 

Snoring can be very loud indeed and cause severe social and marital upset. While many wives or partners, can fall asleep close to a snorer, it is often the unpredictability and irregularity of the snoring that keeps the listener alert and awake waiting for a change in the sound of snoring. 

Snoring is the sound of a partially obstructed or vibrating upper airway. The sound of snoring arises in the collapsible or non-rigid part of the airway. The collapsible area is from just above the voice box (base of tongue) below to the back of the nose (posterior choanae) above and involves the soft palate, uvula, the tonsils, base of tongue and the pharyngeal (throat wall) lining. Any of the soft tissue in the collapsible part of the airway may vibrate and produce sound of snoring. The most commonly identified areas that vibrate and produce the sound of snoring are the uvula and soft palate, (the area that hangs down at the back of the throat) excessive pharyngeal mucosa and excess of tissue at the base of the tongue. 

A number of factors can contribute to and worsen snoring.

  1. Incompetence or weakness of palatal pharyngeal (throat) and glottal (tongue) muscles which help to maintain patency of the collapsible part of the airway during an intake of breath. If these muscles are weak, then the airway can collapse inwards on inspiration and the vibratory sound of snoring develops. Weakness of these throat muscles occurs with sedative drugs and alcohol. Swelling within the airway such as big tonsils and adenoids, cysts in the throat or an enlarged base of tongue may narrow the throat and contribute to an obstructed airway. Obesity is associated with an over all narrowing of the upper airway and consequently, an increase in snoring.
  2. An excessively long and bulky uvula (the bit that hangs down at the back of the mouth) can create a slit like opening from the back the back of the nose into the throat. This produces a one way valve, which is worst when lying on the back. This one way valve worsens snoring.
  3. A blocked nose produces a negative pressure during inspiration and this draws the soft structures such as the uvula and palate towards the back of the nose and produces vibration of snoring. This is why many people who do not normally snore may do so when they have cold. Large septal deformities enlarged turbinates and nasal polyps cause nasal obstruction and may produce snoring.

Lying on the back especially with your chin on the chest will worsen many of the factors that produce snoring. The upper airway is most narrowed, when someone is sitting in a seat and their chin slumps forward onto their chest. As they fall asleep in the chair snoring starts! 

Snoring is both a social and medical problem. Heavy snorers are more likely to have high blood pressure and to suffer from strokes and angina than non snorers of similar age and weight. The most advanced stage of snoring is obstructive sleep apnoea (OSA). Snoring is the sound of a partly obstructed upper airway. Apnoea means a total obstruction of the upper airway and the person affected stops breathing! Obstructive sleep apnoea affects 4% of middle aged men and 2% of middle aged woman. 

OSA (obstructive sleep apnoea) can cause the symptoms of daytime sleepiness and difficulty with concentration and results in the affected person having difficulty thinking clearly. There is an increase in heart attacks and strokes in patients with obstructive sleep apnoea and as a result more of these people die at a younger age group than those people without obstructive sleep apnoea. There are five fold increases in road traffic accidents and a nine fold increase in single vehicle accidents involving people who suffer from obstructive sleep apnoea. The increase in single vehicle accidents is likely due to the drivers falling asleep at the wheel. This situation is worsened on motorway driving and in monotonous drives. 

Obstructive sleep apnoea is a total airway obstruction. The snoring gives way to an episode of total silence during which time the snorer struggles to get a breath. Hypoxia (drop of oxygen level in the blood) is associated with apnoea. At the end of a period of apnoea, a snort often occurs and the patient may become partially awake. There may be contortion or flailing of the arms as the patient kick starts their own breathing and subsequently snoring recurs. An occasional apnoeic event such as as this is quite harmless, but repetitive episodes particularly when each episode lasts longer than 30 seconds and occurs more than 30 times per night is very serious and considered pathological. There can be a surge in blood pressure associated with each severe apnoeic episode and this maybe the reason behind increase in heart disease and strokes in these patients. An overnight sleep study, in hospital, identifies the presence; frequency and severity of sleep apnoea.

In the assessment of an adult with snoring and possible sleep apnoea, the first question is how much difficulty the snoring is creating at home. One should identify whether the patient stops breathing at night and whether the partner has to wake the patient because they stop breathing. One should look for signs of sleepiness during the day (the Epworth Sleepiness Score) and also evidence of poor concentration. A history of heart disease or stroke in a patient, who is younger than one would expect for this disease, may suggest evidence of obstructive sleep apnoea. The Body Mass Index (BMI) is also important to assess, as surgery has no role to play (apart from tracheostomy) in patients with a BMI > 30.

In a child if there is evidence of severe snoring, or suggestion of stopping breathing at night, then this is often an indication for an adenotonsillectomy. 

Often, the first line of management for patients with severe snoring is an improvement in lifestyle. Loss of weight is, of course, ideal and trying to improve a patient’s lifestyle by increased sporting activity is helpful. Patients should avoid alcohol for 4 hours before going to sleep. Tranquillisers and sleeping pills should be avoided if possible. 

In those patients with nasal congestion or obstruction, a nasal steroid spray is tried first (Beconase, Flixonase, Nasacort, Nasonex). A cotton reel placed on the back of pyjamas or a night gown, may prevent a patient from sleeping on their back and thus reduce the volume of snoring. Raising the bed head or using a collar or pillow to extend the neck may help to open the airway and reduce the sound of snoring. A cup of coffee at night may help since the snorer may not fall asleep before his or her partner. 

The out-patient assessment of snorer requires an endoscopic (miniature telescope) examination of nose, throat and voice box. If there were obvious blockage to the nasal or upper airway, then it would probably be appropriate for the block to be removed. If there is suggestion of obstructive sleep apnoea, then an overnight assessment to document and assess the degree of apnoea is helpful. If obstructive sleep apnoea (OSA) is identified is identified in the absence of any obstructive disease of the nose and throat, then the treatment is CPAP (continuous positive airway pressure) mask in the first instance.

If snoring is the only significant symptom without any evidence of apnoea, then surgery can be considered to reduce the volume of snoring. It is unlikely that any surgery will guarantee to remove the sound of snoring but there is likely to be reduction in volume of snoring. Such surgery may involve nasal surgery to correct nasal septal deviations or to remove nasal polyps. Such operations can be done as day case and the recovery time is 1-2 weeks.

The most common vibratory area of snoring is the soft palate and uvula. There are number of operations to reduce the size of palate and uvula and to tighten the palate. See the page on treatments for snoring.  The palate operation can be done with Diathermy, Laser or Radiofrequency (RF) machine (Somnoplasty). Palatal surgery (except for Celon radiofrequency) is painful for 2 -3 weeks post operatively. Radiofrequency is also used to reduce the bulk of the base of the tongue. Base of tongue treatment is performed under general anaesthesia.

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