As a result of participation in this activity, participants should be able to:
1. Describe the most common causes of nasal obstruction.
2. Outline the initial treatment protocol that should be prescribed.
3.Discuss when referral to ENT and surgical intervention may be helpful.
Selected Podcast
Nasal Obstruction
Featuring:
Learn more about Jeffrey Johnson, MD
Jeffrey Johnson, M.D.
Jeffrey Johnson II, M.D., is an assistant professor and chief of the Division of Facial Plastic and Reconstructive Surgery in the University of Florida Department of Otolaryngology. Dr. Johnson received his medical degree from Indiana University School of Medicine in Indianapolis, Indiana. He then went on to complete his residency in Otorhinolaryngology- Head & Neck Surgery at the University of Texas Health Science Center in Houston, Texas. Dr. Johnson went back to Indiana University School of Medicine to complete his fellowship training in Facial Plastic and Reconstructive Surgery.Learn more about Jeffrey Johnson, MD
Transcription:
Intro: The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity. Welcome to UF Health Med EdCast with UF Health Shans Hospital. I'm Melanie Cole. Joining me today is Dr. Jeffrey Johnson. He's the division chief in facial plastic and reconstructive surgery and an assistant professor in the department of otolaryngology at the University of Florida College of Medicine.
Melanie Cole: And he practices at UF Health Shans Hospital. He's here to highlight nasal obstruction for us. Dr. Johnson, it's a pleasure to have you join us. As we get into this topic, tell us a little bit about the prevalence of nasal obstruction and what you see every day.
Dr. Jeffrey Johnson: So, this is a very common issue. There's multiple reasons to have nasal obstruction, but many people, you know, probably more than 50% of people suffer from some sort of nasal obstruction. That's difficulty getting airflow through the nose. And so people are getting chronic mouth breathers or at least intermittent mouth breathers. A lot of times it's more noticeable at night when people are lying down to sleep, but it could happen anytime throughout the day.
Melanie Cole: So, what are some of the most common causes that you see and deal with on a daily basis?
Dr. Jeffrey Johnson: The main issues we see are either more environmental related or structural. The environmental causes. These will vary throughout regions of the country, but usually have to do with pollen or pet dander, dust mites, other tree and wheat allergens. These particles are in the air. You're breathing through the nose. These are causing congestion. They cause increase in the size of the inferior turbinate, which are structures inside the nose that are designed to help warm and humidify the air as we breathe in, before it enters our lungs.
And when they become enlarged over time from chronic allergen exposure. That's what we call allergic rhinitis. So that's one of the most common diseases affecting adults. It's the most common chronic disease in children in the United States today, and a fifth, most common chronic disease in the US like overall population. Other symptoms would be clear red and watery eyes, itchy throat.
Melanie Cole: So Dr. Johnson as primary care providers are typically the first line of defense for patients as they present with some of these symptoms, tell us a little bit about what they would notice and what would send them for referral to ENT? Because sometimes these can be cared for in the primary provider or the medical home, but then there are times when the patient is presenting with other symptoms that would need referral.
Dr. Jeffrey Johnson: Definitely. And even if the cause is structural, not just the kind of allergens, like we talked about it, it is a deviated septum or they've had trauma in the past and there's some kind of structural abnormality. The first line of treatment is the same. And before we would pursue any kind of surgical intervention and as an ENT doctor, as a facial plastic surgeon, the first steps are a couple things. One is usually saline rinses. So one the major brain you'll see is Neo Meds sinus rinse. People might have heard of Netty parts.
You'll see ads on TV for Novage or other expensive ones. Not usually necessary, but some sort of nasal irrigation. It. Usually you're mixing distilled water with little premade saline packets, and that's getting rinse in one side of the nose and out the other side. So what this does, is it rinses out any of that mucus and clear drainage they're having it rinses out all the little allergen particles that are breathing into the nose, and it kind of moisturizes the nasal mucosa so that the Celia on the mucosa are moving well, gets your nose overall, cleaned and ready to receive the medication.
So the first line for allergic rhinitis or nasal obstruction is usually nasal steroid. The three most commonly used nasal steroids are fluticasone our trade name, Flonase, mometazone or trade name, Nasonex, and then triamcinolone, which goes by the trade name Nasal Court. These sprays are administered, at least once a day, usually twice a day, once in the morning, once at night.
It's important that the patient breathes through the mouth or holds their breath when they use the spray, rather than trying to inhale it strongly like a, like an asthma inhaler, the medicine's already aerosolized. So it will squirt into the nose where it needs to go. And the bottle needs to be aimed away from the septum, which is the layer of cartilage and mucosa that separates the two sides of the nose. So you want to end the tip of the bottle towards the outside corner of the eye on each side.
