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