With A Deviated Septum, Why Does Nasal Obstruction Come and Go?

A deviated septum is a well known factor causing nasal obstruction in people. However, many patients with a deviated septum will also state that there are times when they can breath just fine from their nose. As such, can a deviated septum truly be the cause of their nasal obstructive symptoms? Shouldn't the obstruction be constant?

The blunt answer is ABSOLUTELY nasal obstruction can be intermittent OR constant with a deviated septum!!! It's more a question of degree.

To begin with, a deviated septum is when the wall that separates the right and left nasal cavities is bent one way (green arrow) instead of being perfectly straight.

If there is no mucosal swelling, a person with a deviated septum is able to breath from both sides just fine. However, if there is the slightest bit of mucosal swelling from turbinate hypertrophy, allergies, upper respiratory infection, or any other environmental irritation, the side that is more narrow will obstruct much more readily with less swelling given there is just "less room" for swelling to occur before obstruction occurs.

Below is the same exact nose and septum as above, but with mucosal swelling present.

As you can see, with the same exact amount of swelling present, the deviated septum significantly influences how much space is present for air to pass through compared with a straight septum.

As such, even though a deviated septum may not technically be obstructive, given there is less room for any swelling to be accomodated, a patient will complain of nasal congestion and obstruction much more readily compared to someone with a straight septum due to the slightest changes in mucosal swelling.

How is a deviated septum fixed? Click here to read more.

Of course, one can try and control the mucosal swelling to avoid any surgical intervention, typically with steroid or anti-histamine nasal sprays. The downside is that such medications need to be used daily to prevent swelling from occurring in the first place.

The Doctors TV Show Does Chronic Throat Clearing

The Doctors TV show recently did a segment on chronic throat clearing. The ENT expert who explained this very annoying condition was Dr. Reena Gupta, a well-respected laryngologist with the Osborne Head and Neck Institute.

During this TV show, Dr. Gupta provided the two most common reasons for chronic throat clearing which were post-nasal drainage and reflux.

At its most basic explanation, mucus can come from the nose down into the throat (post-nasal drainage) OR mucus can come up from the stomach into the throat (reflux). The end-result is a person desiring to throat clear the mucus up and out.

However, there are other causes which were not addressed by Dr. Gupta during the show.

Other reasons for chronic throat clearing include:

Medication Side Effect
Food Allergies or Sensitivities
Zenker's Diverticulum
Laryngeal Sensory Neuropathy
Anatomic Triggers
PANDAS
Non-Organic Tic

Read more about chronic throat-clearing here.

Watch the TV show segment here.

Treatment for Hiccups Based on Science

So... I came across a few references addressing treatment of hiccups (otherwise known as singultus) based on science rather than heresay. Here are a few methods than can be done at home without the need for medications or procedures.

It is felt that hiccups may be secondary to irritation of the phrenic nerve (which innervates the diaphragm). As such, scientific treatment of hiccups have relied on increasing PaCO2 (breath holding, breathing into a paper bag), therapy using diaphragm relaxation (baclofen or phrenic nerve block), or positive airway pressure.

So, one paper described a technique called supra-supramaximal inspiration that would increase PaCO2, diaphragmatic immobilization, and positive airway pressure. The technique is as follows:

Patients are instructed to inspire maximally, hold the breath for 10 seconds, then add an additional, small, “supra-maximal” inspiration, without any expiration. The breath is held for 5 seconds, followed by a third, “supra-supramaximal” inspiration, held for 5 seconds, before resuming normal breathing.

A variant on this technique requires an assistant. The assistant first applies firm pressure just anterior to the tragus of the ear, firm enough to completely occlude the ear canal. The patient than drinks a glass of water for about 10 seconds. If no liquid is available, the Valsalva manoeuvre would suffice.

In another method, pressure is applied to the sphenopalatine ganglion. This method involves sliding a finger (or thumb) to the junction between the hard and soft palate in the mouth. In this region, firm pressure is appled for 5-10 seconds towards the back-top part of the head. Enough pressure needs to be applied to cause some pain. One can massage this junction as well. I believe this method was reported in the New England Journal of Medicine, but for the life of me, I can't find the reference.

Digital rectal massage has been reported in the literature to help stop hiccups, mainly by disrupting the vagal afferent limb of the hiccup reflex arc. Name says it all. Essentially, you stick a finger up the anus and massage the area firmly until hiccups stop.

Direct vagal stimulation, such as by carotid massage, Valsalva maneuver, and ocular pressure have also been reported.

Reference:
Miracle hiccough cure gets the attention it deserves. BMJ. 2006 December 9; 333(7580): 1222.
doi: 10.1136/bmj.39051.721632.3A.

Bloodletting and miraculous cures. BMJ 2006;333:1127-a (25 November.)

Termination of idiopathic persistent singultus (hiccup) with Supra-Supramaximal Inspiration. J Emerg Med. 2004 Nov;27(4):416-7.

Termination of intractable hiccups with digital rectal massage. J Intern Med. 1990 Feb;227(2):145-6.