And that'll help prevent irritation of the nasal septum and for help prevent it from drying out too much. And so that's usually the first line treatment, the irrigations followed by the nasal steroids. It's also important to counsel the patients that these medications take about three to four weeks of daily use. To really get the full effect. It's not the sort of thing that will work immediately. Like other decongestants or over the counter decongestants. And many of these medications are over the counter now. Fluticasone can be bought over the counter or it can be got with a prescription.
If they have other allergy symptoms like itchy, watery eyes, scratchy throat, those sort of things. You could add an oral antihistamine second generation as well, which would be Allegra, Zytech or Claratin.
Melanie Cole: So then discuss when surgical intervention may be helpful. And what does that discussion look like with patients?
Dr. Jeffrey Johnson: So when patients have tried the irrigations and the nasal steroids for at least four to six weeks, and they haven't had any significant improvement, that's when it's a good time to refer to an ENT doctor to kind of see if there's other structural abnormalities going on. Ideally at that point in time, all the inflammation in the nose should be minimized. There are still cases where the medications just don't work that well. and you need to add on another medication or you may allergy testing, but either way, that's a good time to refer from primary care when they've failed the first line treatment, which is the nasal steroids.
And generally it depends what the actual issue. Usually there may be some bit of inferior turbinate hypertrophy. 70% of the population has a deviated septum. That doesn't mean 70% of the people in the population need a septoplasty, but is very common to have a nasal septal deviation. And that can either be from trauma. That could be minor, early on in life or major trauma with nasal fractures at the same time, or sometimes they just kind of grow crook ed as we develop. And so surgery, usually involves shrinking the sides of the inferior turbinates, straighten the septum.
And then a lot of people also have what we call nasal valve collapse. This is where the side walls of the nose and the cartilages that form the tip of the side walls of the nose are weak and they collapse against the septum obstructing the nasal airway as well. So it's usually important to figure out which of those three things are causing the issue. Generally surgery is done through just cuts on the inside of the nose without any external changes to the nose in most cases.
If people have had trauma previously, or there's other issues with the nose, either congenital or cosmetic deformities that they see as well, that can all be taken care of at the same time as the surgery for the inside of the nose.
Melanie Cole: Before we get into, when you feel that it's important for primary care providers to refer to ENT at UF health Shans Hospital. When you're speaking to patients about home care and things that they can do while they're doing lavage, steroids, possibly surgical intervention, what would you like them to know about triggers and things that happen at home? So that primary care providers may counsel their patients on these home care solutions.
Dr. Jeffrey Johnson: Very important. So, if they haven't had allergy testing or they have if they've had allergy testing, we may know what the triggers are, or even without that, the patient may notice that they're around the dog more, they get more symptoms, right? So pet dander may be an issue or there's a bunch of yellow pollen on all the cars outside. So maybe that's a trigger certain times of the year or worse. Other things like dust mites, you may not notice. So good things to do at home are get a HEPA filter for the room, make sure that you're laundering the sheets regularly.
Making sure that the house is clean overall, those things can all help. You can see there's certain times where you're outside versus inside that's worse, but main thing is just keeping the air quality as, as good as you can inside the house as well. And if you do have exposure to animals, then that seems to make it worse. Then maybe trying to limit that.
Melanie Cole: And when do you feel it's important to refer to ENT because that certainly is the question for the medical home and primary care is when can they deal with these in office and when should they refer?
Dr. Jeffrey Johnson: Definitely. I think once they have tried a patient on the nasal irrigations and the steroids and patients are actually been compliant with that, used for at least four or six weeks. And they've gotten no improvement or only minimal improvement. I think that's a reasonable time to refer refer. Or if on physical exam they see an obvious deviation of the septum or anything that looks like it might be a growth inside the nose or increased size of the inferior turbinate. Either way, we need to make sure that they've tried the nasal steroids for at least four or six weeks first.
That's really the major turning point in when we want to refer to ENT and then from there, we know you can we get allergy testing if necessary, we can try other nasal sprays to add on top of that. One of them is as elastin or Astilin, that's a nasal antihistamine. So you could add that in addition to the Flonase, at the time of referral, that's another option, but any obvious deformity of the nose would be a good 10 fur. And then once they've failed the irrigation nasal steroid routine for about a month or six weeks, that's a good time to refer.
One other thing to rule out during the initial period is something we call rhinitis Medica mentosa. So this is from overuse of oxymetazoline, trade name Afrin, but the more I've seen patients, the more I've noticed that VIX simply sailing all the, a few other brands have their own kind of nasal sinus spray that they've rebranded and it's just oxymetazoline under a new name. So patients don't know that it's Arine and if this is used more than three days in a row, you can get a rebound swelling of the nasal tissue. And that only thing that will make it feel better is more of the Aron or more of the oxymetazoline. That's really important that we get patients weaned off of this medication, if they are using it.
