Congenital nasal obstruction in infants: A retrospective study and literature review

Nasal Disorders

Nasal obstruction, rhinorrhea, and epistaxis are common presenting concerns in primary care clinics. Nasal disorders affect the quality of life for many children and families. Rarely, these complaints may represent a life-threatening condition among infant obligate nasal breathers or cases of unusual pathology. The most common causes of rhinorrhea and nasal obstruction vary by age and include physiologic, infectious, allergic, foreign body, irritant, and traumatic causes. Less commonly, children may have congenital malformations, sinonasal masses, or autoimmune disease. The most common causes of epistaxis are inflammatory, environmental, and traumatic causes and medication misuse, but rarely, children may have predisposing anatomic, hematologic, or vascular abnormalities or even sinonasal tumors. In this article, we provide a thorough review of the common nasal disorders treated every day in primary care clinics and mention briefly some of the rare but serious cases that may be overlooked without considering a full differential diagnosis.

Features and Strategies in the Management of Choanal Atresia: A 6-Year Retrospective Analysis

INTRODUCTION

Choanal atresia although rare, is the most common inborn nasal deformity and an important cause of newborn airway obstruction. This study aims to describe a single-center experience in the management of choanal atresia and emphasize the ambiguous issues regarding its surgical repair.

PATIENTS AND METHODS

The authors retrospectively analyzed the treatment strategy of 18 patients with choanal atresia and their outcomes during the follow-up period.

RESULTS

Bilateral choanal atresia was diagnosed in 9 patients, 6 of those had mixed bony-membranous type (67% versus 33% who had pure bony type). Almost half of the 18 patients had a mixed bony-membranous type of atresia (56%). Interestingly, 89% of patients with bilateral atresia underwent transnasal endoscopic repair with stenting, compared to 44% of those with unilateral atresia (P = 0.04). A trend to preference of stent procedure in patients with bony type was also observed, in comparison with mixed bony-membranous type (89% versus 50%, P = 0.09). No significant difference in the need for revision treatment was noticed among the two treatment groups.

CONCLUSIONS

Both in our data and literature there is no clear supremacy of stenting. Considering the high incidence of re-stenosis, all patients should be under close follow up for a long-term period. Inevitably, further investigation is necessary to establish an ideal surgical procedure.

Novel maxillary enlargement technique in congenital nasal pyriform aperture stenosis: a case report and literature review

Congenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of neonate nasal obstruction. Because newborns are natural nasal breathers, urgent treatment may be needed. CNPAS is diagnosed by clinical symptoms and signs, and CT. In severe cases, surgical approach is needed. The most often used approach is widening of pyriform aperture via sublabial incision with nasal tubing. We report a novel surgical approach as a curative treatment for CNPAS by immediate transverse enlargement of the maxilla. We also review current literature of the condition focusing on surgical management of the disease.

New concepts in pediatric rhinitis

Rhinitis-and especially allergic rhinitis (AR)-remains the most frequent hypersensitivity condition, affecting up to a quarter of the population and impacting the quality of life of individual patients and the health economy. Data, especially with respect to underlying pathophysiologic mechanisms, mainly derive from studies on adults and are subsequently extrapolated to the pediatric population. Therapeutic algorithms for children with rhinitis are long based on the same principles as in adults. We explore and describe novel aspects of rhinitis, ranging from mechanisms to disease classification, phenotypes, diagnostic and monitoring tools, and the use of treatments, with a focus on the traits of pediatric age groups.

Congenital bony nasal cavity stenosis: A review of current trends in diagnosis and treatment

Congenital bony nasal cavity stenosis is caused by alterations of the normal embryological development of the nasal cavity. Depending on the site of the obstruction, the most important types of stenosis are: choanal atresia and stenosis, congenital nasal pyriform aperture stenosis, congenital midnasal stenosis, arhinia and nasal septum deviation. Although they are uncommon, they could be potentially life-threatening conditions that require early diagnosis and proper treatment. In case of neonatal nasal obstruction, appropriate differential diagnosis with other causes, such as rhinitis and sinonasal masses, are performed by nasal endoscopy and radiological exams. Treatment strategy consisting of medical nasal therapies and endoscopic or open nasal surgery should be tailored according to the types and the degree of the stenosis. When indicated, endoscopic endonasal approach is considered the most effective technique in neonates warranting minimal surgical invasiveness and maximum effect. In order to promote the management of these rare yet clinically relevant neonatal nasal breath disorders, we review the current trends in diagnosis and treatment of congenital bony nasal cavity stenosis.

