Nasal obstruction is a common reason patients are referred to an otolaryngologist and can be associated with a wide variety of disease processes affecting the nose. The challenge for the physician is to correctly determine the reason for the obstruction and recommend the appropriate management. Depending on the cause this may include medical or surgical therapy or perhaps both in combination.
Obstruction occurring in combination with facial pain or pressure and discolored discharge may in fact be a symptom of a sinus infection requiring treatment addressing these structures as opposed to only the nose itself (for a complete description of sinusitis click here). Similarly, patients may have obstruction in conjunction with an itchy nose and eyes, and clear post nasal drip which may be a sign of an allergic problem (for more information on allergic rhinitis click here).
When a patient is unable to breathe through their nose this may also be a symptom of an anatomic abnormality of one or several parts of the nose. This may contribute to sinusitis, snoring and/or obstructive sleep apnea. These patients may have a deviated septum (the midline structure which separates the two sides of your nasal cavity), enlarged turbinates (mucosal lined projections in the nose that serve to warm and humidify air) or a narrow nasal valve.
The nasal valve which has an internal and an external component is the most important part of the nose for breathing purposes. The internal valve is the rate limiting part of the nose for airflow and is composed of the space between your septum and the midportion of the sidewalls of your nose. If this area is narrowed congenitally (from birth) or from trauma or previous nasal surgery, collapse and obstruction can result. The external nasal valve is composed of the nostrils and lower part of the nasal septum. In some patients, due to similar reasons as for internal valve problems, the nostrils will be too floppy, retracted or too narrowed leading to collapse and nasal obstruction. Lastly, the turbinates may also contribute to valve collapse and may appear inflamed, enlarged or may impact on the sidewall of the nose.
Patients with nasal valve collapse are usually diagnosed on the basis of physical examination. The examiner may attempt to pinpoint the area of collapse by watching you breathe in or by applying a cotton applicator to various parts of the nose to see if breathing can be improved by reinforcing a particular area.
Occasionally initial therapy with valve collapse are nasal steroids and other medical measures, but most often these patients will eventually require surgery. Other options to temporize or to be used in patients who are not good surgical candidates are things like breathe rite strips which serve to mechanically open the valve. Surgical therapy for nasal obstruction may include straightening the septum (septoplasty), reduction of the turbinates as well as widening and strengthening the nasal valve. In order to fix the nasal valve most often small cartilage grafts are obtained from the septum or occasionally discretely from the ear.
If you or one of your patients has issues with nasal obstruction that you think may be due to a deviated septum and or nasal valve issues please give don’t hesitate to give us a call.
BONE SPURS IN THE NOSE CAN CAUSE MIGRAINE-TYPE HEADACHES
Migraine headaches are a very debilitating problem that affects millions of Americans annually. There are an estimated 23.6 million migraine sufferers in the United States. There are another 11.3 million who suffer moderate to severe headaches, and another 4.5 million who have at least one or more migraine headaches per month. These are staggering figures. Approximately 18% of all adult women are afflicted with the problem. Women also suffer from migraines at a rate of 3:1 ratio over men. This equals approximately 18 million women or 1 in 6 American women suffering from headaches. In addition, 90% of all migraine sufferers have a positive family history of migraine.
SOCIAL IMPLICATIONS OF HEADACHES
The implications of migraine headaches include a myriad of problems. Migraine sufferers are usually thought to have a "short fuse". They can be very unpleasant because of their debilitating headaches. They tend to isolate themselves from others while suffering these headaches. Other problems include missed work or school, and limited involvement in social activities. They are often labeled as "sickly" because of multiple visits to the emergency room or the doctor's office. They can be labeled as having "poor attitudes" or drug dependent. All of these are compounded by marital and family discord. The relationships within families are strained when there is one member who is isolated from the family because of debilitating migraine headaches.
ECONOMIC COST OF MIGRAINE HEADACHES
Migraine headaches can affect productivity in the workplace across the board. It is stated that 89% of migraine sufferers worked at about half their usual level of productivity for an average of 6 days per month. Fifty-six percent of migraine sufferers miss an average of 2.2 work days per month. These figures equate to monthly lost labor costs of $570 per working male and up to $300 per working female.
