The blocked nose and its impact on your health – What can be done?

In the previous article, we discuss the impact of a blocked nose and how many of us may not be aware we are blocked nor the health implications. So what can we do?

For any blocked nose, there are two components. Firstly a reversible component that is usually due to the congestion of the nasal lining. Secondly there is a non-reversible component due to a bent septum or excessive tissue that has built up over time and has become non-reversible.  These may exist in isolation by themselves, or co-exist and collaborating together to narrow the nasal airway to the detriment of your health.

Saline nose douching, topical steroid sprays and antihistamines as well as rest can reduce the reversible component of the blocked nose. When we are stressed and do not have enough sleep, our nasal vessels are more likely to be congested. In individuals with only allergy related blockage, this is very effective treatment, which is usually required seasonally, or long term for as long as the offending allergen/s is in your environment e.g. house dust, molds, pollens, etc. A good regimen of care will also reduce the severity of the other down line impacts of a congested nose e.g. sinusitis, mouth breathing and sore throats. In some case with headaches, the reduction in contact between the internal nasal tissues as well as reduced congestion and re-venting of the sinuses also reduces or abolishes these headaches.

However even after a trial of medical treatment, you may still find your nose blocked, and the treatment only partially effective. An endoscopic examination of the nose with possible imaging of the sinuses may declare that the obstruction is substantial due to pre-existing anatomical changes in the nose. The septum may be bent, the nasal lining now too swollen and thickened, nasal polyps may have formed which no longer can be reduced and/or the sinuses are chronically infected, and their openings now are too blocked for medical treatment to reverse the condition. Under these conditions, together with a clear history of symptoms and signs, surgery may be the solution. Surgery may include straightening the septum, reducing the turbinate size, removing the nasal polyps, re-venting the sinus openings and rinsing out the sinuses, or any of these combinations. Essentially the aim is to undertake whatever is necessary to improve the nasal airway and to permit natural re-venting of the sinuses.

So we can now breathe better after surgery and our overall health and sleep has improved. But does it end with surgery? Our environment usually remains the same; there is house dust, molds and pollens around us still. Some of us are still going to require saline irrigation of the nose and nasal sprays for the allergic flare-ups. Well funnily enough, opening the nasal airway by surgery does not only just improve airflow, it also improves the access for delivery of saline during nasal douching, and drug delivery via nasal sprays. That is the bad news. The good news is that most of us do not require long-term medical treatment… and all of us will live and sleep better now that the nose breathes better.

The Chinese version of this article was published in Hong Kong Economic Journal on 20 July 2015

The blocked nose and its impact on your health

Who hasn’t had a blocked nose? Especially when we have a cold and, thank goodness that the blocked nose, runny nose, sneezing as well as fever last only a few days. So can you imagine having a blocked nose all the year round? Most of us cannot imagine this! Yet most of us who live in polluted cities like Hong Kong probably are walking around with a blocked nose; a chronically blocked nose that creeps up on us so slowly that we never even guessed it.

Aside from smelling fragrances, the aroma of food, the appreciation of flavor as well as making our face look more beautiful, our nose has another far more important job. It protects our lungs by warming, filtering and cleansing the air before it reaches our delicate lungs. If the air is dirty, it causes our turbinates to swell inside so as to narrow or even block our nasal passages so that the air cannot enter. Our nose secretes mucus to wash away the dust and pollen, and if that is not enough, it gets all itchy and makes us sneeze so we can blow out the dust-filled mucus. So what happens to us when our nose gets chronically blocked? Actually quite a lot can happen. It affects our nose, our sinuses and eyes, our ears, our throat and finally our beauty sleep.

When the nose is blocked, we experience a nasally voice and have a postnasal drip. As the sensitive turbinates inside the nose swell up, they may make contact with one another or with the septum, and this sometimes causes “Sluder’s headaches” with pain of one/both temples, at the top and/or the back of the head. This may sometimes be mistaken for the more uncommon migraine.

When the lining of the nose is swollen, it also blocks the openings of structures that open into the nose. Blockage of any of the sinuses that drain into the nose can cause sinus pressure headaches above, below, between or behind the eyes as well as at the top of the head. A bacterial sinusitis can also occur if the sinuses cannot drain themselves. Our tear ducts also drain into the nose so a blocked nose may cause our eyes to “flood” more with tearing, impairing our clear vision. This can be troublesome indeed.

