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Nasal obstruction in Nasal obstruction in children children
BYBYAhmed Y. Al-Ammar, MD, FKSUAhmed Y. Al-Ammar, MD, FKSUAssociate professor, pediatric Associate professor, pediatric
otolatyngologist otolatyngologist KAUH, King Saud University KAUH, King Saud University
PhysiologyPhysiology
Obligate nasal breathing for 6 to 8 Obligate nasal breathing for 6 to 8 WKs (degree and duration is variable)WKs (degree and duration is variable)
Other basic function of the nose; Other basic function of the nose; temperature, humidification, temperature, humidification, protection, protection,
Endogenous and exogenous stimuliEndogenous and exogenous stimuli- result in vasomotor reaction - result in vasomotor reaction - control nasal respiration - control nasal respiration - -
regulates Oregulates O2 2 intake of lungs intake of lungs
AnatomyAnatomy
nasal AW is smaller in newborn nasal AW is smaller in newborn Resistance to AF is approximately 4X Resistance to AF is approximately 4X
that in adults that in adults Areas of AF resistance;Areas of AF resistance;
- nasal valve (50% of nasal - nasal valve (50% of nasal resistance) resistance) - vestibular area - vestibular area
- nasal septum - nasal septum - anterior end of the inf. - anterior end of the inf.
turbinate turbinate
Clinical assessment of child Clinical assessment of child with nasal obstructionwith nasal obstruction
Time (age) at onset of nasal obstructionTime (age) at onset of nasal obstruction Sign of distress, difficulty in feeding, Sign of distress, difficulty in feeding,
cyanosis, apnea, failure to thrivecyanosis, apnea, failure to thrive Complete or partial obstruction Complete or partial obstruction Unilateral or bilateral obstructionUnilateral or bilateral obstruction Crying improves resp. distress caused Crying improves resp. distress caused
by nasal obstruction in infants by nasal obstruction in infants
ExaminationExamination
Rigid and fiberoptic nasoscope and Rigid and fiberoptic nasoscope and nasopharyngoscopenasopharyngoscope
Infants; Infants; failure failure to pass # 6- 8 catheterto pass # 6- 8 catheter - - pyriform aperture stenosis pyriform aperture stenosis (1 (1 CM)CM) - choanal atresia (3.5 cm)- choanal atresia (3.5 cm)
Objective measures of nasal Objective measures of nasal obstructionobstruction
RhinomanometryRhinomanometrylimitted use in infants and young limitted use in infants and young
childrenchildren Acoustic rhinometryAcoustic rhinometry
for diagnosis and follow up after for diagnosis and follow up after interventionintervention
Lateral radiograph of nose and NP.Lateral radiograph of nose and NP. CT scan CT scan MRIMRI
Etiology of nasal obstructionEtiology of nasal obstruction
Nonspecific nasal mucosal edema is the Nonspecific nasal mucosal edema is the commonest in neonates commonest in neonates
Congenital Congenital Inflammatory & infectiousInflammatory & infectious Allergic Allergic Toxic Toxic Nasopharyngeal Nasopharyngeal Traumatic Traumatic Foreign bodiesForeign bodies Neoplastic Neoplastic Metabolic Metabolic
Consequences of ch. Nasal Consequences of ch. Nasal obstructionobstruction
Effect on facial growth and Effect on facial growth and development is controversial development is controversial
May include;May include;mouth breathing, abnormal mouth breathing, abnormal
tongue tongue posturing posturing - dental arch - dental arch changeschanges - - craniofacial changes craniofacial changes
Belenky & Madgy
ManagementManagement
Dictated by the significance of AW Dictated by the significance of AW distress distress
Temporary Temporary - McGovern nipple - McGovern nipple
- oropharyngeal - oropharyngeal - ET intubation - ET intubation - tracheotomy - tracheotomy
Definitive management Definitive management
