How does a doctor get to the right diagnosis? He follows the clues. Most of the time, he has to extract the clues from an uncooperative patient. Get your white coat. Now you need to display all your sleuthing skills... and become a hybrid between a blood hound (known for following the trail), Dr Gregory House (known for fitting the puzzle pieces together) and Florence Nightingale (known for her emphathy and care). So let's call this the "Dr Sniffles Housingale Diagnostic Game".
Background about the crime scene (your nose)
The nose's main function is to humidify, warm and filter air before it reaches the lungs.
Secondary functions are to provide smell (an aid to diet and a warning sense), an airway for breathing, and sinuses to lighten the skull. The sinuses are also the brain's own airbags - they protect the midbrain and brain stem from frontal trauma.
The nasal lining is a respiratory lining (similar to the lining inside your lung pipes and lungs with mucin-producing cells, and brushlike hairs. Most nasal pathology can be related to changes in airway anatomy, in the quality or quantity of the secretions, or in the function of the mucosa.
Critical to understanding the workings and function of the nose is the unified airways theory, an understanding that the nasal passages, throat and lungs comprise a single unit in terms of much pathology and need to be treated as such.
For example, 70% of asthmatics also have hayfever or blocked nose and may not improve on asthma medication alone until the nose problem has been treated. If you ignore the humble nose, many respiratory ailments will not get better on treatment. This applies particularly to children with other ear-, nose or throat and/or respiratory problems.
Now you are ready to go.
Step 1. Look and evaluate the clues
In nasal problems there is usually visual evidence of the cause of the pathology. A bit of knowledge and practical equipment can go a long way to help treat nasal conditions appropriately and successfully.
Is the nose deviated?
It is important to notice the overall shape of the nose – if the whole nose is deviated due to an earlier fracture (maybe in a car accident, or during a rugby game, or a blow to the nose), the septum between the right and left nostrils has to be deviated. So if the septum is deviated, an element of obstruction may be present.
Look for obstruction
A lump protruding from either the midline or the sides of the noses, into the nasal passage, may indicate if your are dealing with a septal problem (if the lump is from the midline) or maybe nasal polyps from the sides of the nose.
Look for signs of inflammation
The nasal mucosa may look:
- more red, swollen and inflamed than normal, with scabbing and crusting anteriorly as in vestibulitis (it may be any form of rhinitis except allergic rhinitis), or
- pale and boggy as in allergic rhinitis. A good sign of definite rhinitis is to see strands of mucus spanning the nasal cavity from one mucosal surface to another.
Look for nasal polyps
They are large, grapelike or fleshy in nature and can be grasped and removed without discomfort.
Look for a discharge
A yellow discharge from the nose is indicative of sinusitis, but not all pus in the nose is indicative of bacterial sinusitis. A unilateral nasal discharge in a child usually indicates a foreign body, particularly if associated with halitosis (bad breath) or nose picking. The same symptoms in an adult may indicate the presence of a tumour.
Step 2. Putting it all together
A. Can it be rhinitis (nose infection)?
If the nasal passages are red and swollen, with or without a deviated septum or an obstruction, with a runny nose, it can be any form of rhinitis (nose infection) but not allergic rhinitis (hayfever).
If the nasal passages are pale and boggy, with or without a deviated septum or an obstruction, with a runny nose, it can be hayfever (allergic rhinitis).
Finding the cause of the rhinitis (nose infection), will determine the management
This inflammatory condition has many causes, some of which may co-exist.
1. Hayfever (Allergic rhinitis). There is usually a clear history of provocation due to dust, animals or pollen. Some kinds of food can provoke allergic rhinitis. The nasal mucosa is usually pale and boggy with evidence of marked secretion.
2. Hyperactivity in the nose. This is the case when sneezing is followed by profuse watery nasal discharge and a blocked nose. The hyperactivity may be triggered by smells, emotions, temperature changes, foods etc. It is important to note that, this condition can co-exist with hayfever.
3. Oral contraceptives
4. Solvents and chemicals
5. Smoking. All smokers have a nose infection. Smoking cessation is the best treatment. A saline spray may help.
6. Pregnancy, due to hormonal changes. Corticosteroid sprays may be helpful and are generally accepted as being safe in pregnancy. Nasal decongestants, however, are less certain. The active chemicals are absorbed systemically, and may in theory enter the foetal circulation and could cause spasm of a critical vessel during formation of the organs of the foetus.