At the back of the nose lies the opening to the Eustachian tubes that re-pressurise our middle ear compartment. If the nose, and therefore the tube is blocked, a lower middle ear pressure can result. This is the same feeling we experience when a plane lands. Sometimes though it can be very painful especially for children. Longstanding obstruction of this tube often leads to repeated middle ear infections and/or perforated eardrums, and hearing problems especially in children.

So our nose is block. That is not a problem as we can breathe though our mouth, right? Correct…we can breathe through our mouth but why then do we need a nose? Actually most of us would automatically start to breathe though our mouth without realizing it when our nose is blocked. This leads to so many things like dry lips, bad breath, repeated mouth ulcers, sore throats that lead to large tonsils and repeated tonsil infections. Breathing and speaking through our mouth becomes a problem too. As the mouth gets drier, we cannot sense that we are breathing in less air than we should so. So when we speak, we cannot project our voice well. So we compensate by powering up our voice box to do all the work and that is why we end up with a hoarse voice.

Finally the blocked nose and the compensatory mouth breathing affects even our sleep. Although the mouth is a larger opening for air, inside our throat sits our mobile tongue and also tonsils. These sometimes are sucked in and obstruct during sleep, as the nose cannot act as its usual passage for air intake. Snoring, poor quality sleep and maybe even obstructive sleep apnea then occurs. Over time, the poor quality sleep we get every night makes us irritable, easily frustrated, gives us oily skin with acne, eye bags and a generally darker facial complexion.

All the above can occur because of a chronically blocked nose. The interesting thing is that many of us remain unaware that is happening as the process is such a gradual one. However, as quietly as it can be blocked, thankfully it can also be reversed with medication and/or surgery. So yes… we can still get the beauty sleep in our beautiful city…and all because of a nose!in our beautiful city…and all because of a nose! 

The Chinese version of this article was published in Hong Kong Economic Journal on 1 June 2015

Sinus and nose-related headaches – Treatment

In the last article, we discussed the causes of sinus and nose related headaches. These include causes such as:

·        nose allergy,

·        a bent nasal septum blocking the sinus opening or in contact with the    

         opposite nasal lining,
·        a narrowed sinus opening/s with a sinus infection and
·        an obstructed sinus with a negative sinus pressure

Sometimes possibly all of the above can be present in the same person at the same time. All of these conditions can stimulate and irritate the trigeminal nerve, which then generates the headache that we feel.

Treatment begins with the correct diagnosis. A full external and internal endoscopic examination of the nose should be undertaken. In instances when a sinus-related cause is suspected e.g. facial pains above, behind and below the eyes, and at the top of the head, a CT scan of the sinuses can exclude sinus disease. X-ray of the sinuses are traditionally undertaken but for a more comprehensive picture, CT scans provide a great deal more information as well as serve as the roadmap for sinus surgery should that be required.

Usually common things happen commonly, and by far the commonest nasal cause of a headache is inflammation of allergy or infection. If infection is seen, a simple course of antibiotics can be undertaken. Nasal allergy is easily treated also by avoiding the allergen e.g. house dust or pollen, saline nasal irrigation, topical nasal steroids and/or antihistamines. The reduction in the inflammation desensitizes the nasal lining as well as reduces the possibility of nasal lining contact and sinus obstruction.

Perhaps the next most likely cause for nasal irritation is when two opposing nasal linings touch one another forming a trigger point. This is likely to occur when the nasal septum is bent inside the nose. Often the patient would be aware of the bent septum as they are aware of a blocked nose, more on one side than the other although both may be equally blocked.

Sometimes a frank sinus infection is seen on endoscopy. Then antibiotic treatment with nasal decongestants also, would normally suffice, as sinus surgery is not the usual first line treatment modality. However in situations when the sinus condition becomes chronic without relenting or recurrent, then usually a more permanent solution to re-open the sinus drainage and re-vent the sinuses may be indicated. Nowadays, sinus surgery is extremely high tech, using endoscopes for minimally invasive surgery. Surgery is targeted at re-opening the natural openings of the sinuses. To make the surgery even less traumatic, when appropriate, the sinus openings can be re-dilated with inflatable balloons; this technique is known as balloon sinuplasty.

