Blocked nose and nasal breathing

If it is always the same side, something structural is likely — a deviated septum, a narrowed nasal valve, or occasionally a growth — and that side needs to be examined with an endoscope. If the blockage cycles from one side to the other and back, it is the lining of the nose: the nasal cycle, in which the two sides of the nose take turns swelling and shrinking, is normal, but people with allergy, rhinitis or anything else that irritates the lining feel it far more than most.

Lying flat raises the pressure in the veins of the nose by about 8 mmHg, and the lining swells with it. A normal nose compensates by constricting its blood vessels; a nose that is already inflamed — allergy, rhinitis, enlarged turbinates — cannot, and you feel it the moment your head hits the pillow. Some medicines make this worse by preventing the compensation: blood pressure tablets, the alpha-blockers used for prostate symptoms, and a few others.

With rhinomanometry — a pressure-and-flow test. It measures how much air flows through each side of the nose against the pressure your breathing generates, and from that curve calculates the nasal airway resistance for each side. It needs to be done in a controlled clinical setting by a respiratory or research scientist who knows how to obtain a reliable result; this is available in our suite at Kogarah through the group’s nasal airway laboratory. The measurement matters because it is very hard, simply by looking in the nose, to tell whether what a patient calls ‘blocked’ is a true restriction of airflow or a sense of congestion from the lining — two different problems with different treatments. Prof Harvey’s review of nasal congestion (above) explains the distinction.

A corticosteroid spray will often unblock a nose when inflammation is the cause, and used correctly it is safe for long-term use. The better question is what you are treating. For a mild seasonal allergy, a regular steroid spray through the season is entirely appropriate. For a persistent, year-round problem — dust mite, or a reaction to something in the home or workplace (chlorine, hair dyes and other occupational exposures are common examples) — the spray is only suppressing the reaction. The solution then is to identify the trigger and remove or avoid it, or, for an allergen you cannot avoid such as dust mite (attempts to remove it from the home are largely unsuccessful in adults), to treat the allergy itself with immunotherapy. A steroid spray can fix the nose temporarily; when the rhinitis is chronic, the question is why it is there and whether something more permanent can be done about it.

Three operations deal with the structure of the nose: straightening the septum (septoplasty), re-supporting and tightening the nasal valve — the narrowest part of the airway, just inside the nostril — and reducing an inferior turbinate that is enlarged or no longer functioning. Which, if any, is right for you depends on first working out whether the nose is truly physically obstructed or whether the feeling is congestion from the lining — and that is why examination with an endoscope and airflow measurement come before any discussion of surgery.