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Importance of Nasal Cavity Care for Relieving Dyspnea in Patients With Advanced Cancer

Open ArchivePublished:August 20, 2014DOI:https://doi.org/10.1016/j.jpainsymman.2014.08.005
      To the Editor:
      Dyspnea is one of the most important problems in the management of cancer patients and has numerous etiologies. The nasal cavity is part of the upper respiratory tract; thus, nasal obstruction can be one of the causes of dyspnea. Dyspnea resulting from nasal obstruction caused by significant amounts of dried nasal mucus is occasionally encountered in patients with advanced cancer. The observation and management of the nasal cavity is easy, but its care can be overlooked and is easily forgotten. Furthermore, the removal of dried nasal mucus is usually simple and easy; thus, the resulting dyspnea can be immediately reduced. However, the importance of clinical examination and care of the nasal cavity, especially in managing dyspnea in patients with advanced cancer, has not yet been reported. In the present report, we demonstrate the potential for the occurrence of dyspnea caused by nasal obstruction from dried mucus and describe the importance of nasal care in effectively treating dyspnea. Both patients' families gave permission for these cases to be reported.

      Case 1

      An 82-year-old man with a three-year history of malignant lymphoma that had metastasized to the brain, nasal cavity, and testis was admitted to the palliative care unit. He also had chronic rhinitis and mild impaired consciousness caused by Parkinsonian syndrome; his performance status was 4. One day, he complained of dyspnea and uncomfortable respiration without respiratory failure. Initially, there were no identifiable causes of dyspnea on clinical examination. We then examined the nasal cavity and detected an enormous volume of dried nasal mucus bilaterally in the nasal cavity (Fig. 1).
      Figure thumbnail gr1
      Fig. 1Enormous volume of dried nasal mucus bilateral in nasal cavity.
      After removing the dried nasal mucus with tweezers, the dyspnea immediately disappeared. The same symptom was reported again two weeks later, and the same treatment proved effective. We periodically examined the nasal cavity and applied moisturizing cream to the region.
      • Björk-Eriksson T.
      • Gunnarsson M.
      • Holmström M.
      • Nordqvist A.
      • Petruson B.
      Fewer problems with dry nasal mucous membranes following local use of sesame oil.
      Once this protocol was enacted, the dried nasal mucus no longer accumulated.

      Case 2

      A 70-year-old man with a three-month history of hepatocellular carcinoma and mild impaired consciousness from hepatic encephalopathy was admitted to the palliative care unit. His performance status was 4. He previously lost swallowing function and, therefore, was fed using a nasogastric tube. One day, he complained of dyspnea and uncomfortable respiration without respiratory failure. On clinical examination, a large amount of dried nasal mucus was detected bilaterally in the nasal cavity. The nasal mucus was removed in a manner similar to that used for Case 1, and his respiratory symptoms were similarly relieved.

      Comment

      Dried nasal mucus comprises a desiccated piece of nasal mucus and dust from the air. Relatively large accumulations of dried nasal mucus cause discomfort and respiratory symptoms; however, most patients can eject the debris on their own. Therefore, dried nasal mucus does not typically grow to an extremely large size. Patients with advanced cancer often have impaired consciousness and cannot eject dried nasal mucus themselves; thus, the debris can grow to enormous size. Large pieces of dried nasal mucus obstruct the nasal cavity, resulting in dyspnea. In these cases, the patient compensates by breathing through the mouth; this ensures that oxygen saturation does not decrease. If we can assess the cause of dyspnea appropriately, then treatment is simple and easy and does not require medication or oxygen supplementation. In our experience, patients at a high risk of recurrence of dried nasal mucus obstructions may be any patient with an impaired consciousness, low performance status, nasal tumor, nasal catheter or oxygen cannula, and chronic rhinitis.
      • Das S.K.
      Etiological evaluation of foreign bodies in the ear and nose.
      Although observation of the nasal cavity is sometimes forgotten and easily overlooked, examination is an important component in relieving dyspnea in patients with advanced cancer.

      References

        • Björk-Eriksson T.
        • Gunnarsson M.
        • Holmström M.
        • Nordqvist A.
        • Petruson B.
        Fewer problems with dry nasal mucous membranes following local use of sesame oil.
        Rhinology. 2000; 38: 200-203
        • Das S.K.
        Etiological evaluation of foreign bodies in the ear and nose.
        J Laryngol Otol. 1984; 98: 989-991