7. Drug-induced nose-infections (rhinitis medicamentosa). This is rebound swelling after overuse of nasal decongestants. A safe period of use of decongestants is about a week. Remember these sprays can aggravate hypertension if overused. Treatment involves stopping the spray, using cortisone in tablet or cream form. Cauterisation or a surgical procedure may be necessary.
8. Septum problems. Normal nasal function depends on smooth, laminar air flow through the airways. Disrupted anatomy makes this air flow turbulent, causing local mucosal trauma, drying and inflammation. The mucosa responds by making more mucus. The mucus cannot flow smoothly due to the anatomical narrowing, builds up, falls to the floor of the nose and is felt as a postnasal drip.
9. Infections such as the common cold. Treatment for rhinitis is removing the cause (if possible), topical cortisone or antihistamine nasal sprays.
B. What if it's sinusitis?
By definition sinusitis spans the clinical situations ranging from asymptomatic and minimal thickening and inflammation of the sinus lining due to something as simple as a cold, to complete filling of all sinuses with fungal, infective or inflammatory material that may require surgery.
Any attempt to classify or stage sinusitis is bedevilled by this range of extremes. The extent of the problem and the scope of this article permit only a few general statements.
Clinical diagnosis of sinusitis requires demonstration of inflammation and/or pus within the sinuses, either by visualisation of pus draining from the sinus cavities into the nasal passage, or radiological evidence.
X-rays are of little use in this situation – a limited CT scan of the sinuses has greater diagnostic value where there is uncertainty.
There is surprisingly poor correlation between severity of changes on a CT scan and symptoms. Diagnosis of sinusitis in children may be difficult and require a CT scan of the sinuses, but be aware of the dangers of overexposure to radiation in children.
Antibiotic treatment should be given for long enough to eradicate the infection – for most antibiotics this means for at least two weeks, continuing until the patient has been symptom-free for a week.
Surgery should be reserved for situations where thorough and appropriate medical therapy has beenunsuccessful, or the patient has been fully advised of the risks of surgical failure, complications or aggravation of the condition and still prefers the surgical route.
There is still uncertainty among surgeons as to what defines appropriate medical therapy: six weeks of antibiotics or as much as six months.
C. Can it be postnasal drip?
Are you aware of mucus dripping down the back of your throat?
The normal nose secretes up to a litre of mucus per day in a healthy subject. This mucus is normally moved by ciliary action in a blanket towards the throat where it is swallowed. Conscious awareness of this is due either to excessive secretions, secretions thicker than normal or increased sensitivity of the mucosal linings due to other influences.
A deviated septum or septal spur may be the cause, as is rhinitis due to any of the reasons mentioned above. Another major cause is heightened sensitivity and reflex hypersecretion of mucus due to extraoesophageal reflux, also known as silent reflux.
D. Can it be a blocked nose. Full stop?
In neonates a blocked nose is due to the hormonal influences of the mother during pregnancy. While distressing for the parent, it is seldom a serious issue. Using breast milk as a nasal drop, or saline, may solve the problem.
But Dr Housingale, you have to check if the nasal passage is indeed functional. You can do this by holding a flat, cold metal surface beneath the nose and watching for misting of each breath indicating the airway is indeed open.
Remember foreign bodies in young children. For some reason bits of sponge, pencil rubbers and BB gun bullets have a magnetic attraction for the nasal cavity at this age. This will usually be accompanied by a nasal discharge from one of the nasal passages.Bad breath may be the parent’s presenting complaint.
In adults the causes range from anatomical defects to inflammatory problems to possible cancer lesions. The entire nose has to be examined if simple treatments don’t work.
The nasal valves are the junction between nasal septum and upper lateral cartilages of the nose and are responsible for many cases of nasal obstruction where the septum itself looks normal and there is no other apparent cause. Cottle’s test (see above) is easily performed and diagnostic. Correction is by surgery.
E. if it is a nose-bleed, let's have a look at possible underlying causes
Nose-bleeds (epistaxis) is a common occurrence in young children, where local inflammation or vestibulitis can be exacerbated by nose picking. Staph aureus is often the thriving bacteria. Keep finger nails short and manage the vestibulitis with a topical antibacterial cream such as mupericin. Topical Vaseline is a good agent for long-term use.
If unsuccessful, the child will usually need cautery of the offending blood vessels.