So to summarize, nose and sinus-related headaches are not altogether that uncommon especially today in our polluted modern world. It should be differentiated from all the other causes of headaches by its picture. Treatment of these headaches are usually very successful once the correct diagnosis has been established, as there is often a triggering point that fires off the nerve-endings of the trigeminal nerve that gives us these so-called Sluder’s headaches. You can almost imagine Dr. Sluder himself having a bad headache when he first described it too! 

The Chinese version of this article was published in Hong Kong Economic Journal on 5 Jan 2015

Sinus and nose-related headaches – Why? & Causes

Headaches! We have all had them. There are many causes of headaches but this article relates to that arising from conditions that affect the nose and sinuses. Our nose is very sensitive. It has to be as it forms one of our earliest sense organ for finding food as well as arousing us to the presence of danger from predators or our changing environment. Many of us know the nose as an organ of smell (and therefore flavor) and this sensation comes from the olfactory nerve. The nose however has another nerve supply that provides us with the sensation of heat, cold, dry, humid and of course, pain. This sensation arises from the fifth nerve of our brain called the trigeminal nerve.

 

You all know this nerve, which innervates your face, eyes, nose, sinuses and teeth. It burns and gives you a headache if you do somersaults underwater in the swimming pool or take too much wasabi on your sushi. Your face burns from the inside and your eyes water. This is when your trigeminal nerve is being hyper-stimulated.

 

This same nerve is responsible for the headaches one can get from sino-nasal disease. If someone has nasal allergy, and especially if the septum (the bone inside your nose that separates the right from the left nostril) is bent, the lining of the nose expands considerably. When the hypersensitive linings touches one another, they can cause a localized headache at the top of the head, the temples or the back of the head. This kind of headache, or nerve pain, is known as Sluder’s neuralgia or Sluder’s headache.

 

Our sinuses are air-filled cavities inside our skull. These cavities have very narrow openings into the nose. Again, due to:

 

·        a nose allergy,

·        a bent septum blocking the sinus opening,

·        a narrowed sinus opening/s from recurrent infection

·        or all of the above in the same person at the same time,

 

The sinus opening/s become blocked. When this happens, a negative pressure is generated within the sinus and this can cause facial pains and headaches. If, on the other hand, there is a bacterial infection with pus formation, the pus will build up an intense pressure from within the sinus causing pain too. This change in pressure stimulates the nerve endings in the nose and sinuses, causing a sinus headache.

 

If only specific sinuses are affected like the frontal sinuses above the eyes, then a headache above and behind the eye may be felt.  Sinus headaches are peculiar in that the pain changes in intensity with position, being usually more painful when the head is lowered i.e. tying the shoelaces or picking something from the floor. Also the bony surface of the face just outside the inflamed sinus is painful to applied pressure from outside the face.

 

Naturally, as you now understand that sino-nasal inflammation can cause headaches, you will realize that any infection of the inside of the nose can do this too. Even when we are stressed, the nose lining inside swells up and this can manifest as a headache. Equally cancers of the nose, sinuses and nasopharynx can cause headaches as they stimulate the trigeminal nerve or block the sinus openings. Cancers are thankfully much, much less common than allergies. However in any case, any persistent or recurring headaches is best investigated for its cause and the correct treatment offered.

 

 

The Chinese version of this article was published in Hong Kong Economic Journal on 22 Dec 2014

Epistaxis / Nosebleeds – What to do

Nosebleeds can happen when you least expect it. At the very least, they are alarming especially with small children, and at the worst, possibly life threatening. So what can you do about the bleeding nose and what action should you take after it has stopped bleeding?

The first thing is to stop the “stoppable” bleeding. Bleeding that comes from the front of the nose can be stopped by pressure. All other bleedings from the middle or back of the nose stops only by your own blood clotting or with medical attention. The first thing to do in a nose bleed is place your head forward, breathe through the mouth and press gently but firmly on the soft part of the nose. This is the lowest third of the nose that you can wiggle with your fingers. Placing your head forward means that you will be less likely to choke and swallow your blood, and any continuing bleeding is clear to see. Pressure should be applied for 15 minutes and this is usually more than enough to stop the small bleed, as our blood will effectively clot in less than 3 minutes. If you are on blood-thinning medication, this can take much longer.

