Blocked Nose
Differential Diagnosis
Common Diagnoses
- Vasomotor Rhinitis
- Allergic Rhinitis (Seasonal and Perennial)
- Nasal Polyps
- Adenoidal Hypertrophy (in Children)
- Nasal Septal Deviation (May Affect 20% of Adults)
Occasional Diagnoses
- Overuse of Over-the-Counter Nasal Decongestants (Rhinitis Medicamentosa)
- Chronic Sinusitis
- Papilloma
- Trauma (Including Septal Haematoma)
- Foreign Body (Especially Toddlers)
Rare Diagnoses
- Iatrogenic (e.g. Doxazosin)
- Carcinoma of Nose and Sinuses: Squamous Cell, Adenocarcinoma
- Other Rare Nasal Tumours (e.g. Melanoma, Teratoma)
- Unilateral Choanal Atresia
- Fibroangioma of Puberty
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Vasomotor Rhinitis | Allergic Rhinitis | Adenoids | Polyps | Septal Deviation | |
|---|---|---|---|---|---|
| Sudden Onset | Yes | Yes | No | No | No |
| Discharge | Yes | Yes | Possible | Possible | No |
| Sneezing | Possible | Yes | No | Possible | No |
| Unilateral | No | No | Possible | Possible | Yes |
| Previous Trauma | No | No | No | No | Yes |
Possible Investigations
Likely:None.
Possible:Sinus X-rays, allergy tests.
Small Print:FBC, adenoid X-ray, CT scan.
- Sinus X-rays may be helpful in confirming chronic sinusitis.
- Allergy tests may identify sensitivities to particular allergens.
- FBC: Eosinophilia in allergic rhinitis (though rarely required for diagnosis).
- Adenoid X-ray: Will confirm adenoidal hypertrophy.
- CT scan defines size and extent of nasopharyngeal carcinoma and sinus pathology.
Top Tips
- Nasal obstruction is usually the cause rather than the result of recurrent sinusitis. Dealing with the underlying problem may well relieve the sinusitis.
- Nasal allergy and polyps often coexist. It is worth trying medical treatment to relieve the symptoms before referring for polypectomy.
- Very sudden nasal blockage with profuse watery rhinorrhoea is likely to be caused by vasomotor rhinitis.
- If adenoidal nasal obstruction is present with possible hearing or speech difficulties, or possible sleep apnoea, refer with a view to adenoidectomy.
Red Flags
- Unilateral bloodstained discharge in an older patient with nasal blockage is sinister and suggests malignancy.
- Soft swelling on either side of the septum following trauma suggests septal haematoma. This should be evacuated to reduce the risk of cartilage necrosis and infection.
- Check what over-the-counter nasal sprays the patient has been using, remembering the possibility of rhinitis medicamentosa.
- A toddler with a unilateral nasal blockage and foul-smelling discharge is likely to have a nasal foreign body.