Congenital nasal pyriform aperture (bony inlet) stenosis

Congenital Nasal Piriform Aperture Stenosis or Bony Inlet Stenosis: A Report of Three Cases

Background

Congenital nasal piriform aperture stenosis is an uncommon disorder causing nasal obstruction in neonates. Findings on computed tomography (CT) greatly facilitate the diagnosis.

Methods

Three cases of congenital nasal piriform aperture stenosis are reported, with an emphasis on CT findings.

Conclusions

At birth, a diameter of the piriform aperture at the level of the inferior nasal meatus of ≥5 mm on CT may indicate a good chance of success using conservative treatment.

The natural course of congenital nasal pyriform aperture stenosis

OBJECTIVES/HYPOTHESIS

Patients with congenital nasal pyriform aperture stenosis (CNPAS) may become less symptomatic with age. Therefore, we aimed to develop a growth curve of the pyriform aperture so that a more comprehensive plan can be designed for CNPAS patients who show little response to conservative treatment.

STUDY DESIGN

A single-institution study, retrospective review of CNPAS patients during the period November 1997 to December 2014.

METHODS

We measured the distances between the bilateral nasal processes of the maxilla (interprocess distance [IPD]) on three-dimensional computed tomography images and then divided the patients into five different age groups. A growth curve of the pyriform aperture was then constructed based on the distance-age relationship.

RESULTS

Fifty-four IPD measurements were included. The mean IPD was 3.57 mm in neonates < 1 month old, 4.08 mm in infants aged 1 to 3 months, 5.19 mm in the 4-month to 11-month age group, 6.61 mm in the 12-month to 36-month age group, and 9.20 mm in children > 36 months of age. We found that the cubic curve was the most appropriate growth curve, and that growth tended to be slower from 3.5 years to 6 years of age.

CONCLUSIONS

The growth curve of the pyriform aperture in children with CNPAS developed in this study can aid in treatment planning and predict clinical outcome of CNPAS patients. Although CNPAS patients may become less symptomatic with age, when the observed IPD falls progressively farther from the curve, more aggressive intervention should be considered, such as changing the management strategy from observation to conservative treatment or from conservative treatment to surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:2399-2402, 2016.

Solitary median maxillary central incisor syndrome (SMMCI) with congenital nasal puriform aperture stenosis: literature review and case report with comprehensive dental treatment and 14 years follow-up

BACKGROUND

Solitary median maxillary central incisor syndrome [SMMCI] is an extremely rare anomaly, especially when no other abnormalities are present. The defect is often found together with various nasal abnormalities and short stature with or without decreased levels of growth hormone. In more severe cases, SMMCI has been associated with holoprosencephaly, the CHARGE and the VACTERL association. Also, published sporadic cases have been related with rare variants of ectodermal dysplasia, chromosomal abnormalities, precocious puberty, hypothalamic hamartoma, congenital heart defects, physical/mental retardation, genital hypoplasia and ear abnormalities. For these reasons when the initial diagnosis is made by the paediatric dentist, ENT, neurological and paediatric evaluations are essential.

CASE REPORT

A 4-year-old boy with SMMCI was referred for dental treatment. Clinical/radiographic examination revealed a symmetrical primary and permanent SMMCI, a skeletal Class I and a unilateral crossbite. Medical history indicated respiratory distress and surgery soon after birth due to congenital nasal puriform aperture stenosis. Gradual orthodontic treatment started at the age of 4 years and completed at the age of 13 years. Following maxillary expansion, upper lateral segments were moved backwards and anterior space was created for accommodating a second central incisor. Retainers with a supplementary acrylic incisor were provided for aesthetic and functional replacement until the age of 16 years, when a fixed Maryland ceramic bridge was placed.

FOLLOW-UP

Two years recall, at the age of 18 years, revealed a satisfactory and stable aesthetic and functional result.

CONCLUSION

Successful dental management of SMMCI patients is possible, following a detailed long-lasting treatment plan requiring multidisciplinary paediatric dental, orthodontic and prosthetic approach.

A case of solitary median maxillary central incisor (SMMCI) syndrome with bilateral pyriform aperture stenosis and choanal atresia

Solitary median maxillary central incisor syndrome is a rare disorder involving midline abnormalities. It may present with life threatening respiratory distress in the neonate secondary to nasal malformations. These include pyriform aperture stenosis and choanal atresia. We present the first reported case of simultaneous choanal atresia and pyriform aperture stenosis in a neonate with solitary median maxillary central incisor syndrome. The clinical presentation and the management of congenital pyriform aperture stenosis are discussed.

Effects of nasal continuous positive airway pressure and cannula use in the neonatal intensive care unit setting

OBJECTIVE

To investigate the effects of nasal continuous positive airway pressure (CPAP) and cannula use in the neonatal intensive care unit.

DESIGN

Cross-sectional study.

SETTING

Tertiary care children's hospital.