After releasing the pressure, if there is no further active bleeding, this suggests that the bleeding is from the front of the nose. Dry weather and a long flight travel in a dry cabin may be the cause and applying some Vaseline ointment inside the nostrils will help. Seeking the early attention of your ENT Physician would be recommended so that a good check up can be done to prevent further bleeds and treating the underlying cause. You can usually expect that the nose will be clearly visualized with an endoscope of the front, middle and back of the nose. Sometimes a scan of the sinuses may be required as the cavities of the sinuses are not usually visible to the naked eye or endoscope. If a bleeding point is identified, it can be electro-cauterized and this is very successful in preventing future bleeding in 90% of cases. If a nasal allergy causing rhinitis exists, this is also easily treated with medication.

If the bleeding is especially heavy and/or does not stop, it is usually from the middle to the back of the nose. Here the reason is because the vessels are larger and we cannot physically press on them as they are situated inside the face. Situations such as this will require immediate attention at your nearest hospital as you may have lost a lot of blood. Your attending doctor’s priority would be to stop the bleeding first. This is usually undertaken with nasal packs placed into the nose. They are uncomfortable to put in but their intention is life saving. They may then possibly refer you to the ENT Physicians to identify with their special endoscopes where the bleeding is coming from, and treat you accordingly. Nowadays modern endoscopes for the body cavities have revolutionized epistaxis care. After identifying the bleeding point, if appropriate, the source maybe cauterized.

 

Nosebleeds are frightening for the sufferer as well as family and friends. Thankfully the majority of nosebleeds are minor and easily stopped by pressure as mentioned above. If the bleeding is unduly heavy and does not stop, urgent hospital attention should be sought.

The Chinese version of this article was published in Hong Kong Economic Journal on 29 Sept 2014

 

Epistaxis / Nosebleeds – Why? & Causes

 

“Epistaxis” is the Latin word for the nosebleeds. Nose bleeding is very common and every one of us has experienced it at least once in our lifetime. As common as it is, 90% of nosebleeds do not have an identifiable cause after investigation. This is not a bad thing as it means that most nosebleeds have no sinister causes.

Our nose is supplied by blood from an internal and external arterial system. The external vascular supply comes from the vessel that brings blood to our face; hence it enter the nose from outside, causes the bleeding from the front of the nose where we get most of the bleeding. The internal vascular supply is more elaborate, coming off the vessels that bring blood directly to the brain. They supply the nose from the back under higher pressure and therefore nose bleed from the internal system tends generally to be more heavier; this is because we cannot press and stop the bleeding at the back for the nose with our fingers and also as the arterial blood pressure is stronger too.

So what causes nose bleeding? Several factors affect and cause nose bleeds. Firstly we need a blood vessel as the source, preferably near the surface of the lining. Vessels in the front of the nose are nearer the surface as the lining is thinner so nose bleeds from the front is therefore commoner. Next we also need a condition that makes the vessel more prone to bleeding. So, for example, if there is an existing inflammation like a nose allergy, infection or sinusitis, there is inflammation of the vessel with an engorgement by blood. Perhaps the wall of the vessel might be weak and breaks easily; we sometimes see this as the sole reason in the elderly population. Trauma from an accident to the nose or repeated trauma by the patient picking his/her nose can break the vessel too.  Obviously nasopharyngeal cancers, cancers of the nose and sinuses, vascular tumors and malformations can cause bleeding too. All tumor growths require a good blood supply to feed their growth and hence may present as a nosebleed early on.

 

Our environment also plays an important part in causing nosebleeds.  Our nose should be moist, and not dry. If it is dry, the lining breaks down and we bleed.  So sudden changes in the environment make the nose drier and can cause bleeding. This happens if we fly especially for long journeys or go from a warm, humid climate to visit a dry climate like a winter skiing holiday in the Alps or if the temperature suddenly drops like during the Winter Solstice in Hong Kong. An underlying condition or drug may also cause dryness of the nose. Patients with radiotherapy to the nose for previous cancer or atrophic rhinitis (an inflammatory condition of the nose that has caused a reduction in the mucus secreting cells of the nose) will predispose the lining of the nose to easy breakdown and bleeding.

