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# Approach to nasal blockage

- Approach to a complaint

One-sided, fixed nasal blockage suggests a structural cause or a tumour; bilateral, variable blockage is usually inflammatory.

Updated Nov 5, 2026

## Key points

- Bilateral and variable: think of the mucosa (rhinitis, rhinosinusitis). One-sided and fixed: think of structure or a mass.
- Prolonged use of topical decongestants causes rhinitis medicamentosa (rebound congestion).
- An intranasal corticosteroid is first line for allergic rhinitis.
- Bilateral nasal polyps in a child: rule out cystic fibrosis.
- Bilateral choanal atresia in a newborn: airway emergency.

## What it is

Nasal blockage is very common and almost always benign, but its pattern helps you not to miss the serious causes. Bilateral, variable blockage usually comes from the mucosa: allergic or non-allergic rhinitis, rhinitis from decongestant overuse, and rhinosinusitis. One-sided, fixed blockage points to structure (septal deviation) or to a mass: a polyp, a foreign body in a child, an angiofibroma in an adolescent or a tumour in an adult. In a newborn, who breathes through the nose, bilateral choanal atresia is an airway emergency.

## Key questions in the history

- One side or both? Fixed or alternating?
- Sneezing, itching, runny nose, loss of smell, nosebleeds or facial pain?
- Decongestant sprays? For how long?
- Nasal trauma or previous surgery?
- Asthma or reaction to aspirin?
- In children: snoring, mouth breathing, one-sided foul discharge?

## Causes and classification

- Mucosal (bilateral, variable): allergic rhinitis, non-allergic rhinitis, rhinitis medicamentosa and rhinosinusitis.
- Structural (often one-sided, fixed): septal deviation, turbinate hypertrophy, nasal fracture and nasal valve collapse.
- Masses: polyps (bilateral in chronic rhinosinusitis), a one-sided polyp, sinonasal tumours and juvenile angiofibroma.
- Children: adenoid hypertrophy, foreign body and unilateral choanal atresia.
- Newborn: bilateral choanal atresia.

## Step-by-step approach

- Pin down the side, whether it is fixed or alternating, the time course and associated symptoms.
- Ask about topical decongestants, trauma, surgery and asthma or aspirin intolerance.
- Do anterior rhinoscopy before and after a vasoconstrictor: septum, turbinates, polyps, discharge and masses.
- In a child, think of adenoids with mouth breathing and snoring, and of a foreign body with one-sided foul discharge.
- If a child has bilateral polyps, rule out cystic fibrosis.
- Order nasal endoscopy or sinus CT if chronic rhinosinusitis or a mass is suspected, or surgery is planned.

## Differential diagnosis of nasal blockage

| Cause | Pattern | Key clue |
| --- | --- | --- |
| [Allergic rhinitis](https://durgical.com/en/conditions/allergic-rhinitis/) | Bilateral, variable | Sneezing, itching, watery discharge, triggers |
| Rhinitis medicamentosa | Bilateral, rebound | Prolonged topical decongestant use |
| Septal deviation | Fixed, often one side | Previous trauma; deviated septum |
| [Chronic rhinosinusitis with polyps](https://durgical.com/en/conditions/chronic-rhinosinusitis-and-nasal-polyps/) | Bilateral | Loss of smell, discharge, over 12 weeks; asthma |
| Adenoid hypertrophy | Bilateral, children | Mouth breathing, snoring, nasal voice |
| [Foreign body](https://durgical.com/en/conditions/foreign-bodies-of-the-ear-and-nose/) | One-sided, children | One-sided foul discharge |
| [Nasal fracture or septal haematoma](https://durgical.com/en/conditions/nasal-fracture-and-septal-haematoma/) | After trauma | Deformity; soft septal swelling |
| [Juvenile angiofibroma or sinonasal tumour](https://durgical.com/en/conditions/juvenile-nasopharyngeal-angiofibroma/) | One-sided, progressive | Nosebleeds, pain, eye symptoms |

## Red flags

- Progressive one-sided blockage with nosebleeds, facial pain, double vision or numbness: sinonasal tumour.
- An adolescent boy with one-sided blockage and nosebleeds: juvenile angiofibroma.
- A one-sided or atypical-looking polyp.
- A soft, tender septal swelling after trauma: septal haematoma.
- A newborn with breathing difficulty that improves when crying: bilateral choanal atresia.

