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Nasal obstruction in children

Physiology . Obligate nasal breathing for 6 to 8 WKs (degree and duration is variable)Other basic function of the nose; temperature, humidification, protection, Endogenous and exogenous stimuli- result in vasomotor reaction - control nasal respiration - regulates O2 intake of lungs .

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Nasal obstruction in children

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    1. Nasal obstruction in children BY Ahmed Y. Al-Ammar, MD, FKSU Associate professor, pediatric otolatyngologist KAUH, King Saud University

    2. Physiology Obligate nasal breathing for 6 to 8 WKs (degree and duration is variable) Other basic function of the nose; temperature, humidification, protection, Endogenous and exogenous stimuli - result in vasomotor reaction - control nasal respiration - regulates O2 intake of lungs

    3. Anatomy nasal AW is smaller in newborn Resistance to AF is approximately 4X that in adults Areas of AF resistance; - nasal valve (50% of nasal resistance) - vestibular area - nasal septum - anterior end of the inf. turbinate

    4. Clinical assessment of child with nasal obstruction Time (age) at onset of nasal obstruction Sign of distress, difficulty in feeding, cyanosis, apnea, failure to thrive Complete or partial obstruction Unilateral or bilateral obstruction Crying improves resp. distress caused by nasal obstruction in infants

    5. Examination Rigid and fiberoptic nasoscope and nasopharyngoscope Infants; failure to pass # 6- 8 catheter - pyriform aperture stenosis (1 CM) - choanal atresia (3.5 cm)

    6. Objective measures of nasal obstruction Rhinomanometry limitted use in infants and young children Acoustic rhinometry for diagnosis and follow up after intervention Lateral radiograph of nose and NP. CT scan MRI

    7. Etiology of nasal obstruction Nonspecific nasal mucosal edema is the commonest in neonates Congenital Inflammatory & infectious Allergic Toxic Nasopharyngeal Traumatic Foreign bodies Neoplastic Metabolic

    8. Consequences of ch. Nasal obstruction Effect on facial growth and development is controversial May include; mouth breathing, abnormal tongue posturing ? - dental arch changes - craniofacial changes

    10. Management Dictated by the significance of AW distress Temporary - McGovern nipple - oropharyngeal - ET intubation - tracheotomy Definitive management

    11. Indication for surgical intervention for nasal obstruction Sleep apnea Repeated intubation & failure of extubation Feeding difficulties with cyanosis Failure of conservative management

    13. Congenital nasal pyriform stenosis (CNPAS) Rare cause of AW obstruction in infants, easily mistaken for choanal atresia Initially described radiologically by Ey et al in 1988 CT scan finding Height of nasal cavity is usually normal width < 11mm in term infants is considered diagnostic Belden et al. 1999

    14. Management of CNPAS Milder forms can be treated conservatively humidification, topical decongestants, suctioning Surgical intervention - time; based on respiratory status Approach - tansnasal; technically difficult in infants - sublabial

    20. Choanal atresia Uncommon anomaly (1 in 5000 – 8000 births) Roederer in 1755 CA may be associated with other anomalies in 20-50% of cases CHARGE VATER craniofacial anomalies

    21. Management of CA Many surgical approach Endoscopic repair using powered instruments became very popular Tools to improve outcome; - Nasal stent - Topical mitomycin

    22. KAUH Experience Thirty-eight cases of CA between Jan 1999- Dec 2005 Twenty-three cases had unilateral 83% involved the RT side 95% had mixed bony & membranous atresia 32% had other associated congenital anomalies Al-Ammar Saudi Med J 2006

    23. STUDY Effect of nasal stent on CA Total of 32 CA cases Bilateral = 11 Unilateral = 21 cases NS used in 13 cases NS was not used in 18 cases No clear benefit for bilateral cases Deleterious effect when used for unilateral cases, failure rate; - NS 7/8 (86%) - no-NS 3/12 (25%) p= 0.00988

    24. Study effect of mitomycin C on outcome of CA repair 20 children underwent endoscopic repair of CA with no prior surgical intervention nor use of NS Intra-operative application of MMC (0.4mg/ml for 4 min) for 13 cases Result; success - MMC 69% - no-MMC 57% p= 0.23 Unilateral CA, success; - MMC 7/10 (70%) - no-MMC 3/5 (60%) p= 0.7

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