Revisit on How Nasal Blockage has an Effect on Eminence of Life: Facts & Specifics

Nasal breathing distributes roughly 70% airflow to lungs, but airway obstruction can limit airflow through nose. While it is a known fact that ear, nose & throat are interlinked with each other in the form of “triangular immersion”. Hence, any cause of nasal block can in a way limit the functioning capacity of the other two systems [1,2]. This limitation of nasal airway obstruction (NAO) through nose has mucosal &mechanical causes that range from PNS to DNS that can significantly compromise the excellence & eminence of life leading to un pleasant alarms [3].


Introduction
Nasal breathing distributes roughly 70% airflow to lungs, but airway obstruction can limit airflow through nose. While it is a known fact that ear, nose & throat are interlinked with each other in the form of "triangular immersion". Hence, any cause of nasal block can in a way limit the functioning capacity of the other two systems [1,2]. This limitation of nasal airway obstruction (NAO) through nose has mucosal &mechanical causes that range from PNS to DNS that can significantly compromise the excellence & eminence of life leading to un pleasant alarms [3]. D. Selection criteria: A random sample of 626 patients (pts) who consulted the ENT outpatient department with nasal obstruction as one of the clinical presentation were assessed &evaluated clinically, diagnosis was made. Following which, required management algorithm was adapted in all the patients both conservatively as well as surgically.

1) Inclusion criteria
a) Age group from 5-70 years were considered for the study. b) All cases of only nasal pathology were considered for the study.

2) Exclusion criteria
a) Age group of < 5years and >70 years were excluded from the study.

E.
Procedure of the study: Over a period of 1 year, a random sample of 626pts who consulted ENT OPD with nasal obstruction as one of their main symptom were clinically evaluated after taking a detailed & thorough history. Following which a probable diagnosis was made. The relevant investigations wherever necessary were done to arrive at a diagnosis.
Management was given based on the diagnosis which was both conservative as well as surgical. They were then followed up for about 6 months. Patients have shown good response to treatment on follow up with symptomatic relief. Informed written consent was taken during the study period. Ethical clearance has been taken from Institutional Ethics Committee before the start of the study.

Results
The observations drawn from the study are depicted both in diagrammatic as well as tabular representation below: (Table 1-

Discussion
Nasal congestion is the most common symptom for both mucosal & mechanical cause in nose & PNS region. Congestion, due to physical obstruction of nasal passages as a result of structural variations &/or modulation of sensory perception. Mucosal inflammation has precise and solid factors that contribute to nasal congestion [4,5]. Biologically active agents & cell types (eg, histamine, TNF-α, IL's, cell adhesion molecules) contribute to inflammation, that manifest as raised nasal secretions, venous engorgement &tissue oedema. This can possibly cause impaired airflow & feeling of nasal congestion [6,7]. Altered sensory perception & subjective sense of congestion are due to inflammation-induced changes in sensory afferents which innervate nose through expression of peptides & receptors [8,9].
Nasal congestion has many causes that range from a mild irritation to lethal condition. The various sources for nasal block can cause headache to halitosis due to inflammatory to iatrogenic pathology& developmental to dangerous concern [10,11]. Various origins range from simple coryza to complex concha bullosa, narrow nasal valve to wide cleft palate as well as upper airway resistance syndrome to empty nose syndrome all of which can lead to nasal obstruction. As it known that face has a rich blood supply, specifically nose which has the most constricted and confined vessels and (danger area of face). Hence, any neglected conditions can lead to severity in the form of cavernous sinus thrombosis etc, jeopardising life [12,13].
Most people are referred to as "obligate nasal breathers". During first few months of life, nasal congestion in an infant can interfere with breastfeeding causing respiratory distress while in older children & adolescents it can just be bothersome with certain difficulties. Nasal congestion can interfere with hearing and speech [14,15]. Significant congestion mainly in adults and sometimes in children even may interfere with sleep cause snoring with mouth breathing that can be associated with sleep apnoea or upper airway resistance syndrome [16][17][18]. While in children, nasal congestion from adenoid hypertrophy has caused chronic sleep apnoea with insufficient levels of oxygen causing hypoxia as well as right-sided heart failure. This problem can be resolved with knocking out both tonsils & adenoids. However, this problem often relapses later in life due to craniofacial alterations from chronic nasal congestion [19,20].
Hence, any cause of nasal obstruction must evaluate thoroughly. After which proper treatment modality has to be administered & followed either conservative line as in Antibiotics, Nasal decongestants either topical & oral, Antihistamines with +/-Analgesics. Surgical line of treatment [21,22] as per requirement is Septoplasty +/-Submucous resection, Partial inferior turbinectomy & Functional Endoscopic sinus surgery (FESS). The same protocol was followed in our case too. After a Diagnostic nasal endoscopy & CT PNS, appropriate treatment measures were adapted [23][24][25]. Total 626pts were considered for the study. Pts presented with various nasal pathology comprising of 26 conditions (with 20 single causes & rest 6 with combined causes). They presented with nasal obstruction as their Primary Symptom (PS) over a study period of 1 year and were followed over for 6 months now. Nasal obstruction has been categorically dissected into various groups which are individually elaborated in the matter mentioned below.
Out of 26 causes for nasal obstruction that were presented at the OPD, 412pts (66%) belonged to single causes while 214pts (34%) belonged to combined causes for nasal obstruction. The top 5 causes for nasal obstruction are DNS-85pts, Rhinitis-81pts, DNS with AR-63pts, Rhinosinusitis-57pts & Nasal polyposis-50pts. While it is mostly combined causes with DNS which form the bulk of pts, that totals up to (214+ 85=299pts) (48%). This data in the study here shows that nearly 50% of causes fall under Mechanical group which is superior to Mucosal cause for nasal obstruction that is DNS.