Interestingly also the internal passage size of our nose also affects our frequency of nose bleeding too, by creating a drier environment. If one’s nose is narrower on one side, there is more turbulence generated when we breathe normally. This turbulence causes local drying effects, lining breakdown and therefore bleeding. This narrowing can be caused by a deviated septum of the nose, enlarged turbinate from nose allergy or sinus polyps that narrow the passages themselves.

So epistaxis/nosebleeds are common. The cause/s of any nosebleed is varied and is the interplay between the anatomy of the nose, an underlying condition and environment factors. As mentioned earlier, most nosebleeds have no significant cause. However if any nose bleeding persists, recurs and/or is unusually heavy, it is always best to seek an assessment by your ENT Specialist to exclude all causes. Thankfully here too, most causes are easily

treated.
 

The Chinese version of this article was published in Hong Kong Economic Journal on 15 Sept, 2014
      

Nose and throat causes of bad breath

Bad breath….we all have this sometimes, perhaps far more often than we know, and almost always when we do not want it like when we are about to meet an important client or on that important date, wanting to impress. Usually the causes of bad breath are due to foods, drinks and habits like garlic and onions, alcohol and smoking cigarettes, cigars or pipe tobacco. But bad breath can occur in health as much as in illness. Often we are able to tell if the bad breath is due to foods, drinks, smoking or illness.

So what causes bad breath in illness? Essentially our nose, mouth, throat and lower aero-digestive tracts (esophagus, lung, stomach, intestines) are colonized with bacteria at all times. The distribution of the different bacterial types ensures a nice equilibrium for health usually, and the continuous production of saliva and nasal mucus ensures that this population of bacteria remains well controlled. However when a nose and throat condition occurs to change this environment, especially to make it drier than the normal, the balance can change to favor bacterial overgrowth and/or the wrong bacterial type. In any and all situations for diseases causing bad breath, it is the change in the bacterial growth that causes the bad smells.

Let’s first look at the commonest causes of bad breath - a dry mouth. Whether the nose is blocked due to nose allergy or infection, the mouth tends to be drier as the mouth is now used to breath. This slowly changes the bacterial environment. This dry mouth feature is seen amongst us with obstructive sleep apnea and snoring where our noses tend to be blocked especially at night. Also some conditions may cause our salivary glands to shrink and produce less saliva e.g. Sjogren’s disease, radiation therapy, etc.

Mouth breathing has other consequences too. In addition to the bacterial change, a dry mouth predisposes us to gum disease and tonsil infections with consequently more infective bacterial colonization. If you have ever flossed your teeth, you will realize the fetor (bad smell) of the bacterial overgrowth that collects in the gum line. “Furring” of the tongue also occurs with mouth breathing. This means that the skin lining of the tongue becomes thicker and therefore can support more bacterial overgrowth. As for our tonsils, they have craters on the surface with sometimes deep skin-lined fissure that go deep into it. These fissures can collect bacteria with dead skin, be a source of bad breath and in some of us, produce “tonsils stones” which are the smelly soft and yellow-brown balls sometimes seen in the saliva we spit out.

Sinusitis is another cause of bad breath, with the smell coming from the nose. When the sinus openings are blocked, infection with pus can build up in the sinuses. This bad smell may sometimes be noted by the person himself and we call this “cachosmia”.  A more horrible Latin word is “ozaena” where the bad smell is noted by others, and not necessarily by the sufferer. Sufferers with “ozaena” include unfortunate patients with previous radiation therapy to the nose and sinuses, or any disease that can severely damage the natural mucus production of the nose. If it becomes so excessively dry, sometimes with crust formation, “saprophytic bacteria” (bacteria with a liking for dead tissue) dominates, and is the cause for the bad breath. In children, an interesting cause of ozaena is a foreign body e.g. bead, cotton bud, etc., placed in the nose, usually by the child. This becomes a source of infection and bad breath. Removal is necessary as well as to understand if the child is trying to tell us that they have a nose condition that requires treatment.

Thankfully the treatment philosophy is straightforward. Your doctor should investigate the cause and then treat the underlying problem either by medication, surgery or both. In addition, and at all times, good oral and nasal hygiene with good oral rehydration, tooth brushing, flossing, tongue scrapping, and saline nasal douching, should help to ensure  a sweeter breath for the day and night.

The Chinese version of this article was published in Hong Kong Economic Journal on  16 Jun, 2014