Nasal Breathing – What is Normal, and What Causes Congestion?

Abnormal nasal breathing is one of the most common symptoms that lands a patient in an ENT clinic. In kids, the causes tend to be allergic in nature (enlarged turbinates, nasal polyps, etc.) as anatomy problems such as septal deviations are
rare. In adults, anatomical problems become much more prevalent and allergies, while still contributing in many, are less frequently the only cause of nasal congestion.

Problems That Affect Nasal Breathing

Most individuals have a “nasal cycle” that alternates enlargement of the turbinates on one side of the nose compared to the other, which is related to changes in blood flow between the two sides and reverses every few hours. When other anatomy issues are present, such as one side obstructed by a deviated septum, it may feel like one side is always obstructed and the opposite side intermittently obstructs when this cycle enlarges the turbinates on that side. Similarly, when lying on one side this may impact nasal breathing to the point that it is only possible while lying with a certain side up to avoid obstructing the
good side.

Hormones (ex. Pregnancy) and overuse of decongestants (such as Afrin spray) also alter nasal blood flow and may lead to significant congestion due to enlargement of the turbinates. In the case of decongestants, these changes may be permanent depending on the duration of use and may require surgery to re-establish normal nasal breathing.

What Is Considered “Normal” Nasal Breathing?

For those who breathe some through their nose, but aren’t sure if they are breathing a “normal” amount, the best way to determine if congestion is problematic is while lying down flat on your back for greater than 30 minutes. Lying flat increases the size of the turbinates naturally due to increases in venous pressure impacting drainage of blood from the head while lying compared to standing. Once in this position for more than 30 minutes, assess overall nasal breathing and also gently compress each nostril and determine if one or both sides feel restricted on their own. If you feel short of breath or like you need to catch your breath by mouth breathing, chances are this is occurring during sleep and may be impacting your health (dental hygiene issues, contributing to airway resistance problems such as snoring and obstructive sleep apnea, etc.). Over-the-counter treatments for nasal congestion include short-term options (Afrin, oral decongestants, etc.) that can be used safely for 2 to 3 days, and long-term options such as topical steroid sprays (Flonase, Nasonex, etc.), antihistamines, etc. that are often needed for longer to control allergy-related nasal congestion.

Evaluating the Cause of Nasal Congestion

Evaluation in the ENT clinic helps uncover the exact reasons why your nose feels congested and exactly which treatments are most likely to succeed. Nasal endoscopy involves a quick 30 to 60 second evaluation of the inside of your nose with a small camera that provides a much better view of the nasal anatomy and can show problems such as a deviated septum, enlarged turbinates, and inflammation that might suggest more severe allergies or sinus problems. Nasal polyps might also be encountered, which often present with painless nasal congestion rather than symptoms of sinusitis. In-office CT scanners also allow accurate assessment of anatomy problems, and can help patients visualize the problems easier than nasal endoscopy by seeing all of the factors impacting nasal airflow on both sides at once. CT scans are also better at evaluating for the
presence of sinus disease compared to nasal endoscopy alone.

Correcting Abnormal Nasal Breathing

Nasal anatomy problems leading to congestion, such as a deviated septum and enlarged turbinates, can be corrected with simple outpatient procedures when treating with nasal steroid sprays and allergy meds fail to provide relief and the congestion is impacting your quality of life. Snoring, while often more severe during flareups of significant congestion, may or may not improve with correction of the nasal airway alone and should be seen as a potential side benefit rather than a primary aim of any nasal procedure performed to alleviate congestion.

Correcting abnormal nasal breathing can significantly improve the quality of sleep, energy levels, and overall quality of life for those with obvious nasal anatomy problems. If you’re uncertain, visit with an ENT specialist and evaluate your nose for anatomy problems and inflammatory conditions that might require more specialized treatment than over-the-counter medications alone. When done properly, corrective nasal surgery provides a lifetime of better breathing and helps reduce the need for ongoing treatments such as nasal sprays.