ERO.000557. 3(2).2020
As per age & sex distribution in this study, 95pts were children (C) & 531pts were adults (A) and their ratio of C:A is nearly 1:6. While 338pts were males (M) & 288pts were females (F) and their ratio of M:F is nearly 1:2. This data in the study here tells us that there is wide gap difference between Children & Adults while that is not so in Males & Females.
In this study with reference to the chroni city of conditions, 126pts (20%) had Acute (A) causes for nasal obstruction while rest 500pts (80%) had Chronic (C) causes. Hence the ratio of A:C is 1:4. This data in the study refers to the fact that acute cases are far less in occurrence compared to chronic. Hence, mostly conservative management is by far proven sufficient and also pts have become more aware& alert to get medical help at the earliest. But considering the laterality of involvement in terms of causes for nasal obstruction, 145pts (23%) had Unilateral (U/L) involvement while rest 481pts (77%) had Bilateral (B/L) involvement. B/L involvement specifies the need for immediate surgical management and also postulates the importance to have a good quality of life in terms of breathe, smell & sleep as a part of healthy lifestyle. Hence, the ratio of U/L:B/L is nearly 1:4. There is no particular preference or any relevance to the side of involvement either Right or Left side of the nose for nasal obstruction in this study.
Along with nasal obstruction as the Primary symptom during presentation during OPD visit, there were around 21 other symptoms as Secondary & Associated for all nasal pathology. Based on which, both region of involvement as well as symptoms as such were gathered down. Among all the symptoms, Rhinorrhoea topped the list of most common accompanying symptom mainly as Secondary symptom and was seen in 132pts (21%), while Headache in 107pts (17%), h/o recurrent URI along with Mouth breathing/ Halitosis & Snoring were seen in 59pts (9%) which ranked second and third in the list of symptom presentation. While, distribution of accompanying symptoms with nasal block in all pts were somewhat evenly dispersed with no particular inclination as such.
While coming over to the region involvement in terms with clinical presentation, but obvious Nose is most common system among the other two to involve in 481pts (77%). While 39pts (6%) in Ear & 106pts (17%) in Throat & Other region of involvement.

Conclusion
This study is one of a kind with numerous, exclusive conclusions are drawn: a) Mechanical group> Mucosal group in terms of cause for nasal obstruction, which is DNS; seen in nearly 50% (i.e 299pts).
b) Based on Age distribution, the ratio for (Children: Adult) is nearly 1:6.

c)
As per Gender predilection, the ratio for (Males: Females) is nearly 1:2. h) As per aetiology of occurrence of all the conditions causing nasal obstruction, inflammatory diseases fall with 36% (i.e227 pts).

i)
Rhinorrhoea was seen as the most common accompanying Secondary symptom in 21% (i.e 132 pts).

j)
According to region involvement in terms with clinical presentation, but obviously Nose is most common system in 481 pts (77%).
The purpose of this study is to also bring into light which was somewhere out of focus & dusted amidst other priorities are3 simple & must essentials that are needed to lead a healthy living which is being hindered. Those 3 basic amenities needed are Air to Submit Article respire, Aroma to make food tastier& palatable and calm &peaceful Nap. All of them are crucial for a strong body and mind. Hence, nasal obstruction should be simply not neglected but must be sorted at the earliest for a well-being.