Be aware that tumours, foreign bodies and blood diseases such as leukaemia can present with nose bleeds. In adults there is usually a local predisposing condition such as nose-infection or a deviated septum, or a general condition such as hypertension, or the patient may be on bloodthinning medication. If the bleed can be controlled by pinching the nose shut, the bleeding orginates from the front end of the nose, and is usually readily treated with local nasal packing.
However, nosebleeds from the deeper end of the nasal passage are far harder to treat. Nasal tampons (such as Merocel) that expand after insertion are easily used, require no special equipment to insert and are very practical. The modern standard of care in a difficult nosebleed is for an Ear-, nose- and throat specialist to indentify, cauterise and control the bleeding site under direct vision.
Prolonged periods of admission to hospital with uncomfortable nasal packs is an inferior (and barbaric) treatment alternative. Treatment of nosebleeds can in more serious cases involve surgical exploration, tying off of blood vessels and/or radiological embolisation.
F. What if it's a sinus headache?
Sinus headaches are very seldom experienced without other nasal symptoms.
The pain of facial congestion due to sinusitis is usually worse when the patient bends forward as blood rushes into the area of inflammation. A doctor should always ask about eye strain, dental problems and temporomandibular joint (TMJ) issues.
if a doctor examines the jaw joint for symmetry, and listen for clicks when the jaw is opened and closed, assymetry and clicks will often reveal the cause of headaches as a sinus headache. But remember that spasms in the large bulk of muscle on the inside van jaw (between the joint of the jaw and the eyes) causes headache often misdiagnosed as sinusitis.
Sinugenic headaches may be related to sinus congestion without infection, due to inefficient sinus drainage. These headaches sometimes manifest during change in air pressure, similar to ear discomfort due to change in altitude. Decongestants and nasal cortisone sprays may be useful, with surgery reserved for cases that do not respond to this treatment.
G. Can your nasal problems be due to trauma?
Facial trauma can fracture the septum without breaking the nasal bones, especially in children. X-rays for a fractured nasal pyramid are really of little practical use other than documenting an injury – the diagnosis is clinical. After trauma to tyhe face (a blow to the face/nose, a car accident, falling from a bunker bed or a bike) the doctor should always check to see that the septum remains central and there is no septal bleeding.
If a haematoma (a small dam of blood) is left undrained, it can result in a septal abscess which can cause damage to the brain or destroy the septum.
An undisplaced or cosmetically acceptable nasal fracture need not be reduced. The best time to decide is about a week after the injury when swelling has gone down and any deformity can be seen easily.
The two optimal times to reduce a fractured nose are either immediately or after all the swelling has settled, about a week to 10 days later. Any longer and the nasal bones will have already set and need to be refractured and reduced later.
H. Then theres the nasty Facial pain syndromes
Facial pain can result when the junction between septal cartilage and the bony part of the maxilla (upper jaw bone) grows into a septal spur, impinging on the outer nasal structures, and causing nose-infections and a postnasal drip.
Another consideration is this junction has been found to produce cytokines and substance produced during the inflammation process. Cytokines can cause pain and lead to headaches, facial pain or migraines. No diagnostic test can confirm this and surgical removal is the only means of confirmation and treatment.
I. Smell and taste - are these functions intact?
Normal taste is dependent on normal smell.
Appreciation of smell can be diminished due to congenital defects, trauma, inflammation, infection, a cancer lesion or due to the use of drugs or toxins. The specialist will need to perform a thorough endoscopic examination of the nose and a CT scan of the sinuses and base of skull.
J. And if the patient is enquiring about cosmetic nasal surgery?
Cosmetic nose surgery (rhinoplasty) may well be the most difficult cosmetic surgical procedure and has a 30% revision rate.
The more the change requested by the patient, the less certain the outcome. Male patients requesting rhinoplasty for reasons other than deviation after a fracture have a high rate of dissatisfaction after surgery.
A useful tool is to ask a patient to rate his/her nose out of seven with one being the worst possible and seven the best possible scenario. Surgical improvement by one point is quite doable, by two points expected, and by three points or more only in the hands of the best and most experienced rhinoplasty surgeons. Choose your surgeon wisely!
Dr Sniffles Housingale's conclusion:
It is not that easy or obvious to alway distinguish between some of the conditions which affects the nasal passages. Some symptoms apply to almost all conditions, but many are very specific. You get to the right diagnosis - and thus the proper treatment - by excluding some possibilities.
Compiled by Mari Hudson, medical editor Health24 and Dr Martin Young, a Knysna ENT surgeon in private practice, July 2011.