Step 1 of 6
Entry, Triage & Red-Flag Screen
Laterality · chronicity · progression · associated epistaxis / anosmia / facial pain → red-flag screen; unilateral progressive obstruction routes urgently.
The first decision in every adult with nasal obstruction is whether this is a routine inflammatory presentation or a flag for a sinister underlying process. Laterality (unilateral vs bilateral), chronicity (acute vs chronic), progression (stable vs progressive), positional variation (worse supine → valve collapse), associated epistaxis (neoplasm warning), anosmia (polyposis / CRS), and facial pain or pressure (rhinosinusitis) all shape the differential at this step.
The red-flag malignancy box is binding — unilateral obstruction, recurrent epistaxis, facial numbness, diplopia, proptosis, neck nodes, weight loss, persistent unilateral pain, loose teeth, and adult-onset otitis media with effusion all mandate urgent ENT pathway with nasal endoscopy, contrast imaging (CT + MRI), and biopsy where appropriate.
Critical safety warning — never biopsy a suspected Juvenile Nasopharyngeal Angiofibroma (adolescent male with epistaxis and a nasopharyngeal mass) before contrast imaging; uncontrolled haemorrhage from this hypervascular lesion is a real risk. See pathway_G (sinonasal tumour) and pathway_H (nasopharyngeal mass) for the diagnostic algorithms.
- Laterality — unilateral vs bilateral (tumour vs inflammatory)
- Chronicity — acute (infection) vs chronic (structural / inflammatory)
- Pattern — intermittent (allergy) vs persistent (anatomy)
- Progression — progressive (malignancy concern) vs stable
- Positional — worse supine suggests valve collapse
- Associated epistaxis — neoplasm warning until disproven
- Associated anosmia — CRS / polyposis
- Associated facial pain or pressure — rhinosinusitis
- Red-flag malignancy box — see framework_red_flag and red_flag_to_concern_matrix
- Adolescent male + epistaxis + nasopharyngeal mass — do NOT biopsy before imaging
★ High-yield pearls (chapter-wide)
- Unilateral nasal obstruction is neoplasm until proven otherwise — sinonasal or nasopharyngeal malignancy must be actively excluded.
- Normal anterior rhinoscopy does NOT exclude significant pathology — nasal endoscopy is the diagnostic pivot.
- Topical decongestants beyond 5–7 days drive rhinitis medicamentosa — counsel every patient on duration limits.
- Adolescent male with epistaxis and a nasopharyngeal mass is Juvenile Nasopharyngeal Angiofibroma until proven otherwise — DO NOT biopsy before imaging.
- Children with nasal polyps require evaluation for cystic fibrosis — paediatric polyposis is rare and CF-associated until disproven.
- Nasal valve dysfunction is among the most commonly missed causes of chronic nasal obstruction — every chronic case warrants a Cottle manoeuvre.
- Adult-onset otitis media with effusion without an obvious cause raises nasopharyngeal carcinoma — refer for endoscopy of the nasopharynx.
- Crusting plus septal perforation plus saddle nose plus bloody discharge is granulomatous disease (especially GPA) until proven otherwise.
- CRS with polyps plus asthma plus aspirin sensitivity is Samter's triad (AERD) — consider type-2 biologic therapy alongside FESS.
- Empty Nose Syndrome is paradoxical obstruction after aggressive turbinate surgery — humidification, implant reconstruction, and psychological support are all part of standard care.
Evidence base
5 sources- HIGH
Rosenfeld RM et al. · Otolaryngology-Head and Neck Surgery · 2015National CPG (AAO-HNSF)PMID 25832968
AAO-HNSF CPG anchoring red-flag and escalation triggers in adult sinonasal disease; underpins triage step.
- HIGH
Fokkens WJ et al. · Rhinology · 2020International consensusPMID 32077450
EPOS 2020 explicitly enumerates red-flag features (unilateral symptoms, bleeding, orbital/neurological signs) that mandate escalation in nasal obstruction triage.
- HIGH
Chen YP et al. · Lancet · 2019Narrative reviewPMID 31178151
Lancet seminar on NPC outlining presenting red flags (unilateral OME, neck mass, cranial neuropathy, epistaxis) relevant to adult nasal obstruction triage.
- MOD
Sheu SH, Wu CC, Liu MT · Kaohsiung Journal of Medical Sciences · 1998Cohort studyPMID 9838766
Foundational evidence that adult-onset unilateral OME has a non-trivial probability of underlying NPC and warrants nasopharyngeal endoscopy / biopsy.
- HIGHCummings Otolaryngology - Head and Neck Surgery, 7th edition
Flint PW et al. · Elsevier · 2020Textbook
Standard reference textbook chapter on adult nasal obstruction and red-flag assessment; anchors clinical pathway.
Decision tree
The red-flag screen is the first gate. For a non-red-flag presentation, the phenotype splits the algorithm into six columns — each terminating in one or more of ten diagnosis-keyed pathways. The JNA pattern (adolescent male + epistaxis + nasopharyngeal mass) and Samter triad (asthma + aspirin sensitivity + polyps) bypass standard phenotype routing.