Neonatal nasal obstruction

PURPOSE

Congenital nasal obstruction can be a significant cause of respiratory distress in the newborn, given that they are considered to be obligate nasal breathers. Several different causes have been described, which can be broadly classified as anatomical/malformative, non-tumoral masses and cysts, benign and malignant neoplasia, inflammatory/infectious, traumatic/iatrogenic, and miscellaneous. The purpose of this review is to provide updated and useful clinical information for teams involved in neonatal care, especially in a hospital setting.

METHODS

A review of the available literature was performed. Studies were sourced from PubMed with searching of relevant headings and sub-headings and cross-referencing.

RESULTS

The most common etiology is inflammatory, which can have different precipitating factors or be idiopathic, a condition known as neonatal rhinitis. On the other hand, some less frequent but nonetheless relevant conditions causing severe nasal obstruction include choanal atresia, midnasal stenosis, and pyriform aperture stenosis. Some cystic lesions, such as dacryocystoceles with intranasal mucocele, can also produce significant obstruction. Diagnosis usually requires a nasal endoscopy and in some cases imaging such as computed tomography. Management includes different medical and surgical strategies and will greatly depend on the etiology and the severity of symptoms.

CONCLUSION

Congenital nasal obstruction can be a significant cause of respiratory distress in the newborn. The wide spectrum of differential diagnoses requires a thorough knowledge of nasal anatomy, physiology, and pathology; as well as different management strategies.

Clinical and imaging evaluation of Congenital Midnasal Stenosis

OBJECTIVES

To illustrate the clinical and radiological presentation of a rare etiology of nasal obstruction in neonates, midnasal stenosis (MNS), including a comparison of nasal dimensions with those of normal infants.

METHODS

We retrospectively reviewed medical charts and computerized tomography (CT) imaging of neonates with nasal obstruction diagnosed as stenosis in the midnasal area in a tertiary pediatric medical center. MNS was defined clinically by inability to visualize the middle turbinate with an endoscope despite the absence of stenosis of the anterior aperture or any gross septal deviation. CT measurements of the midnasal width were taken by an experienced neuroradiologist. We compared widths between the bony inferior turbinate to the bony septum in the narrowest area of symptomatic patients, to widths in a control group of asymptomatic children.

RESULTS

Nine neonates from birth to three months old presenting with nasal obstruction, severe stertor, and blocked nasal passage at the midnasal level in endoscopic examination, were diagnosed with MNS. 6/9 had CT scans. Four had isolated unilateral stenosis, two unilateral MNS and contralateral choanal atresia, and three bilateral MNS. All patients were managed conservatively, initially with nasal saline irrigation and local steroids and topical antibiotics; Median time to resolution of symptoms was 14 days. When comparing the dimensions at the midnasal narrowest area of the stenotic group with a control group of 139 healthy children, the median bony width was 1.7 mm vs. 3.2 mm, respectively (p < 0.00001). Average dimensions according to age groups until the age of 12 months are given.

CONCLUSION

In neonates with nasal obstruction, when choanal atresia and pyriform aperture stenosis are excluded, stenosis of the midnasal area should be considered. Most of these neonates can be managed conservatively.

LEVEL OF EVIDENCE

4.

Congenital midnasal stenosis: Conservative management

INTRODUCTION

Congenital midnasal stenosis (MNS) is an extremely rare disease which may be life threatening, and shows difficulty in diagnosis and management. This case series summarizes superiority of using intranasal mometasone furoate spray (IMS) and continuous positive airway pressure (CPAP) to treat nasal obstruction in neonates with MNS.

METHODS

This study reviewed six consecutive cases of MNS.

RESULTS

Three patients were treated with IMS and CPAP. Two patients were treated with endoscopic balloon dilatation without stenting, followed by IMS and CPAP due to persisting nasal obstruction after the operation. One patient was treated with endoscopic balloon dilatation without stenting alone.