Melanie Cole: What a great point that you made Dr. Johnson so important and what an educational podcast this was, thank you so much for joining us today. And to refer your patient or to listen to more podcasts from our experts. Please visit UFhealth.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shans Hospital. I'm Melanie Cole.
Intro: The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity. Welcome to UF Health Med EdCast with UF Health Shans Hospital. I'm Melanie Cole. Joining me today is Dr. Jeffrey Johnson. He's the division chief in facial plastic and reconstructive surgery and an assistant professor in the department of otolaryngology at the University of Florida College of Medicine.
Melanie Cole: And he practices at UF Health Shans Hospital. He's here to highlight nasal obstruction for us. Dr. Johnson, it's a pleasure to have you join us. As we get into this topic, tell us a little bit about the prevalence of nasal obstruction and what you see every day.
Dr. Jeffrey Johnson: So, this is a very common issue. There's multiple reasons to have nasal obstruction, but many people, you know, probably more than 50% of people suffer from some sort of nasal obstruction. That's difficulty getting airflow through the nose. And so people are getting chronic mouth breathers or at least intermittent mouth breathers. A lot of times it's more noticeable at night when people are lying down to sleep, but it could happen anytime throughout the day.
Melanie Cole: So, what are some of the most common causes that you see and deal with on a daily basis?
Dr. Jeffrey Johnson: The main issues we see are either more environmental related or structural. The environmental causes. These will vary throughout regions of the country, but usually have to do with pollen or pet dander, dust mites, other tree and wheat allergens. These particles are in the air. You're breathing through the nose. These are causing congestion. They cause increase in the size of the inferior turbinate, which are structures inside the nose that are designed to help warm and humidify the air as we breathe in, before it enters our lungs.
And when they become enlarged over time from chronic allergen exposure. That's what we call allergic rhinitis. So that's one of the most common diseases affecting adults. It's the most common chronic disease in children in the United States today, and a fifth, most common chronic disease in the US like overall population. Other symptoms would be clear red and watery eyes, itchy throat.
Melanie Cole: So Dr. Johnson as primary care providers are typically the first line of defense for patients as they present with some of these symptoms, tell us a little bit about what they would notice and what would send them for referral to ENT? Because sometimes these can be cared for in the primary provider or the medical home, but then there are times when the patient is presenting with other symptoms that would need referral.
Dr. Jeffrey Johnson: Definitely. And even if the cause is structural, not just the kind of allergens, like we talked about it, it is a deviated septum or they've had trauma in the past and there's some kind of structural abnormality. The first line of treatment is the same. And before we would pursue any kind of surgical intervention and as an ENT doctor, as a facial plastic surgeon, the first steps are a couple things. One is usually saline rinses. So one the major brain you'll see is Neo Meds sinus rinse. People might have heard of Netty parts.
You'll see ads on TV for Novage or other expensive ones. Not usually necessary, but some sort of nasal irrigation. It. Usually you're mixing distilled water with little premade saline packets, and that's getting rinse in one side of the nose and out the other side. So what this does, is it rinses out any of that mucus and clear drainage they're having it rinses out all the little allergen particles that are breathing into the nose, and it kind of moisturizes the nasal mucosa so that the Celia on the mucosa are moving well, gets your nose overall, cleaned and ready to receive the medication.
So the first line for allergic rhinitis or nasal obstruction is usually nasal steroid. The three most commonly used nasal steroids are fluticasone our trade name, Flonase, mometazone or trade name, Nasonex, and then triamcinolone, which goes by the trade name Nasal Court. These sprays are administered, at least once a day, usually twice a day, once in the morning, once at night.
It's important that the patient breathes through the mouth or holds their breath when they use the spray, rather than trying to inhale it strongly like a, like an asthma inhaler, the medicine's already aerosolized. So it will squirt into the nose where it needs to go. And the bottle needs to be aimed away from the septum, which is the layer of cartilage and mucosa that separates the two sides of the nose. So you want to end the tip of the bottle towards the outside corner of the eye on each side.
And that'll help prevent irritation of the nasal septum and for help prevent it from drying out too much. And so that's usually the first line treatment, the irrigations followed by the nasal steroids. It's also important to counsel the patients that these medications take about three to four weeks of daily use. To really get the full effect. It's not the sort of thing that will work immediately. Like other decongestants or over the counter decongestants. And many of these medications are over the counter now. Fluticasone can be bought over the counter or it can be got with a prescription.