Indication for surgical Indication for surgical intervention for nasal intervention for nasal
obstructionobstruction Sleep apneaSleep apnea Repeated intubation & failure of Repeated intubation & failure of
extubationextubation Feeding difficulties with cyanosis Feeding difficulties with cyanosis Failure of conservative management Failure of conservative management
Congenital nasal pyriform Congenital nasal pyriform stenosisstenosis(CNPAS)(CNPAS)
Rare cause of AW obstruction in infants, Rare cause of AW obstruction in infants, easily mistaken for choanal atresia easily mistaken for choanal atresia
Initially described radiologically by Ey et Initially described radiologically by Ey et al in 1988al in 1988
CT scan finding CT scan finding Height of nasal cavity is usually normalHeight of nasal cavity is usually normalwidth < 11mm in term infants is width < 11mm in term infants is considered diagnostic considered diagnostic
Belden et al. 1999Belden et al. 1999
Management of CNPASManagement of CNPAS
Milder forms can be treated Milder forms can be treated conservativelyconservatively humidification, humidification, topical decongestants, topical decongestants, suctioningsuctioning
Surgical interventionSurgical intervention- time; based on respiratory - time; based on respiratory
statusstatus Approach Approach
- tansnasal; technically difficult in - tansnasal; technically difficult in infants infants
- sublabial - sublabial
Choanal atresiaChoanal atresia
Uncommon anomalyUncommon anomaly(1 in 5000 – 8000 births)(1 in 5000 – 8000 births)
Roederer in 1755Roederer in 1755 CA may be associated with other CA may be associated with other
anomalies in 20-50% of casesanomalies in 20-50% of casesCHARGE CHARGE VATER VATER craniofacial anomalies craniofacial anomalies
Management of CAManagement of CA
Many surgical approach Many surgical approach Endoscopic repair using powered Endoscopic repair using powered
instruments became very popular instruments became very popular Tools to improve outcome;Tools to improve outcome;
- Nasal stent - Nasal stent
- Topical mitomycin - Topical mitomycin
KAUH KAUH ExperienceExperience
Thirty-eight cases of CA between Jan 1999- Thirty-eight cases of CA between Jan 1999- Dec 2005 Dec 2005
Twenty-three cases had unilateral Twenty-three cases had unilateral 83% involved the RT side 83% involved the RT side 95% had mixed bony & membranous 95% had mixed bony & membranous
atresia atresia 32% had other associated congenital 32% had other associated congenital
anomalies anomalies Al-Al-AmmarAmmarSaudi Med J 2006 Saudi Med J 2006
STUDYSTUDYEffect of nasal stent on CAEffect of nasal stent on CA
Total of 32 CA casesTotal of 32 CA cases Bilateral = 11 Unilateral = 21 cases Bilateral = 11 Unilateral = 21 cases NS used in 13 casesNS used in 13 cases NS was not used in 18 casesNS was not used in 18 cases No clear benefit for bilateral casesNo clear benefit for bilateral cases Deleterious effect when used for unilateral Deleterious effect when used for unilateral
cases, failure rate;cases, failure rate;- NS 7/8 (86%) - NS 7/8 (86%) - no-NS 3/12 (25%) p= 0.00988- no-NS 3/12 (25%) p= 0.00988
Study Study effect of mitomycin C on effect of mitomycin C on
outcome of CA repairoutcome of CA repair 20 children underwent endoscopic repair 20 children underwent endoscopic repair
of CA with no prior surgical intervention of CA with no prior surgical intervention nor use of NS nor use of NS
Intra-operative application of MMC Intra-operative application of MMC (0.4mg/ml for 4 min) for 13 cases (0.4mg/ml for 4 min) for 13 cases
Result; success - MMC 69% Result; success - MMC 69% - no-MMC 57% p= 0.23 - no-MMC 57% p= 0.23
Unilateral CA, success;Unilateral CA, success;- MMC 7/10 (70%)- MMC 7/10 (70%)- no-MMC 3/5 (60%) p= 0.7- no-MMC 3/5 (60%) p= 0.7