Introduction
Sleep is a very important process that every human being goes through. It helps us restore our energy and get some rest before we start a new day that requires energy. Therefore, having a good sleep is something everyone needs. Unfortunately, some people have a poor sleeping quality that in return affects their quality of life, and one of the factors that can decrease sleep quality is nasal congestion.
Nasal congestion, if not treated, can lead to otitis media (middle ear infection), sinusitis (sinus infection), and major sleep disorders like obstructive sleep apnoea.1
Definition of Nasal Congestion
Blockage or obstruction of the nasal passages
Nasal congestion means the nasal passages are partially or totally blocked due to inflammation. However, not every nasal obstruction is caused by nasal congestion.
One of the reasons for nasal congestion is rhinitis. Rhinitis is defined as an inflammation of the lining of the nose causing sneezing, nasal congestion, itching, and rhinorrhoea (which is a runny nose).1
To decide whether the patient has nasal congestion or not we should ask about the frequency of symptoms, their duration, and pattern of obstruction, as well as whether there are any types of sleep disorders, symptoms of allergy, or rhinitis.1
Overview of Sleep Issues
Knowledge about the physiology of sleep is considered recent. Scientists who studied sleep realised that there are two sleep states in which we go through one is called rapid eye movement sleep (REM) and the other is non rapid eye movement sleep (NREM).3
The normal breathing patterns and control are different in these two sleeping states.
In REM, the muscle tone decreases and the breaths become slow and deep, which increases the chance of apnoea in this sleeping state.3
This drove scientists to study sleeping disorders more. The American Psychiatric Association divides sleeping disorders into primary sleep disorders, sleep disorders due to medical issues, sleep disorders due to mental issues, and sleep disorders due to substance or drug use.3
Types of sleep disorders
Sleep disorders like obstructive sleep apnoea and insomnia can affect health significantly.
Obstructive sleep apnoea happens to older people. It is defined as repeated obstruction of the airway during sleeping. Sometimes it is due to a complete obstruction or a partial obstruction of the airway, which leads to decrease in the oxygen levels in the blood and it is stopped by waking up.
This leads to a decrease in the quality of sleep and if it is repeated several times during sleep, it will stimulate the sympathetic nervous system. The sympathetic nervous system is stimulated in case of fear or fight, and also affects the cardiovascular system.4
Causes of Nasal Congestion
To understand the reasons behind nasal congestion, we first need to understand how it happens.
Nasal congestion means decreased air flow through the nasal passage, giving a sense of fullness in the face. The veins and venules in the nose get congested, the lining of the nose gets inflamed, and finally there is swelling of the nasal mucosa. Sometimes it it is related to the structure of the nose, such as a deviated septum.2
Allergic rhinitis
About 10% to 30% of adults have allergic rhinitis - in children the percentage increases to 45%. These patients suffer from allergic rhinitis for more than 4 months per year.2
Common allergens (e.g., pollen, dust mites)
Allergens are the substances that elicit an allergic reaction. In the case of allergic rhinitis, these most often include common allergens such as dust and pollen grains, etc.
Symptoms and triggers
For patients with allergic rhinitis, when their allergy is stimulated the body releases some inflammatory mediators as a reaction to the allergy. This results in inflammation of the lining mucosa of the nose and swelling, leading to nasal congestion.2
Patients may also have other symptoms besides nasal congestion such as a runny nose, sneezing, and itchy eyes and nose.
Rhinosinusitis
Rhinosinusitis is a two-part word: “rhino” refers to inflammation of the nasal lining, and “sinusitis” refers to the inflammation of the paranasal sinuses, meaning the air sinuses surrounding the nose.
Rhinosinusitis has many causes, but the most common cause is a viral infection, usually called the common cold.
Studies have proven that the symptoms a patient has are not caused by the viral infection but rather caused by the inflammation that the viral infection stimulates. This inflammatory response is the main reason behind the longer period of time spent experiencing symptoms even after the body gets rid of the virus.2
Acute rhinosinusitis vs. chronic rhinosinusitis
Rhinosinusitis can be acute or chronic depending on the time taken by the symptoms to pass. If it is short term, then it is called acute rhinosinusitis, and usually it is caused by an infection with a microorganism whether it is bacteria or virus.
However, if it lasts for a longer period of time, then it is called chronic rhinosinusitis and usually is caused by allergy or immunological causes.2
Symptoms and impact on nasal passages
The symptoms of rhinosinusitis and its effect on the nasal passages is similar to rhinitis. The release of the inflammatory mediators causes inflammation and swelling, leading to an increase in the nasal fluids and nasal congestion.2
Structural abnormalities
Nasal congestion can happen due to some structural abnormalities such as deviation of the nasal septum, cleft palate, and hypertrophy (increase in size) of the adenoids.
