Nasal Obstruction (Chronic Blocked Nose)

What nasal obstruction is

Air enters the nose through the narrowest part of the whole airway, the nasal valve, just inside the nostrils. Even small changes here make breathing feel much harder. The septum divides the nose in two, and on each side three shelf-like turbinates warm and humidify the air. Their lining swells and shrinks naturally, alternating sides every few hours (the nasal cycle), which is why one side often feels a little blocked.

Doctors separate:

• Congestion: swelling of the lining, which changes over hours or days. See nasal congestion for short-term causes and relief.
• Structural obstruction: fixed narrowing from bone, cartilage or growths, which stays constant.

Most people with long-term blockage have a combination of both.

Common causes

Swollen lining (rhinitis)

• Allergic rhinitis: blockage with sneezing, itching and watery discharge, seasonal or year-round with dust mites and pets
• Non-allergic rhinitis: blockage and drip triggered by cold air, smells, smoke, alcohol or spicy food
• Rhinitis medicamentosa: rebound blockage from using decongestant sprays for more than a few days
• Hormonal causes: pregnancy rhinitis, hypothyroidism
• Medicines: some blood pressure drugs, erectile dysfunction drugs, and aspirin or NSAIDs in sensitive people

Structural causes

• Deviated nasal septum: a bend in the central wall, present from birth or after injury. Usually worse on one side.
• Turbinate hypertrophy: enlarged inferior turbinates, often alongside a deviated septum or chronic rhinitis
• Nasal valve collapse: the side walls of the nose fall inward when you breathe in, often after previous surgery or with age
• Nasal fracture that healed out of position

Growths

• Nasal polyps: soft, painless, grape-like swellings in both sides of the nose, linked to chronic sinusitis and asthma. They often cause loss of smell.
• Adenoids: in young children, enlarged adenoids at the back of the nose cause mouth breathing, snoring and a nasal voice.
• Tumors: rare. Most are benign, such as inverted papilloma, but cancer of the nose and sinuses must be ruled out when blockage is one-sided and progressive.

Other causes

• Foreign bodies in children, such as beads, toys or food, usually with a smelly, one-sided discharge
• Chronic sinusitis with thick discharge and facial pressure
• Inflammatory diseases such as sarcoidosis or granulomatosis with polyangiitis, which can cause crusting and bleeding

One side vs both sides

How doctors assess nasal obstruction

• History: when it started, one side or both, allergy symptoms, injuries, spray use, snoring and sense of smell
• NOSE score: a short questionnaire that rates how much the blockage affects you
• Examination with a light, and the Cottle test (pulling the cheek outward to see if breathing improves)
• Nasal endoscopy: a thin camera passed into the nose in the clinic, after a numbing spray, to see the back of the nose, polyps and adenoids
• CT scan of the sinuses if surgery is planned or chronic sinusitis is suspected
• Allergy testing by skin prick or blood test

Treatment

Medical treatment

• Steroid nasal sprays such as fluticasone, mometasone or budesonide: the most effective treatment for rhinitis and polyps. They take 1 to 2 weeks to work fully and must be used daily. Aim the spray toward the outer side of the nostril, away from the septum.
• Saline rinses with a squeeze bottle or neti pot, using distilled, sterile or boiled and cooled water
• Antihistamine sprays (azelastine, olopatadine) or combined steroid-antihistamine sprays for allergic rhinitis
• Ipratropium spray for a heavy runny nose
• Decongestant sprays for no more than 3 days
• Allergen avoidance and immunotherapy for confirmed allergies
• Biologic injections, such as dupilumab, for severe nasal polyps with chronic sinusitis that return after surgery

Surgery

When structure is the main problem and medicines have not helped:

• Septoplasty to straighten the septum
• Turbinate reduction using radiofrequency, coblation or partial removal, often combined with septoplasty
• Functional valve surgery or implants for nasal valve collapse
• Endoscopic sinus surgery to remove polyps and open sinuses
• Adenoidectomy in children

Most procedures are day surgery, and the nose stays somewhat blocked for 1 to 2 weeks while it heals.

Complications of untreated obstruction

• disturbed sleep, snoring and worsening of sleep apnea
• dry mouth and sore throat from mouth breathing
• recurrent sinus infections
• reduced sense of smell and taste
• in children, poor sleep, behavior and concentration problems, and changes in facial growth with long-term mouth breathing

Frequently asked questions

Why is my nose always blocked?

The most common reasons are allergic or non-allergic rhinitis, a deviated septum, enlarged turbinates, nasal polyps or overuse of decongestant sprays. Often several are present together. If a daily steroid spray used correctly for a month does not help, see a doctor or ENT specialist for an exam and possibly endoscopy.

Why is only one side of my nose blocked?

Mild alternating blockage is normal because of the nasal cycle. Constant one-sided blockage is usually a deviated septum. If it is getting worse or comes with bleeding, smelly discharge, facial numbness or pain, it needs examination to rule out a polyp, foreign body or, rarely, a tumor.

What is the best treatment for nasal obstruction?

It depends on the cause. A daily steroid nasal spray with saline rinses is the first treatment for rhinitis and polyps. Structural problems such as a deviated septum, enlarged turbinates or valve collapse respond best to surgery. Avoid long-term decongestant sprays, which make blockage worse.

Can a blocked nose cause sleep apnea?

A blocked nose alone rarely causes obstructive sleep apnea, but it worsens snoring and can make existing sleep apnea worse and harder to treat with CPAP. Treating nasal obstruction often improves sleep quality and CPAP comfort. In children, large adenoids and tonsils are a common cause of sleep apnea.

Is nasal obstruction surgery worth it?

For people whose blockage is mainly structural, septoplasty and turbinate reduction improve breathing in most patients, according to otolaryngology consensus statements. Surgery does not cure allergies, so many people still need sprays afterward. A specialist exam helps decide whether surgery is likely to help.