Greg Smith: There are plenty of non-surgical treatments, and there are minor surgical treatments, and larger surgical treatments. And it is a very tailored, specified to each individual patient, depending on the cause, the structure, the anatomy, and everything, all the way down.
Nishant Reddy: Hello, everyone. Welcome to the We Nose Noses podcast, where we discuss anything ENT. Here, we talk about a variety of things for anyone wanting to learn more about ENT, or ear, nose, and throat related topics. The three of us make up NJENT, a newly formed ENT group based in central New Jersey. My name is Dr. Reddy, and I’m joined here with my two wonderful partners, Dr. Smith and Dr. Undavia. So first, for today’s topic, we’re going to discuss a very common question that we get asked from our patients, which is why can’t I breathe through my nose?
This is a relatively complicated topic with many different causes, but can be grouped kind of strategically in two broad categories. The first category is structural problems with your nose, where you have something that’s actually blocking the airflow going through your nose. And that’s kind of an anatomic reason for why you may or may not be able to breathe. The second big possibility is that there’s a physiologic reason that may be causing swelling in your nose. Maybe your nose might be reacting to something in the environment. Most people have some type of combination between a structural and a physiologic problem causing their breathing issues. So I’m going to turn it over to Dr. Undavia who’s going to talk a little bit about these structural causes.
Samir Undavia: So when it comes to the anatomy of the nose, and things that can obstruct the nose or affect breathing, we talk about a few structures inside the nose. The first thing we talk about is the outside of the nose. And from a structural standpoint, really talking just about the nostrils here. This part, depending on the size of the nostrils can affect the breathing in a good way or bad way. The bigger the nostril, obviously the bigger the aperture and the more air that you can get into the nose. And when the nostril might be big or small, but just floppy, that can also obstruct the nose. So when we talk about this outside part of the nose right here, we’re talking about the external nasal valve. Then we get a little bit farther into the nose and the nose actually goes all the way back to the front of the ear.
So it’s a much bigger structure than you think. The first thing we think of is the septum. And the septum is a wall that divides the nose into the left and right, and it should be straight all the way back. And the septum along with the turbinates, which I’ll talk about in a second, allow for the air to flow in a laminar way, all the way to the back, which means kind of streamlined. When you have obstructions, whether it’s a septum that’s crooked, called a deviated septum, or turbinates that are enlarged, you can create turbulent flow. So the air doesn’t just flow all the way back, it kind of bounces back and forth. And when that happens, you can feel obstructed. You can have other problems also, like nose bleeds. But for the most part, you need to have a septum that’s straight to breathe well.
The turbinate are these outpouchings next to the septum. And the turbinates are meant to warm and humidify the air as you breathe it back into the lungs. Because if you have warm and humid air, it improves oxygenation. So the turbinates, you have six of them. There’s two on the bottom, two in the middle, and two on the top. The two on the bottom are most important for breathing, they’re called the inferior turbinates. And the inferior turbinates should be about the size of my pinky finger. However, anything bigger than that can encroach and get closer to the septum, and cause obstruction. The nose is really a game of millimeters. There’s a few millimeters that you have to play with, and that’s why small changes in either the septum being crooked or the turbinates being enlarged can have a big impact in your breathing. So often, we see turbinates in the office that are my index finger, and I literally mean like my index finger inside your nose.
And what you want to do is, you want to make that turbinate smaller, like the pinky finger. And just that little bit of improvement in room can make a massive improvement in breathing. Now, when you kind of talk about the interplay of all of these structures, the external nose, plus the septum, plus the turbinates and the side wall of the nose, you have an internal nasal valve. And there’s an angle in there where the septum comes down from here and the side wall comes out from here, and that angle should be at least 15 degrees. And if that angle is narrower, you can have something called the internal nasal valve collapse. We often see patients say, “I read what’s better when I pull out like this, or when I pull out down here.” And that can often indicate an internal nasal valve problem. So those are the main structural problems that people could either be born with or that trauma could cause.
