Dr. George H. Luciuk (biography and disclosures)
What care gaps I noticed
Nasal woes can cause lots of complications. Most of them start insidiously but can progress steadily. Awareness by the family physician of what “can happen” is very important. Most important is the fact that even though a patient doesn’t complain of nasal congestion symptoms, they sometimes are severely affected by nasal mucosal swelling and often times have had problems for many years undetected.
What changed my practice
After years of examining an awful lot of noses, I came to realize that direct visualization of the nose is the best method in conjunction with a good history to help dissect the patient’s problem. One without the other will result in a missed diagnosis. Most persistent symptoms are under appreciated by the patient until they cause a complication. Remember, the patient doesn’t have to complain of nasal congestion in order to have a significant problem with nasal mucosal swelling.
Most commonly, if they have a septal deviation to severe enough degree, then they may never get nasal congestion symptoms even though they have marked nasal mucosal swelling. On the other hand, the patient may have a very large nasal passage opening and can then “tolerate” much more mucosal swelling before actually causing some degree of obstruction. These patients will deny that they have any nasal congestion symptoms when asked even though they have significant pathology. In those cases, they may only complain of a runny nose, that is either runny down the front and dripping like a tap or running down the back of the throat and presenting with lots of “mucous in the back of my throat” or persistent throat clearing . The latter of which usually causes great distress for all others around them because of the repetitive irritating nature of it and oftentimes the patient doesn’t even realize there is a problem.
The converse is true for patients with very small nasal passages who obstruct very early with sometimes very little mucosal swelling. Petite “ski jumped” shaped noses are fashionably beautiful but can cause severe distress very early for their owners. The bigger the nose and the wider the nasal openings, the less trouble the patient will have with nasal congestion symptoms. Upon presentation to the office, these “petite” nose patients may have little to show physically for their symptoms at the time of examination but are severely obstructed at other times in the day especially in the evening. A little bit of mucosal swelling in these patients can cause severe obstruction much earlier.
Nasal congestion symptoms are usually worse at night when patients lie down to go to sleep or early in the morning. During the day patient symptoms are sometimes at their best and that, unfortunately, is usually when their noses are examined by their doctor. The history from your patient can be very important in conjunction with the physical examination.
What I recommend, practice tip
I have compiled a list of some of the signs and symptoms to watch for in the presenting patient with allergic rhinitis which I hope you find useful.
Symptoms: stuffy nose, sore throat especially at night or first thing in the morning, snoring, bad breath, itchy nose, crusty nose, ear plugging, fluctuating hearing, dry or itchy eyes, and nose bleeds (sometimes this can occur for two years before they develop signs of nasal congestion).
Complications are interference with sleep and subsequent effects on cognition, irritability and difficulty concentrating, and sometimes “brain fog”. There could be recurrent infections – sinus, ear or recurrent sore throats with negative cultures.
More long term complications include gingival and periodontal disease. In children, oral facial malformation with open bites can develop. It can also affect a patient’s ability to perform as well as they should otherwise be doing. In other words, the nose can cause a significant effect on the overall quality of life. Not a bad list considering it is “just a stuffy nose!”
A final thought to leave you with from one of my old professors: Remember, the nose is that part of the respiratory track that is easily accessible by your finger and otoscope! So most importantly, get use to looking at lots of noses as a routine part of your physical exam. You will more easily pick up the pale boggy turbinates sometimes with lateral wall pseudo turbinates that are most commonly seen in the allergic nose — even in infants as young as six months of age. It will make you a better clinician and your patients will love you even more when you use this information to help sort out the true ramifications of “just a stuffy nose”!
Additional reading:
http://www.entusa.com/nose_photos.htm
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Need to start looking in more noses!
I always look in noses and recognize most of the issues brought up by Dr. Luciuk. It neatly put together the value of doing such a simple exam.
Good review. Great tips!
Good photos on the link. I haven’t seen a lot of those things in practice, so nice to be able to get a quick refresher, as well as a brief bit on management.
Thanks for the reminder.
good photos!
A lot of nasal pathology out there if you are looking for it. Good reminder.
A good update on a far-too-common condition.
Always a good thing to have a clean nasal speculum in your office. I’m surprised by patients who frequently will comment, ‘Doc, your the first Doctor who ever looked in my nose!”
no change. Comment is valid.
I often look in patients noses. Good reminder.
thanks for the review, will keep in mind the varied symptomatology that can present with allergic rhinitis.
A great reminder, one practice that tends to slide as the years in practice move along. You have motivated me to try harder here. Thanks.
Its true, we forget the nose unless people really complain about it. Why are we shy about looking up there?
Thanks for the reminder.
Great picture reference!
Agree that looking up the nose is very useful. Recently had an 8[!] year old girl with profuse but clear not purulent discharge for 3 months. Lo and behold green plastic bead that ENT had to remove under GA.
A good article….but….how about treating the problem? Nothing seems to work!
Good article careful examination important