## Next step / Initial management

- Allergic rhinitis: an intranasal corticosteroid first line; a second-generation oral antihistamine and saline rinses as needed.
- Rhinitis medicamentosa: stop the topical decongestant, with an intranasal corticosteroid during withdrawal.
- Chronic rhinosinusitis or symptomatic septal deviation not improving with medical treatment: routine ENT referral.
- Urgent same-day referral: septal haematoma, bilateral choanal atresia or blockage with orbital or neurological symptoms.
- Priority referral: progressive one-sided blockage, a mass, a one-sided polyp or associated nosebleeds.

## Test yourself

Think of the answer, then tap the question to see it.

## A 30-year-old woman has rebound nasal congestion after using a decongestant spray daily for two months. Diagnosis and management?

Rhinitis medicamentosa: stop the topical decongestant and use an intranasal corticosteroid during withdrawal.

## A 4-year-old has had one-sided foul nasal discharge for a week. What do you suspect first?

A nasal foreign body; button batteries and magnets must be removed urgently.

## Which disease do you rule out in a child with bilateral nasal polyps?

Cystic fibrosis, because polyps are rare in childhood outside it.

## After a blow to the nose, a young man has a soft, tender septal swelling blocking both sides. What do you do?

Suspect a septal haematoma: urgent drainage to prevent abscess, perforation and saddle-nose deformity.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/ent/approach-to-nasal-blockage/)

## Connections

## Related 4

- [Nasal exam: external nose, anterior rhinoscopy and nasal endoscopy](https://durgical.com/en/ent/nasal-exam-external-nose-anterior-rhinoscopy-and-nasal-endoscopy/)
- [Nasal cavity, septum and Kiesselbach's plexus](https://durgical.com/en/ent/nasal-cavity-septum-and-kiesselbach-s-plexus/)
- [Approach to a runny nose, including CSF leak](https://durgical.com/en/ent/approach-to-a-runny-nose-including-csf-leak/)
- [Paediatric ENT: what is different in children](https://durgical.com/en/ent/paediatric-ent-what-is-different-in-children/)

## Related conditions 3

- [Allergic rhinitis](https://durgical.com/en/conditions/allergic-rhinitis/)
- [Chronic rhinosinusitis and nasal polyps](https://durgical.com/en/conditions/chronic-rhinosinusitis-and-nasal-polyps/)
- [Nasal fracture and septal haematoma](https://durgical.com/en/conditions/nasal-fracture-and-septal-haematoma/)

[← All of ENT](https://durgical.com/en/ent/)

Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: [Septoplasty](https://www.ncbi.nlm.nih.gov/books/NBK567718/) (StatPearls Publishing (NCBI Bookshelf), 2022); [Allergic Rhinitis](https://www.ncbi.nlm.nih.gov/books/NBK538186/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Nasal Polyps](https://www.ncbi.nlm.nih.gov/books/NBK560746/) (StatPearls Publishing (NCBI Bookshelf), 2025); [Choanal Atresia](https://www.ncbi.nlm.nih.gov/books/NBK507724/) (StatPearls Publishing (NCBI Bookshelf), 2025); [Rhinitis Medicamentosa](https://www.ncbi.nlm.nih.gov/books/NBK538318/) (StatPearls Publishing (NCBI Bookshelf), 2026); [Nasal Foreign Body](https://www.ncbi.nlm.nih.gov/books/NBK459279/) (StatPearls Publishing (NCBI Bookshelf), 2023).

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