PATIENTS

One hundred patients (200 nasal cavities), younger than 1 year, who received at least 7 days of nasal CPAP (n = 91) or cannula supplementation (n = 9) in the neonatal intensive care unit.

INTERVENTIONS

External nasal examination and anterior nasal endoscopy with photographic documentation.

MAIN OUTCOME MEASURES

The incidence and characteristics of internal and external nasal findings of patients with nasal CPAP or cannula use.

RESULTS

Nasal complications were seen in 12 of the 91 patients (13.2%) with at least 7 days of nasal CPAP exposure, while no complications were seen in the 9 patients with nasal cannula use alone. The external nasal finding of columellar necrosis, seen in 5 patients (5.5%), occurred as early as 10 days after nasal CPAP use. Incidence of intranasal findings attributed to CPAP use, in the 182 nostrils examined, included ulceration in 6 nasal cavities (3.3%), granulation in 3 nasal cavities (1.6%), and vestibular stenosis in 4 nasal cavities (2.2%). Intranasal complications were seen as early as 8 to 9 days after nasal CPAP administration. Nasal complications from CPAP were associated with lower Apgar scores at 1 (P = .02) and 5 (P = .06) minutes.

CONCLUSIONS

External or internal complications of nasal CPAP can be relatively frequent (13.2%) and can occur early, and patients with lower Apgar scores may be at higher risk. Close surveillance for potential complications should be considered during nasal CPAP use.

Congenital nasal pyriform aperture stenosis: feeding evaluation and management

PURPOSE

We identified four patients with congenital nasal pyriform aperture stenosis (CNPAS) with feeding and respiratory difficulties. While feeding difficulties have been described in infants with other causes of nasal obstruction (e.g., choanal atresia), little attention has been focused on feeding in infants with CNPAS.

FINDINGS

All four patients were treated with nasal steroids and nasal saline and two underwent surgical repair of the CNPAS at 2 months of age. Except for gastroesophageal reflux in one patient, upper gastrointestinal tract (UGI) contrast studies were normal in all patients. Three patients underwent bedside swallow evaluations, two of whom participated in videoflouroscopic swallow studies (VFSS) because of limited oral intake or respiratory problems during feeding. These three patients presented with intact oral-motor coordination at rest and during non-nutritive sucking, and nasal whistling, nasal congestion, or breathing difficulties/desaturations with oral feeding. On VFSS, one infant had trace aspiration with thin and thick liquids. Three patients required supplemental feeding during the first year of life. All three patients with normal brain MRIs were successful oral feeders by 16 months of age, the fourth is undergoing feeding therapy at 24 months of age.

SUMMARY

Feeding problems are common in infants with CNPAS and supplemental feedings may be needed even after management of airway difficulties. Infants with CNPAS should undergo comprehensive feeding/swallowing evaluations which may include bedside swallow evaluations and VFSSs. The prognosis for transitioning to total oral feedings is good and related to the extent of the airway obstruction and presence of other comorbidities.

Congenital nasal pyriform aperture stenosis: diagnosis and management

OBJECTIVES

To review diagnosis and treatment modalities in congenital nasal pyriform aperture stenosis in a newborn population.

STUDY DESIGN

A 6-year retrospective case series review. Mean follow-up of 21.8 months.

SETTING

University hospital, tertiary care center.

PATIENTS

Twenty-one consecutive patients treated for congenital nasal pyriform aperture stenosis. Diagnosis was suspected on physical examination and confirmed by computed tomography scan. Associated abnormalities were present in 15 patients.

SURGICAL TREATMENT

Nineteen patients underwent surgical treatment focused on external bony margins of pyriform aperture and the osseous anterior edge of the inferior turbinate, drilling by a sublabial approach and associated with a partial turbinectomy in seven cases. A stent was placed for 7 to 10 days. A conservative treatment based on topical nasal decongestants and gastroesophageal reflux treatment was proposed for two patients.

RESULTS

Postoperative follow-up revealed septal ulceration in five cases with septal perforation in one case and development of synechiae in two cases. Follow-up revealed normal nasal breathing and pyriform aperture growth after surgery.

CONCLUSION

Our experience confirmed the link described between congenital nasal pyriform aperture stenosis and holoprosencephaly, but associated extracraniofacial malformations suggest that congenital nasal pyriform aperture stenosis should be integrated in a systemic malformative syndrome or genetic disorder and lead us to propose an exhaustive dysmorphology assessment. Some infants may be treated by conservative management, and severely affected patients may undergo surgery by a sublabial approach.

The measurement of congenital nasal pyriform aperture stenosis in infant

OBJECTIVE

In the study we use the image of three dimensional computed tomography (3D-CT) to assess the different widths of the bony framework of congenital nasal pyriform aperture stenosis (CNPAS).

METHODS

We select 17 infants under 4 months old diagnosed as CNPAS for this study. There were four categories of distance measurement. The distance between the caudal end of the nasal bone (nasal tip) and the anterior nasal spine (NPAH). The distance between bilateral bony inner wall of the nasal pyriform aperture at the midpoint of the aperture height (MIVD). The interprocess distance at the level of lower 1/4 of the pyriform aperture height (IPD). The narrowest distance between the bilateral nasal processes (NIPD).