Deviated septum
The amount of air that flows into the nose can be affected by the size, shape, and structure of the nasal openings. If the nasal septum is deviated, this will cause resistance to the air flowing into the nose, thus causing nasal congestion.
If the deviation of the septum is in the anterior part of the nose, then it will cause nasal congestion, but if the deviation is in the middle or posterior part then it won't have a significant effect.
Nasal polyps
Nasal polyps is a chronic inflammatory disease in the airways; it can be due to a chronic infection, allergy, or intolerance to aspirin. Nasal polyps lead to nasal obstruction and congestion due to the release of the inflammatory mediators and swelling.2
Impact of Nasal Congestion on Sleep
Scientists disagree upon whether nasal congestion or obstruction can affect the quality of sleep and cause apnoea.
During the awake state, the resistance to air flow in the oral cavity is more than the resistance in the nose, so when the person goes to sleep the resistance to airflow decreases in the oral cavity and the chance of the pharynx to collapse increases.
If the patient suffers from nasal congestion or obstruction during sleeping, this increases the chance of collapse of the pharynx and can lead to obstructive sleep apnoea.
Sleep apnoea
Connection between nasal congestion and obstructive sleep apnoea
Difficulty breathing through the nose
When a patient has nasal congestion or total obstruction of the nasal passage, the body automatically switches to breathing from the mouth.5
In patients with mild obstructive sleep apnea, the space that can be taken by air at the bottom of the throat decreases and the resistance to airflow into the mouth increases, which can worsen obstructive sleep apnoea.5
Mouth breathing during sleep
Patients with moderate to severe obstructive sleep apnoea usually breathe through their mouths.
Such people have several sites throughout the airway passage that are blocked or obstructed such as the soft palate; this can obstruct the airway passage and the base of the tongue (the posterior part of the tongue). In this case, nasal obstruction or congestion does not have a significant effect on obstructing the airway passage.5
Treatment Options
Medical treatments
There are different routes of treatment to treat nasal congestion, including decongesting drugs, antihistamines, and anti-allergic drugs.
Nasal decongestants
The first line of treatment of nasal congestion is nasal decongestant agents. They can be either topical (applied to the skin) or oral (taken by mouth).
Topical decongestants are vasoconstrictors; they act on decongesting the veins and blood vessels in the nose to alleviate nasal congestion.
Sometimes patients may get an adverse effect called rhinitis medicamentosa. This is a condition of rhinitis caused due to the overuse of nasal decongestants. In this case, they are advised to stop the medication gradually.
Antihistamines
Antihistamines are the first line of treatment for cases of allergic rhinitis, but the best way to treat allergic rhinitis is to know what allergens are triggering the condition and avoiding them. Common examples include pollen or house dust.
Surgical interventions
Septoplasty
Sometimes the reason behind nasal congestion is a structural abnormality such as a deviated septum. In this case, the treatment is surgical correction of that septum through a surgical procedure called septoplasty and it has successful long term results.
Summary
Nasal congestion is a condition that occurs due to several reasons like rhinitis, rhinosinusitis, and structural abnormalities like deviated septum and nasal polyps. This condition occurs through secretion of inflammatory mediators causing inflammation and selling of the lining mucosa of the nose leading to obstruction of the nose. This obstruction can lead to some sleep disorders like insomnia and obstructive sleep apnoea, which has a negative effect on the quality of life.
References
- Corey, Jacquelynne P., et al. “Nasal Congestion: A Review of Its Etiology, Evaluation, and Treatment.” Ear, Nose & Throat Journal, vol. 79, no. 9, Sept. 2000, pp. 690–702. DOI.org (Crossref), Available from: https://doi.org/10.1177/014556130007900908
- Naclerio, Robert. “Pathophysiology of Nasal Congestion.” International Journal of General Medicine, Feb. 2010, p. 47. DOI.org (Crossref), Available from: https://doi.org/10.2147/IJGM.S8088
- Roehrs, Timothy, and Thomas Roth. “Sleep Disorders: An Overview.” Clinical Cornerstone, vol. 6, no. 1, Supplement C, Jan. 2004, pp. S6–16. ScienceDirect, Available from: https://doi.org/10.1016/S1098-3597(04)80043-7
- Ong JC, Crawford MR. Insomnia and obstructive sleep apnea. Sleep medicine clinics. 2013 Sep 1;8(3):389-98, Available from: https://www.sleep.theclinics.com/article/S1556-407X(13)00034-9/abstract
- Friedman, Michael, et al. “Impact of Nasal Obstruction on Obstructive Sleep Apnea.” Otolaryngology–Head and Neck Surgery, vol. 144, no. 6, June 2011, pp. 1000–04. DOI.org (Crossref), Available from: https://doi.org/10.1177/0194599811400977