Overview

Definition of nasal congestion

Nasal congestion is the blockage of nasal passage caused by irritation in tissues or blood vessels inside the nose. This irritation results in a chain reaction that starts with inflammation, swelling of tissue lining and mucus production in the nose. A congested or stuffy nose makes it hard to inhale air through the nose and if left untreated, it may cause problems such as sinusitis, nasal discharge or runny nose, nasal polyps and middle ear infections.¹

Overview of ear infections

An ear infection is an infection of the middle ear and children are more likely to get ear infections than adults. In this infection, narrow tubes that run from the middle ear to the back of the nose and throat (eustachian tubes) become swollen and blocked. This results in the formation of mucus or fluid in the middle ear. When this mucus becomes infected, it causes ear infections.²

Importance of understanding the connection

In the case of nasal congestion, the eustachian tube connecting the middle ear to the back of the throat becomes blocked, which leads to the beginning of an ear infection. In the middle ear, the, the formation of mucus occurs, which then becomes infected. In some instances, this infection may spread to the surrounding regions like the mastoid bone present behind the ear. This may also lead to complex conditions including meningitis or a brain abscess. In this article, we will discuss nasal congestion, its associated reasons and its relationship with ear infections as well as treatment measures.

Anatomy and physiology

Structure of the ear

The ears are organs responsible for detecting and analysing sound. Their location on each side of the head directly over the temporal lobe, helps in hearing and balance. The temporal lobe in the brain is accountable for speech, hearing, memory and some emotions. The ear has the outer ear, middle ear and inner ear as three main parts which are: 

1. Outer ear (external ear): It is the visible part of the ear and most people refer to it as an ear. It is also called pinna or auricle and consists of cartilage and skin. A gland secreting earwax is a part of it and the eardrum or tympanic membrane separates its funnel-shaped canal from the middle ear
2. Middle ear: It starts with the other side of the tympanic membrane/ eardrum. Three tiny bones are present here such as the malleus, incus and stapes, which are often referred to as the ossicles (a combination of three). They are responsible for transferring sound vibrations from the eardrum to the inner ear. The eustachian tube present in both ears is a part of the middle ear, which helps to equalise the air pressure in the ears
3. Inner ear: There are two main parts of the inner ear which are the cochlea and the semicircular canals. The cochlea is the hearing organ and has a snail-shaped structure containing two fluid-filled chambers covered with tiny hairs. When sound enters the ear, fluid present in the cochlea causes the vibration of tiny hairs and sends electrical impulses to the brain. The semicircular canals (labyrinthine) are responsible for balance and tell the brain about the direction of head movement³

Role of the nasal passages

The nasal cavity is the space inside the nose that lies above the bone forming the roof of the mouth and joins the throat by curving down at the back. The nasal cavity is divided into two sections known as nasal passages. During breathing air moves through them and filters as well as moisten the air before it reaches the lungs. Special cells present here provide a sense of smell.

The eustachian tube connected to the nose enters the nasal cavity, leading to the spread of infection to the middle ear through the tube. Diseases of the nasal cavity caused by various reasons result in an infection of the cavity or the surrounding regions. This infection can spread from the nasal cavity to the ear through an eustachian tube.⁴ The causes of nasal congestion are discussed below.

Causes of nasal congestion 

The blockage of nasal passage due to inflammation inside the nose can be triggered by various factors. It includes allergens (pollens, dust), infections like the common cold, flu, or structural deformity such as a deviated septum. The causes of nasal congestion are given as:

Viral infections 

Viral respiratory illness like flu or influenza causes fever, body aches, chills and runny nose. It easily spreads from person to person, while in most people recovery is full. But, in children, elderly people, and people with health conditions it may cause severe illness or even death.⁵ The common cold often occurs with sneezing, runny nose, and nasal congestion among other symptoms. In such infections, swelling of nasal tissues and an increase in mucus production occurs.