The impact of migraine headaches on health care costs is staggering as well. Migraine sufferers frequently visit the emergency rooms and doctors' offices and account for a significant number of pain medication prescriptions each year. For migraines that are refractory to treatment, other nontraditional expenditures can include visit to the chiropractor, trials with acupuncture, meditation, and other relaxation techniques. These sufferers also consume a significant number of herbal supplements and over-the-counter medications searching for headache relief. Overall, the average cost incurred by a patient over a period of 18 months has been estimated as approximately $2,500 or more. Migraine sufferers use medical resources in disproportionate numbers compared to non-migraine patients. They account for 70% more medical claims and 73% more physician visits. They account for nearly 300% more emergency department visits and 70% more hospital visits. In essence, migraine sufferers' activities revolve intimately around hospitals, doctor visits, and other medical resources. Healthcare becomes an integral part of their daily lives.
TRADITIONAL HEADACHE TREATMENT COURSE
The first encounter with healthcare for a migraine headache sufferer usually starts with the over-the-counter preparations. Mild headaches can sometimes be relieved with these medications. However, when a persistent severe migraine headache arises, it usually alerts the patient to seek treatment from their primary care physician. The primary care physician is obligated to rule out organic causes or medical causes of the headache after obtaining a thorough history and physical examination. Common non-prescription medications include non-steroidal anti-inflammatory medications such as Motrin, aspirin and acetaminophen. Chronic use of these medications can lead to the development of gastritis and possibly ulcers of the gastrointestinal tract. Once a trial of these medications has failed, stronger medications such as Tylenol with Codeine, Vicodin, Fioricet, or even morphine and methadone are prescribed. Of course, these medications are potentially addictive and can lead to abuse. Some signs of abuse might be persistent calls for prescription refills, shorter intervals between prescription requests, creative excuses for needing prescription refills and doctor-shopping behavior whereby a patient will go to multiple doctors in order to obtain these medications.
From the primary care's office, a resistant headache can be referred to specialists. This typically involves a neurologist who will examine the patient for possible brain abnormalities, such as tumors and aneurysms. The neurological work-up often includes obtaining an MRI or a CAT scan of the brain and, if negative, these patients are placed on migraine headache medications such as Imitrex and ergotamines. Should these medications prove ineffective, the patient can then be referred to headache and/or pain management clinics that specialize in chronic pain. Here headache sufferers can be subjected to injections of long-acting local anesthetic agents into the vertebrae and muscles. Botulinum toxin injections into the muscles of the neck and forehead have been proven to relieve some migraine headaches. Other common non-surgical therapies include acupuncture, biofeedback technique, hypnosis, and stress management strategies.
For those who suffer from nasal airway obstruction, allergies or sinus problems, referral to an otolaryngologist is indicated. It is this referral that I will be expounding upon, because I feel that the nose potentially plays more of a role in headaches than we are led to believe. Bone spurs within the nose can contribute to migraine headaches and the development of nasal airway obstruction and sinus problems. However, although it is taught in residency training programs and medical seminars, not much emphasis is placed on the potential importance of the nasal structure and the potential to cause headaches.
When headaches are refractory to non-surgical therapies and medications, patients are desperate to find a cure. During this desperate time it is common to be told that the headache is stress related or "in your mind." This response contributes to added stress and desperation and can lead to another debilitating medical entity, depression. The depression then leads to visits to the psychiatrist or psychologist and the use of antidepressant medications. At this point the sufferer is left with compounded problems, no relief and additional medication with potential side effects.
NASAL ANATOMY AND THE DEVELOPMENT OF SEPTAL SPURS
The septum is a midline partition inside the nose comprised of cartilage anteriorly and bone posteriorly. It divides the right nostril from the left nostril and aids in supporting the nose. Within the nose there are three pairs of turbinates along the lateral nasal wall. These turbinates are vascular erectile structures that can become engorged and swell in response to allergies, flu, sinus problems, etc. There are several nerves which innervate the internal nose, namely the anterior ethmoid nerve the branches of the nerve of the pterygoid canal and nasal palatine nerve which innervate the septum. Along the lateral nasal wall the sphenopalatine ganglion and the anterior ethmoid nerve innervate the turbinates and the lateral nasal wall. Trauma to the nose at any time can contribute to the development of a septal spur. A septal spur is a sharp bony projection that can impinge on the lateral nasal wall and the turbinates, irritating nerves and referring pain to the head.
Nasal Obstruction - Ear, Nose Throat Associates
Last edited by Medical Photos; 09-07-2015 at 07:22 PM.
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