Nishant Reddy: So Dr. Smith, maybe you want to comment on some of the physiologic causes.
Greg Smith: Sure. So some of the physiologic causes that cause mainly swelling in the structures that Dr. Undavia was just talking about, the three big that we typically think about are allergies, irritants, and viruses, environmental type things. And so, allergies depending on the zone where you live, anything from tree, grass, weed pollens, dust, mold, pollen, mold spores, and things like that can cause an allergic reaction, creating swelling within the turbinates and the lining of the nose. Irritants and these can be chemicals. Dry air is even an irritant to the nose that creates swelling. And the main purpose of the nose is to heat and humidify the airway. So as you breathe in those turbinate that are heating, humidifying, and filtering out all the dirt, dust, pollen, debris as you breathe in.
So all that dirt, dust, pollen, debris that settles in on those turbinate can create some swelling and irritation. Especially if you’re allergic and you make an allergic reaction to it, or just as an irritant to the inside of the nose. And finally, viruses, which we’re all very commonly aware of now thanks to pandemics, and flus, and things like that, create significant swelling inside the nose. And so if anybody here has ever had an upper respiratory infection or a congestion after a cold or flu virus, you well know that these couple little millimeters that the nose swell significantly clog and obstruct the nose and impair your breathing. And so those are typically the main three things that we start to look at as causing problems with obstruction within the nasal cavity.
Nishant Reddy: Great. Yeah, there’s a lot of things that, as a patient, if you’re suffering from trouble breathing through your nose, that you can do even prior to seeing a physician or an ear, nose, and throat specialist. A lot of these things you can find just over the counter. And some of the things that we recommend trying first is the mainstay of therapy for decreasing swelling in your nose, which is intranasal corticosteroid therapy. The most common sprays that are available over the counter are sold as brand names, such as Flonase or Nasacort.
And essentially, you do two sprays in each nostril twice a day. And you do that for about a month, approximately, to try to decrease any swelling in your nose. You can also combine this with a nasal saline or salt water irrigation, which essentially just washes out all the debris and the allergens, and any irritants that might be built up in your nose, and hopefully decrease the swelling that way. If you’ve tried these methods and you’re still having issues with breathing through your nose, that’s kind of a logical time at that point to potentially see an ear, nose, and throat specialist.
Samir Undavia: You might want to just quickly clarify that the two sprays twice a day that Dr. Reddy talked about is usually done with a physician. So if you want to try this first, you might want to try one spray twice a day or one spray once a day before seeing us too.
Nishant Reddy: Sure. And Dr. Smith, maybe you can comment a little bit on what a patient can expect when they go see an ENT for an evaluation.
Greg Smith: Perfect. So when a patient comes in for evaluation of nasal obstruction, as with any good physician visit, it always starts with a good well detailed history to try to determine what maybe important factors might be causing some of the obstruction, especially physiologic factors. And sometimes, this is the obstruction all the time. Does it kind of change throughout the day? And those kind of simple questions can give us a lot of detail about things that might be environmental or allergic in nature, or an irritant in nature. So a history is very, very important. So make sure you’re prepared to tell the story of where the nasal obstruction is, and how often and how complicated it is. The next step is the physical exam in which we evaluate the inside of the nasal cavity. And first, we’ll do that with just the anterior. What’s called anterior rhinoscopy, which is taking a little tiny nasal speculum, opening up the external nasal valve and taking a look inside of the nasal cavity, looking for the shape of the turbinates, any sign that there may be irritation or inflammation. Sticky mucus, which may be a sign of allergic changes.
