Although many people assume that big nosed people naturally breathe better, there’s nothing further from the truth. The shape and size of your nose is mostly cosmetic. How well you breathe actually depends on what your internal breathing passageways look like. And for many sleep apnea sufferers, a stuffy nose can make or break their treatment therapy.
Yet, opening up the nose through medical therapy or even surgery has been found to “cure” sleep apnea in only 10% of people. Patients will definitely feel and breathe better, but it’s unlikely that their sleep apnea is addressed definitively. However, I have seen many of the people in the “10%” group derive significant benefits from clearing up their nasal congestion. Besides breathing better for the first time in years, opening up the nose can allow the person to tolerate and benefit from other treatment options for OSA besides CPAP.
Why Is My Nose Stuffy?
Problem #1: Deviated Nasal Septum
One of the more common reasons for a stuffy nose is due to a deviated nasal septum. A “septum” is a term that describes a structure that acts as a wall or separator between two cavities. Your heart has one too. No one has a perfectly flat or straight septum.
All septums, by definition, have slight irregularities or curvatures. A major reason for a crooked septum, unbeknownst to many people, even other doctors, is because your jaw never developed fully. Most people with sleep apnea have narrow upper jaws, which pushes up the roof of your mouth into your nasal cavity, which causes your septum to buckle.
If medical options don’t help you to breathe better through your nose, then you may be a candidate for a septoplasty. To get a much more detailed explanation about this procedure see the accompanying article, Myth and Truths About Septoplasty.
Problem #2. Flimsy Nostrils
In some people, the space between the nasal septum and the soft part of both nostrils is either too narrow to begin with, or they collapse partially or completely during inspiration. In many cases, this can be seen years after reduction rhinoplasty, where the nose was made smaller or narrowed for cosmetic reasons. Occasionally, people can have naturally thin and floppy nostrils.
Another common reason for flimsy nostrils is due to a narrow upper jaw. The width of your nose follows the width of your jaw. If the angle between the midline septum and the nostril sidewall is more narrow than normal, then it’s more likely to collapse with any degree of internal nasal congestion. It’s not surprising that people with sleep-breathing disorders will typically have narrower jaws, and thus more susceptible to nostril collapse. Certain ethnicities are also more prone to this phenomenon than others.
One way that you can easily tell if you have this problem is to perform the Cottle maneuver: Place both index fingers on your face just beside your nostrils. While pressing firmly against your face and simultaneously pulling the skin next to the nostril apart towards the outer corners of your eyes, breathe in quickly. Then let go and breathe in again. If there is a major improvement in your quality of breathing while performing this maneuver, then you have what’s called nasal valve collapse.
The simplest way of correcting nasal valve collapse is by using nasal dilator strips, or Breathe-Rite® strips. If you do the Cottle maneuver and there is no significant difference in your breathing, don’t waste money buying these strips. If you perceive an improvement in your breathing, you can continue using the strips at night while you sleep. For some people, these “strips” are not strong enough to hold up the nostrils, or may cause irritation to the skin.
There are also many other “internal” options available over the counter, including metal springs or plastic cones that are placed inside the nostrils. People tolerate these particular devices differently, so the only way to know if you’ll like them is to try them. Three examples are Breathe With EEZ, Nozovent, and Sinus Cones.
To find out if your nasal valve collapse is from weak or flimsy cartilages or is aggravated by internal nasal congestion, you can spray nasal saline (which is a mild decongestant) into your nose. If your nostrils doesn’t collapse as much, then you need to address your internal nasal congestion first. A stronger over-the-counter medication that you can use is oxymetazoline, which is a topical spray decongestant. There are many brand name and generic versions that are sold that contain this ingredient. It’s very important that you don’t use this medication for more than two to three days—otherwise, you may get addicted to it.
If you want a permanent solution to this problem without having to use dilator strips or internal devices, the only option is surgery. The traditional way of dealing with this issue is to perform a kind of reconstructive rhinoplasty surgery, usually by taking small portions of your nasal septal cartilage or ear cartilage and placing in underneath the weakened portions of your nostril walls. A newer, simpler way of addressing this problem is by attaching a permanent suture just underneath the eye socket and tunneling the suture under the skin and looping it around the weakened area to suspend the nostril to prevent collapse.
Problem #3: Wings in Your Nose
Another common source of nasal congestion is from swelling of your nasal turbinates, which are the wing-like structures on the side-walls of the nasal cavity opposite the septum. Turbinates are comprised of bone on the inside and mucous membrane on the out- side. The area just underneath the mucous membrane is filled with blood vessels which can swell significantly. As the turbinates swell due to allergies, colds, or weather changes, the air passageways narrow further, especially if you have a mildly deviated nasal septum, and particularly if you have nasal valve collapse.
One of the most common misunderstandings that I see by both doctors and patients alike is that they think that swollen turbinates are polyps. The nasal turbinates can swell so much that you can sometimes see the reddish-pink, fleshy grape-like mass through your nostrils. Once decongested, they shrink dramatically and the air passageways open up again.
If conservative treatment including prescription allergy medications don’t work, various surgical options are available from very conservative 5 minute in-office procedures to more aggressive procedures that are performed in the operating room. These procedures are usually performed alongside a septoplasty to improve nasal breathing.
Problem #4: Sinusitis
If you suffer from sinusitis, this can cause nasal congestion and inflammation combined with post-nasal drip, sinus pressure, and pain. Put simply, pure misery. Sinus infections typically follow either a routine cold or allergy attack; they cause both swelling and blockage of the sinus passageways, leading to negative pressure initially and, if allowed to progress, can turn into a full-blown sinus infection, with yellow-green discharge, fever and severe facial pain. Your teeth can also hurt since the roots of the upper molars jut up into the floor of the maxillary sinuses. Similarly, dental pain can sometimes feel like sinus pain.
Fortunately, most cases of sinus congestion will eventually go away. The body has a remarkable ability to take care of these issues without any intervention. Sometimes bacterial infections occur, and with proper conservative treatment using saline and decongestants, the infection gradually resolves. Rarely, you may need an antibiotic to control stubborn bacterial infections.
Problem #5: Poor Sleep
As you can see from the above discussion, there are a number of various reasons for having a stuffy nose. But the most common reason for nasal congestion that I see routinely is due to inefficient breathing and poor sleep. This is why sleep apnea sufferers, more often than not, suffer relentlessly from nasal congestion.
Without a doubt, structural reasons like allergies or nasal polyps can definitely block your nose and these issues must be dealt with appropriately. But in general, it’s the inflammation that’s created by a combination of your hypersensitive nasal nervous system and possible stomach acid regurgitation into the nose from multiple obstructions and arousals, that causes nasal congestion. Without addressing this underlying source of inflammation, correcting a deviated nasal septum or treating for nasal allergies will only provide a temporary solution.