Endgames Picture Quiz

A man with a blocked nose

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7567 (Published 16 November 2012) Cite this as: BMJ 2012;345:e7567
  1. O Mulla, specialist registrar, ENT surgery,
  2. N Charaklias, specialist registrar, ENT surgery,
  3. P A Nix, consultant, ENT surgery
  1. 1Ear, Nose, and Throat Department, Leeds General Infirmary, Leeds LS1 3EX, UK
  1. Correspondence to: O Mulla omarmulla22{at}gmail.com

A 40 year old man presented with an 11 year history of nasal blockage and anosmia. He reported that he often had “something” prolapsing from his nose. His medical history included hay fever. He took no regular drugs and had aspirin intolerance. On examination there was a glistening fleshy structure within his left nostril (figure). He had similar masses of the same appearance, consistency, and structure in his right nostril, although they were much smaller.

Questions

  • 1 What is the differential diagnosis of a blocked nose?

  • 2 What does the photograph show?

  • 3 How would you investigate further?

  • 4 What treatment would you recommend?

  • 5 When should patients be referred to specialist care?

Answers

1 What is the differential diagnosis of a blocked nose?

Short answer

A blocked nose can be secondary to the common cold, influenza virus, allergy, rhinosinusitis, nasal polyp, deviated septum, tumour (benign or malignant), septal haematoma, persisting adenoid pad, and rhinitis medicamentosa.

Long answer

Within the medical literature, nasal blockage is used for both nasal obstruction and nasal congestion. In most consultations, patients use it to refer to the process of nasal congestion—when the lining of the nasal passage becomes inflamed. When taking a history, it is important to establish whether this is an acute (less than 12 weeks) or chronic (greater than 12 weeks) problem. It is also important to establish whether symptoms are unilateral or bilateral because this will make the diagnostic process simpler.

The most common acute causes are common cold, influenza virus, intermittent allergic rhinitis, and acute rhinosinusitis.

Chronic allergic rhinitis, chronic rhinosinusitis (with or without nasal polyps), nasal deviation, turbinate hypertrophy, rhinitis medicamentosa, tumours, and adenoid hypertrophy in children are all chronic causes of a blocked nose.

Any allergic reaction can lead to nasal congestion as part of the inflammatory response; however, allergic rhinitis (allergy to dust, pollen, or mites) is commonly associated with nasal congestion. …

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