Nasal Congestion or Obstruction

 

This guideline applies to adults aged 16 years and over.

 

Introduction

Nasal congestion or obstruction can be due to viral illnesses, allergic rhinitis, rhinosinusitis, nasal trauma, nasal polyps, foreign body, congenital malformations, nasal malignancy or drug-induced (e.g. overuse of nasal decongestants).

 

Red Flag Features

Nasal malignancy should be excluded in the context of new onset, persistent and/or rapidly progressive:

• Unilateral facial pain and/or swelling
• Unilateral epistaxis or crusting with nasal obstruction – simple epistaxis is typically unilateral at presentation
• Clear watery nasal discharge (CSF leak presents like a dripping tap)
• Bulging eye associated with visual disturbance, painful eye movements and/or double vision
• Dental changes e.g. loosening of upper teeth

Not an exhaustive list.

 

Management Optimisation

Adequate medical management prior to referral includes:

• Regular saline nasal irrigation.
• Intranasal steroids – maximum tolerated step on the nasal steroid ladder. 
• Allergic symptoms should be treated with intranasal steroids first line, in combination with antihistamines (intranasal or oral).
• Avoid prolonged (more than 1 week) or repetitive use of intranasal decongestants.

 

Advice and Guidance

Refer any suspected nasal malignancy via ENT Advice and Guidance – the consultant will consider the clinical information and advise regarding appropriate prioritisation and urgency of referral.

 

Advice and guidance is also available if:

• diagnostic uncertainty
• patient falls outside of referral criteria

 

Referral

Commissioning criteria apply to the surgical management of nasal obstruction/congestion.

Routine Adult ENT referral

Refer adults for consideration of septoplasty or septorhinoplasty if they have:

• Persistently bothersome symptoms resulting from nasal obstruction which have failed to respond to a 3-month trial of adequate medical management (including maximal tolerated step on the nasal steroid ladder) and where the patient would accept nasal surgery.

Refer adults (and children*) for consideration of adenoidectomy if they have:

• Persistent nasal obstruction secondary to adenoidal hypertrophy.

*Refer children and young people aged less than 16 years old to the Paediatric ENT Service.

 

Exclusions:

• Nasal obstruction associated with snoring, with no other bothersome symptoms, is not an indication for referral.
• Referral for rhinoplasty or septorhinoplasty for purely cosmetic reasons is not routinely commissioned¹.

 

Supporting Information and References

ENT UK – Blocked Nose

Royal College of Surgeons of England – Recovering from nasal septoplasty

 

References

1. NHS Cornwall ICB Treatment Policies

 

Page Review Information

Review date	17/10/2024
Next review date	17/10/2026
GP speciality lead	Dr Laura Vines
Contributors	Ms Aileen Lambert, Consultant ENT Surgeon Mr Neil Tan, Consultant ENT Surgeon