RESULTS

There were 17 infants, nine males and eight females. At the time of performing 3D-CT, the mean age was 49.5+/-35.9 days. The results of measurement were: NPAH: 10.9+/-1.23mm, MIVD: 8.2+/-0.89mm, IPD: 4.9+/-0.93mm, and NIPD: 4.4+/-0.73mm. The MIVD is significantly wider than both IPD and NIPD (p<0.01). There is high correlation between IPD and NIPD. There is no significant difference on age between gender in this study. However, the IPD (4.4+/-0.74) and NIPD (3.9+/-0.47) of male patients are broader, respectively, than those of female patients with significant difference (p<0.05).

CONCLUSION

The measurement of CNPAS by means of 3D-CT may provide useful data for evaluation of the width in different parts of nasal pyriform aperture. These may be used for evaluation of pre- and postoperative status and future investigation in CNPAS patients.

Nasal molding: a cultural practice causing respiratory distress in a term infant

A case of respiratory distress secondary to the cultural practice of "nasal molding" is reported. Nasal molding should be included as an entity causing nasal obstruction without choanal atresia. Furthermore, this report underscores the role of interpreters in provision of health care.

Congenital pyriform aperture stenosis: surgery and evaluation with three-dimensional computed tomography

OBJECTIVE

We described the surgical efficacy of congenital pyriform aperture stenosis by measuring the width of the nasal pyriform aperture with three-dimensional computed tomography.

METHODS

Six patients with congenital pyriform aperture stenosis accepted surgical intervention. Three-dimensional computed tomography was performed for preoperative and postoperative evaluation of nasal pyriform aperture width. We marked the midpoint between the tip of nasal bone and the anterior nasal spine. The distances between the bilateral nasal processes of the maxilla and between the lateral rims of the pyriform aperture were measured by crossing the midpoint horizontally.

RESULTS

Among the six patients (three male and three female patients), the mean age was 76.2+/-23.9 days. Silicon stents were removed 6 to 7 days after operation. During 9 months of follow-up, there were no cases of restenosis, respiratory failure, or cyanosis. The mean preoperative and postoperative interprocess distances were 4.5+/-0.84 and 8.7+/-1.37 mm, respectively, and data were statistically significant at a confidence level of P <.05. The mean preoperative and postoperative interwall distances were 9.8+/-0.75 and 10.8+/-1.5 mm, respectively.

CONCLUSIONS

Congenital pyriform aperture stenosis should be suspected whenever there is both severe nasal obstruction and difficulty in passing a small catheter or nasogastric tube through the anterior nasal valve. Operation is the most extreme treatment, but it is effective for congenital pyriform aperture stenosis. Nasal stenting for 7 days seemed to be adequate. The use of three-dimensional computed tomography to evaluate preoperative and postoperative nasal pyriform aperture is effective and reliable.

Congenital nasal pyriform aperture stenosis: diagnosis and treatment

Congenital nasal pyriform aperture stenosis is an unusual form of nasal airway obstruction in the neonate. Pediatric plastic surgeons are often involved in the management of these children and should recognize this condition and know the treatment options. Fifteen cases of children with congenital nasal pyriform aperture stenosis were reviewed for presentation of the disorder, management, and effectiveness of treatment, making it the largest series to date. There were nine male patients and six female patients in the series. They all experienced varying degrees of nasal obstruction at birth and were managed on the basis of the severity of their symptoms. Twelve patients were treated surgically in the first year of life, with a mean age at operation of 97 days (range, 3 to 362 days). Two patients required surgical intervention during their teenage years (age, 14 and 18 years) because of persistent symptoms, and one patient (age, 2 years) with mild symptoms was managed medically. Associated craniofacial anomalies were present in six cases (40 percent). Surgical enlargement of the pyriform aperture was successfully performed through an upper buccal sulcus incision in 14 patients. Preoperative symptoms of upper airway obstruction were improved in all patients at an average follow-up of 2.4 years (range, 1 month to 5 years). Congenital nasal pyriform aperture stenosis varies in presentation and severity, occurring either as an isolated congenital anomaly or in association with developmental craniofacial anomalies. It can be effectively managed by surgical enlargement of the pyriform aperture without significant recurrence or long-term morbidity.

Congenital nasal pyriform aperture stenosis: non-surgical management and long-term analysis

Congenital nasal pyriform aperture stenosis is a rare cause of airway obstruction in the newborn. Immediate recognition and therapy are essential for this potentially life-threatening condition. After initial management, which includes establishment of an oral airway, surgical repair of the stenotic bony inlet has been traditionally considered. We present a long-term follow-up of two patients with congenital pyriform aperture stenosis, who were managed expectantly. Pertinent embryology, clinical presentation, and general treatment strategies for these patients are also discussed.