I experience difficulty breathing through my nose (nasal breathing) when lying down, what could be causing this symptom?

Difficulty Breathing Through Nose When Lying Down

Your positional nasal obstruction when lying down is most commonly caused by either allergic rhinitis with turbinate congestion, anatomical abnormalities (septal deviation or turbinate hypertrophy), or increased nasal airway resistance that worsens in the supine position—and you should pursue evaluation with nasal endoscopy and consider allergy testing to guide treatment.

Primary Causes to Consider

Allergic Rhinitis and Turbinate Congestion

• Allergic rhinitis causes turbinate hypertrophy and mucosal congestion that worsens when lying down due to gravitational redistribution of blood flow and increased venous pooling in the nasal mucosa 1.
• The most common allergic triggers include pollens, fungi, dust mites, furry animals, and insect emanations 1.
• Increased nasal airway resistance from allergic inflammation is associated with worsening symptoms in the supine position, particularly during sleep 1.

Anatomical Abnormalities

• Nasal septal deviation and inferior turbinate hypertrophy are the major structural components causing positional nasal obstruction 1.
• The nasal septum is off-center in approximately 80% of the general population, but clinically significant deviation causing obstruction occurs in about 26% of patients with nasal obstruction symptoms 1.
• Anterior septal deviation is much more significant than posterior deviation because the internal nasal valve (anterior nose) is responsible for more than 2/3 of nasal airflow resistance 1.
• Compensatory turbinate hypertrophy typically occurs on the side opposite the septal deviation, which can be bilateral with S-shaped deviations 1.

Positional Factors

• When lying down, gravitational forces cause rostral fluid redistribution to the neck and upper airway, increasing tissue edema and narrowing the nasal passages 1.
• The supine position increases venous congestion in nasal turbinates, amplifying any baseline obstruction from inflammation or anatomical variants 1.

Evaluation Algorithm

Initial Assessment

• Obtain a detailed history focusing on: timing of symptoms (seasonal vs perennial), environmental triggers, presence of snoring or sleep disturbance, unilateral vs bilateral obstruction, and history of nasal trauma 1.
• Physical examination should include anterior rhinoscopy to assess for septal deviation, turbinate size, mucosal appearance (pale/boggy suggests allergy, erythematous suggests infection), and presence of polyps 1.

Diagnostic Testing

• Nasal endoscopy is indicated to visualize the entire nasal cavity, identify anatomical variants (septal deviation, concha bullosa, turbinate hypertrophy), and assess for polyps or masses 1.
• Allergy testing (preferably skin testing) should be performed to identify specific IgE-mediated sensitivities that may be contributing to turbinate congestion and inflammation 1.
• Consider formal evaluation for obstructive sleep apnea if you have additional risk factors such as snoring, witnessed apneas, daytime sleepiness, or obesity, as increased nasal resistance is associated with sleep-disordered breathing 1.

Advanced Testing (If Indicated)

• Rhinomanometry can objectively measure nasal airway resistance before and after decongestant use to assess the contribution of mucosal congestion vs fixed anatomical obstruction 1.
• CT imaging is NOT indicated for uncomplicated rhinitis but may be warranted if chronic sinusitis, nasal polyposis, or surgical planning is being considered 1.

Treatment Approach

Medical Management (First-Line)

• Intranasal corticosteroids are the most effective treatment for reducing turbinate congestion and nasal airway resistance in both allergic and non-allergic rhinitis 1.
• Fluticasone, budesonide, and mometasone have been shown to reduce nasal airway resistance and improve symptoms in patients with positional nasal obstruction 1.
• Nasal decongestants provide temporary relief by shrinking swollen nasal membranes, allowing you to breathe more freely 2.
• Antihistamines may be beneficial if allergy testing confirms IgE-mediated sensitivity 1.

Environmental Control

• Implement allergen avoidance measures based on identified sensitivities (dust mite covers, air filtration, pet restriction) 1.
• Elevate the head of your bed to reduce rostral fluid shift and venous pooling in nasal tissues 1.

Surgical Intervention (If Medical Management Fails)

• Surgery may be indicated for severe nasal septal deviation or inferior turbinate hypertrophy refractory to maximal medical treatment 1.
• Septoplasty with or without turbinate reduction can improve nasal airflow and allow more effective delivery of topical medications 1.
• Surgery is particularly beneficial when anatomical obstruction amplifies congestion from allergic inflammation 1.

Critical Pitfalls to Avoid

• Do not ignore positional nasal obstruction, as it may indicate underlying sleep-disordered breathing that can affect cardiovascular health and quality of life 1.
• Avoid prolonged use of topical nasal decongestants (beyond 3-5 days) as they can cause rebound congestion (rhinitis medicamentosa) 2.
• Do not assume the problem is purely allergic without proper evaluation, as anatomical abnormalities are present in a significant proportion of patients and may require surgical correction 1.
• Recognize that subjective perception of nasal obstruction may not correlate with measured nasal resistance, so both subjective symptoms and objective findings should guide treatment decisions 1.

When to Seek Specialist Referral

• Refer to an otolaryngologist if symptoms persist despite 4-6 weeks of optimal medical therapy, if significant anatomical abnormalities are identified on examination, or if surgical intervention is being considered 1.
• Refer to an allergist for comprehensive allergy evaluation and consideration of immunotherapy if multiple allergen sensitivities are identified and environmental control plus pharmacotherapy are insufficient 1.