Nasal congestion, or stuffy nose, is a common complaint that our primary care doctors and Ear, Nose & Throat (ENT) specialists see in the office. Most cases are acute and resolve quickly. However, some patients experience chronic nasal congestion, the cause of which may require further evaluation.
Good nasal airflow is necessary because the nose warms and humidifies the air, which is essential to the health of the throat and lungs.
Acute Nasal Congestion
Acute nasal congestion is most often associated with a viral upper respiratory tract infection – also known as the “common cold.” This congestion is typically short-term and treatable with over-the-counter cold remedies and time. These cases usually do not require seeing a physician. However, more recently, we have seen nasal congestion associated with COVID-19 infection, and patients should follow CDC guidelines and their physician’s instructions should they test positive.
Acute nasal congestion may also be associated with acute sinusitis. This is commonly referred to as a sinus infection and defined as severe cold-like symptoms that continuously worsen past 10-12 days or seem to improve around day 7-8 and then worsen past 10-12 days. These symptoms can be managed by your primary care physician and may require antibiotics. Prolonged events, occurring more than four times per year, require a visit to an ENT physician.
Chronic Nasal Congestion
We diagnose chronic nasal congestion when the patient experiences ongoing difficulty breathing through the nose. It may be constant or intermittent, unilateral or bilateral, meaning it can affect one side or both. When associated with chronic facial pressure, decreased sense of smell, and thick, discolored mucus that continues for more than twelve weeks, it could be chronic sinusitis. At this point, the patient should see their ENT.
However, chronic nasal congestion is often the result of problems with the structures of the nose, namely the septum and the turbinates.
The septum is the wall of cartilage and bone that separates the left and right nasal passages. If deviated, it can cause difficulty breathing through the nose.
The turbinates are structures on the sidewalls of the nose. The largest ones are the inferior (lower) turbinates. When congested, they cause nasal congestion and obstruction.
A deviated septum is diagnosed when the septum is not straight. Sometimes it is from previous trauma, but most cases are developmental. In other words, the septum deflects during early life, usually before the mid-teenage years. Most patients with a significantly deviated septum will notice that the airflow is consistently compromised on one side versus the other. We call this a fixed obstruction.
A septoplasty (or partial septum removal of the underlying cartilage and/or bone) is performed in the operating room under general anesthesia when the septum is significantly deviated. In most cases, turbinate reductions are also performed. If the deviation is not severe, it can sometimes be managed in the office with a procedure that only requires topical and local anesthesia.
Turbinate hypertrophy is diagnosed when the lower turbinates grow too large. Because the turbinates warm and humidify the air we breathe, a significant disruption can be felt when they are not functioning correctly. This can lead to congestion. The classic signs of turbinate hypertrophy are congestion when lying down at night and feeling like a nasal passage is blocked when lying on one’s side. This may occur during the day and at night, but commonly, a person will have fairly good airflow during the day and then notice significant congestion when reclined in the evening. Some describe dependent congestion where congestion alternates right and left depending on which side one is lying on. (The right gets stopped up when lying on the right side, and vice versa.)
For many patients, an in-office procedure known as a partial submucous resection of inferior turbinates to reduce the size of the inferior turbinates and improve airflow is possible. Once the nasal passage is anesthetized with topical anesthetic, most patients report minimal to no sensitivity during the injection and subsequent turbinate reduction procedure. The procedure takes about 20 minutes under local anesthesia, and most patients report better airflow when lying down at night. The risks are generally mild, with bleeding and nasal crusting being two of the most common, both of which resolve in about 3-4 weeks. Most patients ultimately report good improvement of the nasal airflow and improved ability to breathe through the nose lying down.
Other Allergic & Non-Allergic Causes
Patients with allergies to inhalants (like pollen) commonly have chronic nasal congestion (allergic rhinitis). Some patients without allergies have chronic nasal congestion (vasomotor rhinitis). Nasal sprays, like Fluticasone and Azelastine, are sometimes adequate to manage the congestion. Some patients with allergies also develop chronic turbinate hypertrophy and can benefit from the turbinate surgery described above.
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Why Does It All Matter
The nose and its structures warm and humidify the air while passing through the nose to the throat and lungs. Improper function can cause long-term irritation to these structures. Further, patients with chronic congestion may sleep poorly, increasing the risk of memory issues, chronic fatigue, weight gain, diabetes, high blood pressure, and even accidents due to poor sleep health. Many patients decide they can manage nasal congestion on their own by using simple nasal sprays, treating allergies or taking simple medications for a cold. This is a practical and normal way forward for acute nasal congestion because the problem will ultimately resolve itself. However, the problem can be more difficult for those suffering from chronic nasal congestion.
Your Next Step
If you are suffering from nasal congestion that doesn’t seem to be improving, or your bouts with nasal congestion are getting more prolonged or more frequent, you may benefit from one of these procedure options.
Dr. Michael Branch is a board-certified Otolaryngologist born and raised in Florida. After active-duty service in the US Air Force and Navy, he entered private practice in 1996. He is interested in nasal congestion and obstruction, chronic sinusitis, chronic ear disease, and other condition of the ear and nose.
Disclaimer: This blog is not intended to substitute professional medical advice. Every patient is different, so talk with your doctor to learn what treatment options are best for you.