CONCLUSION

This study is the first to review the use of CPAP and IMS as an effective therapy for some patients with MNS. It suggests that conservative management with CPAP and IMS may be an alternative therapeutic option to surgery.

Congenital Dacryocystocele: A Major Review

PURPOSE

To provide a systematic review of the literature on congenital dacryocystoceles (CDCs) and summarize their presentations, investigations, management, and outcomes.

METHODS

The authors performed a PubMed search of all articles published in English on CDCs. Data captured include demographics, clinical presentations, investigations, management modalities, complications, and outcomes. Fourteen major series (10 or more than 10 cases) and 89 isolated case reports/series on CDCs with a collective patient pool of 1,063 were studied in detail. Specific emphasis was laid on addressing the controversial issues including initial conservative versus surgical management and the role of endoscopic evaluation.

RESULTS

Numerous terminologies have been used to describe CDC. Congenital dacryocystoceles are rare variants of congenital nasolacrimal duct obstructions and comprise of 0.1% to 0.3% of all such cases. There is a female predilection (64.2%, 683/1,063) and the mean age at presentation is at 7 days of birth. Initial conservative treatment can be a viable option in the absence of an acute dacryocystitis or a respiratory distress. Endoscopy-assisted probing appears to have better outcomes as compared with the in-office probing. Congenital dacryocystoceles with acute dacryocystitis are preferably managed with intravenous antibiotics and an early probing under endoscopy guidance to avoid missing intranasal cysts. Marsupialization is the preferred technique in the management of intranasal cysts. Silicone intubation was rarely used and has no definitive indications. Dacryocystorhinostomy is very rarely needed in the management of CDC.

CONCLUSIONS

Congenital dacryocystocele is a commonly accepted term and its use should be advocated to enhance uniformity in reporting. Endoscopic evaluation of CDC is useful in the diagnosis and treatment of associated intranasal cysts and enhances the rates of successful outcomes.

Aspiration and Dysphagia in the Neonatal Patient

Dysphagia and aspiration are commonly encountered problems in the neonatal population. It is often multifactorial in nature and management should be tailored to the individual patient. Multiple causes should be considered, including anatomic abnormalities, neurologic/developmental delay, cardiopulmonary disease/infection, and gastroesophageal reflux disease, in addition to those cases where a definitive reason may not be identified. Management should be multidisciplinary in nature and surgical intervention may be indicated in certain populations of patients. Here, we discuss the presentation, workup, and management of the neonatal patient with dysphagia and aspiration.

Congenital Choanal Atresia Repair: An Analysis of Adverse Perioperative Events

Objectives

To identify risk factors and determine the perioperative morbidity of infants undergoing congenital choanal atresia (CCA) repair.

Study Design

Retrospective analysis of the ACS-NSQIP-P database (American College of Surgeons National Surgical Quality Improvement–Pediatric).

Setting

Tertiary medical center.

Subjects and Methods

Patients who underwent CCA repair at age ≤365 days at the time of surgery were queried via the ACS-NSQIP-P database (2013-2016) via Current Procedural Terminology code 30540. Analyzed outcomes include age, length of stay, medical comorbidities, operative time, readmission, reoperation, and postoperative complications.

Results

A total of 168 patients were identified, 70 of which were within the neonatal period. Preoperatively, gastrointestinal disease ( P < .0001), mechanical ventilation ( P < .0001), and oxygen supplementation ( P = .0040) were significantly greater in frequency among neonates. For all children preoperatively, ASA class ( P < .0001), chronic lung disease ( P = .0019), oxygen supplementation ( P < .0001), and prematurity ( P = .0016) had a significant impact on prolonged length of stay. Neonates had a persistent requirement for postoperative mechanical ventilation ( P < .0001) and a prolonged length of stay ( P < .00001).

Conclusion

Neonates undergoing CCA repair are more likely to have a persistent requirement for postoperative mechanical ventilation and a prolonged length of stay. Recognition of key clinical factors may aid in optimizing perioperative risk assessment, patient counseling, and procedural planning.