Blocked nose and the general method for sinusitis

The sinuses lead off the nose, so that disease in them usually follows disease in the nose. Sinusitis has some common features, regardless of which particular sinus is infected, so we will discuss these first, and deal with frontal (25.8) and maxillary (25.9) sinusitis later.

The common presenting symptoms in a patient's nose are: (1) discharge, (2) obstruction of his nasal airway, and (3) facial discomfort or pain.

Nasal obstruction is usually due to engorgement of the erectile vascular tissue in the mucosa over his inferior turbinates due to: (1) Labile control of his mucosal vessels, as the result of a wide variety of ''constitutional' and environmental factors. His mucosa swells and obstructs his airway, often with a watery nasal discharge, and bouts of sneezing. Psychosomatic factors may also affect the nose (''honeymoon rhinitis'). (2) An inherited atopic state. (3) Reaction to a specific allergen. (4) A foreign body can also obstruct his nose (25.11), as can (5) infection and (6) nasal polypi (25.10).

Facial pain or discomfort may be due to sinus disorders. Engorgement of his nasal mucosa may obstruct the natural ventilation of his sinuses, and cause a feeling of pressure in his cheeks, or forehead.

Acute sinusitis often follows a viral upper respiratory infection, and usually involves one of a patient's sinuses only. He presents with fever, a copious purulent discharge, and: (1) Pain, or a sense of pressure in his cheek (sometimes wrongly thought to be ''toothache'). (2) Obstruction of his nasal airway, often without the discharge of mucus or pus. (3) Swelling of his face (this is much more likely to be due to a dental abscess, 5.8). Tenderness over an infected sinus is not a useful sign.

Chronic sinusitis may follow acute sinusitis, if his resistance is low, or if he has nasal polypi, which prevent his sinuses draining. Pain is not a major feature, but he may have a dull ache in his face, usually later in the day. Bending his head forward can be uncomfortable.

BLOCKED NOSE [s8]AND SINUSITIS BLOCKED NOSE See also frontal (25.8) and maxillary sinusitis (25.9).

DIAGNOSIS. Exclude polypi (25.10) and foreign bodies (25.11).

MANAGEMENT. Enquire for psychosomatic factors and do your best to allay them.

If there is no more treatable cause, try a nasal steroid spray (beclomethazone, ''Beconase', or budesonide, ''Rhinocort') puffed into each nostril 3 or 4 times twice daily. Continue for 2 weeks before assessing its benefit. Try this for 3 or 4 weeks, and only continue it if there is improvement.

ACUTE SINUSITIS TREATMENT. Give him a broad-spectrum antibiotic (ampicillin or amoxycillin), and an analgesic (sinusitis is painful). Nasal decongestant drops are not helpful, and are uncomfortable to instil in the head-down position.

CHRONIC SINUSITIS EXAMINATION. Look for: (1) Obstruction (usually on one side only). (2) A discharge from the front of his nose, and a bead of yellow pus high above his inferior turbinate. (3) Pus on the dorsum of his soft palate. (4) Also, look at his handkerchief (if he has one), which may be stiff from dried pus (this does not happen with a watery discharge).

TREATMENT. Give him a broad-spectrum antibiotic, and encourage him to blow through his nose without pinching it to restrict his airway. The Venturi effect of doing this will draw pus out of his infected sinus. If he does not improve, wash out his antrum under local anaesthesia (25.9).

DIFFICULTIES WITH [s7]THE NOSE If he presents with dull red mucous membranes, and his nose contains many dried crusts, suspect CHRONIC ATROPHIC RHINITIS. There is little you can do for him, except not to mistreat him. This mostly means not giving him vasoconstrictor sprays and drops (including ephedrine), and persuading him not to buy them himself. They will only give him temporary relief, after which his symptoms will get worse. He will get some relief from a saline solution, sniffed as many times a day as is practical.