Allergic rhinitis

Allergic rhinitis is induced by allergens including pollens, dust, skin flakes of animals and moulds. This causes inflammation inside the nose with redness and swelling sometimes. It is a common condition that usually causes symptoms like the common cold, sneezing, stuffy nose or runny nose (nasal congestion) and itchiness. The symptoms usually start after contact with allergic things. It occurs seasonally in some people due to allergies to things like grass pollen and may happen all year round in other people.⁶

Sinusitis

Sinusitis is caused by swelling or inflammation of the tissue lining the sinuses leading to congestion. It is an inflammatory reaction or an infection due to microorganisms such as viruses, bacteria or fungi. The sinuses are air-filled spaces located behind the nasal bones, eyes, forehead and cheeks. Usually, mucus drains through them and allows air to flow through the sinuses. When the openings of the sinus become blocked or excess mucus forms, microbes like bacteria grow easily and cause infection.⁷

Deviated septum

A deviated septum is a structural issue that occurs when the nasal septum (separating the right and left nasal cavities) is significantly displaced to one side. It makes one nasal passage smaller than the other and if severe, it can block one side of the nose causing difficulty in breathing. Nasal congestion occurs in this case and begins with swelling of the tissues lining the nasal cavity or from both. The treatment of nasal obstruction includes medications to bring down swelling and correct the deviated septum through surgery.⁸

Relationship between nasal congestion and ear infections

Impact of nasal congestion on the eustachian tube

The eustachian tubes connect the middle ear to the back of the nasal passage and throat and exist as a pair of narrow tubes. The throat end of this tube opens and closes to perform the following functions:

• Regulation of air pressure in the middle ear: The tube opens while swallowing or yawning, allowing small amounts of air. Through this, the air pressure of the middle ear and the environment match and help in the normal function of the eardrum³
• Refresh air in the ear: It closes when not swallowing or yawning, thus protecting the middle ear from microorganisms
• Drain of normal secretions or fluids from the middle ear: It helps to reduce ear infections

The nasal congestion causes blockage of the nasal passage and swelling of the eustachian tubes. Due to this eustachian tubes get blocked, resulting in the formation of fluids in the middle ear. When this fluid becomes infected, it leads to the symptoms of an ear infection.⁴ While in children, the tubes are narrow and more horizontal, causing difficulty in draining and more prone to getting clogged. When the tubes become clogged, an illness called eustachian tube dysfunction happens. It includes symptoms like tinnitus, muffled hearing (clogged hearing), sensation of fullness, and ear pain. 

Increased risk of ear infections

There are many possible ear problems which can triggered by nasal congestion mentioned below.

1. Acute otitis media: In this, swelling with fluid formation occurs in the middle ear with no bacterial or viral infection. This may occur due to many reasons such as the persistence of the fluid even after recovery from an ear infection and noninfectious blockage or some dysfunction of the eustachian tubes²
2. Chronic otitis media with effusion: Fluid remains in the middle ear and returns without bacterial or viral infection. This causes children to be more prone to ear infections and may impact hearing
3. Chronic suppurative otitis media: Here, an ear infection recurs with the usual treatments and may result in a hole in the eardrum
4. Otitis Externa (Swimmer’s Ear): This is an ear canal infection due to bacteria or fungi. The presence of water in the ear is also responsible for this condition. Hair spray and other irritants entering into the ear canal also contribute to it. Usually, ear canal cleaning with cotton swabs may injure it

Symptoms and diagnosis

Symptoms of nasal congestion

Nasal congestion can sometimes be the initial signal that the body is fighting against a viral or bacterial infection. However, rarely, a polyp or tumour in the nose may cause congestion in the nose and this may also induce nasal discharge or runny nose.¹ Nasal congestion or clogging of the nose is often accompanied by symptoms such as:

• Runny or stuffy nose
• Trouble breathing through the nose
• Mouth breathing due to inability caused by a blocked nose
• Postnasal drip (mucus discharge down the back of the throat) may cause a sore throat
• Facial Pressure or pain
• Hay fever or other allergies
• Application of nasal sprays or drops used without a prescription for many days may increase nasal stuffiness
• Sinuses and nasal polyps (occurs in inflamed tissue inside the nose)
• Pregnancy
• Additional symptoms are sneezing, cough and headache

Symptoms of ear infections

In the majority of ear infection cases, it resolves within 3 days. While sometimes the following symptoms of infection may remain for a week:²

• Ear pain or feeling of fullness/pressure
• Hearing loss or muffled hearing
• Fever and irritation (particularly in children)
• Lack of energy
• Fluid drainage from the ear
• Difficulty in hearing

 Nasal congestion being one of the causes of ear infections when found positive, is analysed through various diagnostic techniques which will be discussed here. 

