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

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

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

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

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

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

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

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

Belenky & Madgy

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

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

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

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

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

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

KAUH Experience Thirty-eight cases of CA between Jan Dec 2005 Thirty-eight cases of CA between Jan 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 atresia 95% had mixed bony & membranous atresia 32% had other associated congenital anomalies Al-Ammar Saudi Med J % had other associated congenital anomalies Al-Ammar Saudi Med J 2006

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

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 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 Intra-operative application of MMC (0.4mg/ml for 4 min) for 13 cases Result; success - MMC 69% - no-MMC 57% p= 0.23 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 Unilateral CA, success; - MMC 7/10 (70%) - no-MMC 3/5 (60%) p= 0.7