And so the septum as well can be evaluated from that anterior rhinoscopy and gives us a good idea if there’s a physical obstruction. The anatomy that Dr. Undavia was talking about already. And then often we’ll do formal nasal endoscopy. And that can be with a little telescope or a little flexible camera that allows us to take a look inside the nasal cavity a little bit further up and deeper. Because as Dr. Undavia mentioned, “It goes all the way back to, almost, to the front of the ear.” And so that allows us to look for maybe hidden things that we weren’t expecting, maybe polyps or inflammatory growths within the nasal cavity. And some other obstructing features that can occur.
Growths, tumors, and the like. And so that’s typically what an evaluation will look at. Sometimes ENT physicians may even do that evaluation with and without a decongestant spray, like an Afrin, which is a topical decongestant which can help shrink those turbinates up. A word of caution, which we see frequently in the office are patients that do those over the counter kind of fix it solutions. And they start themselves on a decongestant. They start to get some significant improvement with the congestion of the nose, but then become “addicted to the nasal decongestant,” which leads to long term problems with severe swelling and inflammation, and obstruction of the nasal cavity.
Samir Undavia: Been there, done that. Then I had Dr. Reddy fix my turbinates.
Nishant Reddy: Now, if Dr. Undavia, and if we can go over some of the very general treatment options for nasal obstruction.
Samir Undavia: So we always start with medical treatments. The first thing as Dr. Reddy alluded to was trying some intranasal corticosteroids, or nasal sprays in general. So you can try steroids. They’re very low doses and they’re topical, so they’re typically not absorbed into your body. And they can decrease inflammation in the nose. You can also try other nasal sprays like Azelastine, which are topical antihistamines. And these typically taste bad by the way, so you don’t want to tip your head back as you spray them in, keep your head forward. But these can also decrease congestion in the nose by taking away the inflammatory or the swelling effects of histamine, which is the inflammatory mediator for allergies. You can also wash away the allergens or whatever is causing the inflammation in your nose by using saline. And you can get mists. You can get gel, or you can get a sinus rinse.
As ear, nose, and throat docs, the three of us love sinus rinses, because it just literally washes away and gives your nose a little bath inside. It can be very healthy. There’s no real upper limit to how often you can use them, so long as you use the salt water packets inside them. They can be very helpful. Other things that you can do for a little bit more treatment, you can do the combination of those nasal sprays plus allergy medication, oral allergy medication. There’s typically four allergy pills, Zyrtec, Claritin, Allegra, and Xyzal. Sometimes the three of us will treat your nose with steroids, oral steroids, which is a little bit heftier, but can get a lot more inflammation out faster. You can do antibiotics sometimes. And when all of these things don’t work, we talk about surgery for your nose.
Nishant Reddy: Yeah. So…
Samir Undavia: We also have allergy testing.
Nishant Reddy: Yeah. Even before surgery, we oftentimes we think of even potential for in-office procedures, where we can avoid surgery. And just under local anesthesia in the office, not in the operating room potentially improve the nasal airway with things like radiofrequency ablation or other in-office procedural options. And from a surgical perspective the Dr. Undavia was alluding to, there’s many different kinds of surgeries. And the surgery’s really individually tailored to whatever the specific problem areas are. And that those problem areas are based on what we see on not only physical examination, but oftentimes on imaging studies such as CAT scans. Anything else to add guys?
Greg Smith: No, I think that sums up everything pretty well. The big thing, the big take home picture is that, yep, there are medical treatments. So there are plenty of non-surgical treatments, and there are kind of minor surgical treatments, and larger surgical treatments. And so that concludes the podcast on our nasal obstruction with our well detailed anatomy lesson. Thank you so much for listening.
Nishant Reddy: They’re going to get better over the years.
Samir Undavia: I don’t know about that. I don’t know about that.
Greg Smith: They won’t. They won’t. So that concludes this podcast, thank you so much for listening. If you haven’t already, make sure you subscribe. Rate the podcast a five out of five and share it with a friend. For more information, please visit www.njent.com, or call or text us at 609-710-NOSE.
Nishant Reddy: Take care guys.
Greg Smith: Take care.