Diagnostic techniques

A healthcare provider may diagnose nasal congestion and ear infection using a physical examination focusing on the nose, throat, ear and airways.^1,2,6,8 The other tests performed may include:

• Skin allergy test
• Blood test
• Nasal endoscopy
• Throat culture and sputum culture test
• X-ray of chest and sinuses
• Otoscopy: Examine the middle ear and eardrum for the presence of infection or fluid
• Hearing tests
• Tympanometry
• Acoustic reflectometry: Usually, most of the sound entering the ear gets absorbed by the eardrum. This procedure tests the amount of sound reflected from the eardrum. It is an indirect test for fluids in the middle ear
• Tympanocentesis: In this, a tiny tube is used to pierce the eardrum and fluid is drained from the middle ear to test for viruses and bacteria

Treatment and management

Addressing nasal congestion

Treatment of nasal congestion is initiated by finding ways to keep mucus thin. It will help to drain the mucus/fluid from the nose and sinuses, thus relieving symptoms.¹ Intake of plenty of clear fluids is the simplest way to rectify this and other measures are:

• Decongestants and Nasal sprays: A warm, moist washcloth can be applied to the face many times a day. One can try to inhale steam 2 to 4 times a day or use a vaporizer or humidifier. Gentle saline nasal sprays can be used 3 to 4 times a day and a nasal wash may be helpful to remove mucus from the nose. Nasal sprays present over-the-counter should not be used more than 3 days on and 3 days off. While to use it more than that ask, a healthcare provider. Decongestants are the medicines used to shrink and dry up the nasal passages. Consequently, it helps to dry up a runny nose⁷
• Antihistamines: These are used to treat allergy symptoms and may result in drowsiness⁶

Congestion often worsens with lying down, so try to keep the head elevated. Some adhesive strips are now available when placed on the nose, help to widen the nostrils and make breathing easier. Medicines are now bought without a prescription at the store to relieve symptoms. Carefully read the labels to avoid too much of any medicine.

Treating ear infections

Various treatment measures available to relieve ear infections are:²

• Antibiotics: Treatment with antibiotics is helpful for bacterial infections, to eliminate infection and prevent complications in certain children
• Painkillers: Paracetamol or ibuprofen are used to suppress pain
• Anaesthetic drops: These are used to relieve pain, in case the eardrum has a tear or doesn't have a hole in it
• Myringotomy and Ear Tubes: Surgical intervention for recurrent or chronic infections to improve drainage and reduce pressure

Preventive measures

Infection can not be prevented completely but the following steps may be useful to reduce the risks:^5,6

• Avoid allergens and irritants: Minimise exposure to factors responsible for nasal congestion
• Maintain proper hygiene: Regular handwashing and avoiding contact with sick individuals to prevent viral infections
• Vaccination: Influenza and pneumococcal vaccines to reduce the risk of respiratory infections
• Avoid secondhand smoke: Do not allow smoke in the home and try to stay in smoke-free environments
• Breastfeed the baby for at least six months if possible: Breast milk consists of antibodies that protect from ear infections and other diseases

Complications and considerations

Ear infections and problems of nasal blockage don't cause complications in the long term.^2,3 But the occurrence of such infections, again and again, may result in serious complications:

1. Recurrent ear infections: Risks of speech development delays in children
2. Chronic sinusitis: Prolonged nasal congestion leading to persistent ear infections and complications
3. Impact on quality of life: Discomfort, sleep disturbances, and impact on daily activities due to ongoing symptoms
4. Hearing impairment: Infected fluid in the middle ear can cause more significant hearing loss. If some permanent damage happens to the eardrum or other associated middle ear structures, then permanent hearing loss can be the result

Cough: If it lasts more than 10 days, or with yellowish-green or grey mucus then do not avoid it. Ear infections are normally resolved without antibiotic treatment. The cause of nasal congestion and ear infection diagnosis leads to the implementation of appropriate treatment which is mentioned ahead. The efficacy of treatment depends on many factors, including the cause of infection, age (child’s age) and the severity of symptoms.

Summary

Nasal congestion or blockage of the nose and ear infections are more common in children than others. Although the anatomy, physiology and process of disease are not similar, knowledge of some remedial actions at home may prevent the severity. Ear infection is a middle ear illness, nasal congestion on the other hand is the blockage of the nasal passage. 

The eustachian tube of the middle ear is narrower and more horizontal in children, leading to improper drainage of fluid during blockage of the nasal passage. When this fluid gets infected, it contributes to ear infection. Common colds or flu are infections that may spread easily and act as one of the causes of the problem. However, preventive measures for nasal congestion aid in preventing ear infections and other related complications. However, professional help in severe cases assists in better evaluation and ensures effective management.