If they have other allergy symptoms like itchy, watery eyes, scratchy throat, those sort of things. You could add an oral antihistamine second generation as well, which would be Allegra, Zytech or Claratin.
Melanie Cole: So then discuss when surgical intervention may be helpful. And what does that discussion look like with patients?
Dr. Jeffrey Johnson: So when patients have tried the irrigations and the nasal steroids for at least four to six weeks, and they haven't had any significant improvement, that's when it's a good time to refer to an ENT doctor to kind of see if there's other structural abnormalities going on. Ideally at that point in time, all the inflammation in the nose should be minimized. There are still cases where the medications just don't work that well. and you need to add on another medication or you may allergy testing, but either way, that's a good time to refer from primary care when they've failed the first line treatment, which is the nasal steroids.
And generally it depends what the actual issue. Usually there may be some bit of inferior turbinate hypertrophy. 70% of the population has a deviated septum. That doesn't mean 70% of the people in the population need a septoplasty, but is very common to have a nasal septal deviation. And that can either be from trauma. That could be minor, early on in life or major trauma with nasal fractures at the same time, or sometimes they just kind of grow crook ed as we develop. And so surgery, usually involves shrinking the sides of the inferior turbinates, straighten the septum.
And then a lot of people also have what we call nasal valve collapse. This is where the side walls of the nose and the cartilages that form the tip of the side walls of the nose are weak and they collapse against the septum obstructing the nasal airway as well. So it's usually important to figure out which of those three things are causing the issue. Generally surgery is done through just cuts on the inside of the nose without any external changes to the nose in most cases.
If people have had trauma previously, or there's other issues with the nose, either congenital or cosmetic deformities that they see as well, that can all be taken care of at the same time as the surgery for the inside of the nose.
Melanie Cole: Before we get into, when you feel that it's important for primary care providers to refer to ENT at UF health Shans Hospital. When you're speaking to patients about home care and things that they can do while they're doing lavage, steroids, possibly surgical intervention, what would you like them to know about triggers and things that happen at home? So that primary care providers may counsel their patients on these home care solutions.
Dr. Jeffrey Johnson: Very important. So, if they haven't had allergy testing or they have if they've had allergy testing, we may know what the triggers are, or even without that, the patient may notice that they're around the dog more, they get more symptoms, right? So pet dander may be an issue or there's a bunch of yellow pollen on all the cars outside. So maybe that's a trigger certain times of the year or worse. Other things like dust mites, you may not notice. So good things to do at home are get a HEPA filter for the room, make sure that you're laundering the sheets regularly.
Making sure that the house is clean overall, those things can all help. You can see there's certain times where you're outside versus inside that's worse, but main thing is just keeping the air quality as, as good as you can inside the house as well. And if you do have exposure to animals, then that seems to make it worse. Then maybe trying to limit that.
Melanie Cole: And when do you feel it's important to refer to ENT because that certainly is the question for the medical home and primary care is when can they deal with these in office and when should they refer?
Dr. Jeffrey Johnson: Definitely. I think once they have tried a patient on the nasal irrigations and the steroids and patients are actually been compliant with that, used for at least four or six weeks. And they've gotten no improvement or only minimal improvement. I think that's a reasonable time to refer refer. Or if on physical exam they see an obvious deviation of the septum or anything that looks like it might be a growth inside the nose or increased size of the inferior turbinate. Either way, we need to make sure that they've tried the nasal steroids for at least four or six weeks first.
That's really the major turning point in when we want to refer to ENT and then from there, we know you can we get allergy testing if necessary, we can try other nasal sprays to add on top of that. One of them is as elastin or Astilin, that's a nasal antihistamine. So you could add that in addition to the Flonase, at the time of referral, that's another option, but any obvious deformity of the nose would be a good 10 fur. And then once they've failed the irrigation nasal steroid routine for about a month or six weeks, that's a good time to refer.
One other thing to rule out during the initial period is something we call rhinitis Medica mentosa. So this is from overuse of oxymetazoline, trade name Afrin, but the more I've seen patients, the more I've noticed that VIX simply sailing all the, a few other brands have their own kind of nasal sinus spray that they've rebranded and it's just oxymetazoline under a new name. So patients don't know that it's Arine and if this is used more than three days in a row, you can get a rebound swelling of the nasal tissue. And that only thing that will make it feel better is more of the Aron or more of the oxymetazoline. That's really important that we get patients weaned off of this medication, if they are using it.
Melanie Cole: What a great point that you made Dr. Johnson so important and what an educational podcast this was, thank you so much for joining us today. And to refer your patient or to listen to more podcasts from our experts. Please visit UFhealth.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shans Hospital. I'm Melanie Cole.