Archives of Disease in Childhood 1995; 72: 287-289

Nasal obstruction in infancy

Nasal obstruction is common in infancy, a problem whichis compounded by the fact that infants tend to be obliga-tory nasal breathers. Most frequently such obstruction isassociated with non-specific rhinitis, episodes of which arefortunately not usually severe, are of short duration, andrespond to conservative measures such as instillation ofsaline or sodium bicarbonate solutions and aspiration ofsecretions. This latter manoeuvre is awkward at the best oftimes but is said to be made easier by using a small bulbsyringe. Sometimes addition of topical decongestants isrequired to reduce mucosal oedema but use of theseshould be short term and intermittent and if persistentmucosal swelling is the problem, topic nasal steroids suchas beclomethasone should be substituted. However, thereare infants in whom obstruction is severe enough to pre-sent a difficult management problem, others in whom it isso persistent as to be a significant factor in failure to thrive,and the occasional infant in whom it is life threatening.Disorders that contribute to these states are discussed inthis article.

Choanal atresiaIn the obligate nasal breathing newborn this is a wellrecognised cause of nasal obstruction, although rarelyencountered. It has to be suspected in any neonateunable to breathe until the mouth is opened eithervoluntarily or by insertion of a laryngoscope blade andsuspicion is strengthened by obstruction to passage of asuction catheter through the nose. An oral airway canthen be strapped in place as an emergency relief measure

until the diagnosis can be confirmed. There is an associa-tion with other congenital anomalies and these should beexcluded, the most frequent being the anomalies linkedas the CHARGE syndrome. Confirmation is obtainedeither by direct examination, if a suitable fibreoptic endo-scope is available, or by radiology.' The traditional con-trast study after aspiration of the accumulated mucoidsecretions will confirm an atresia but, if facilities are avail-able, computed tomography will provide greater detail ofboth the atresia partition and the dimensions of the pos-terior nasal cavity, information that aids in planningsurgery.

Surgery is undertaken as soon as the infant is fit for ageneral anaesthetic and can be either performed directlythrough the nose or by using a transpalatal approach.However Pirsig has reviewed long term results and con-cludes that the deformity of palatal development seen aftertranspalatal surgery no longer warrants this approach ininfancy.2 Some restenosis by fibrosis is almost inevitableafter surgery and, if it causes significant obstruction, can bemanaged either by dilatation or by laser ablation of thefibrotic tissue.

Nasal pyriform aperture stenosisIn this more recently recognised condition3 there is exces-sive bone growth in the nasal processes of the maxillarybones with consequent stenosis of the nasal pyriformaperture. These babies present with severe nasal obstruc-tion and in them difficulty is experienced in introducing asuction catheter into the nasal cavity. When examined

(Gomputed tomography of congenital nasal pyriform aperture stenosis.

287

on April 29, 2022 by guest. P

rotected by copyright.http://adc.bm

j.com/

Arch D

is Child: first published as 10.1136/adc.72.4.287 on 1 A

pril 1995. Dow

nloaded from

8Prescott

closely the 'nasal valve' area at the entrance to the nasalcavity is found to be abnormally narrow and, when probed,felt to be firm and resistant to compression as passage ofthe probe is attempted. The bony nature of the stenosis isbest demonstrated by computed tomography (figure).Surgery is required to relieve the obstruction. Through asublabial incision the nasal pyriform aperture is exposed,the excess bone identified and then drilled away using amicrosurgical otological drill. After redraping of themucosa in the nasal inlet stenting with Silastic tubes isrequired for a few days.

Birth trauma to the nasal cavityDuring 'moulding' in the birth canal compressive lateralforces on the midface can cause excessive upward archingof the palate to compress the nasal septum which respondsby either buckling laterally or dislocating. Both the buckledseptum and associated mucosal oedema cause nasalobstruction. There has been a vogue for septal manipula-tion in such cases4 but it has been shown that the majorityof buckled septal cartilages straighten spontaneouslywithin 4-6 months.5 By reducing mucosal oedema usingdecongestant and steroid drops nasal patency can usuallybe obtained. Manipulation is only really required whendislocation has occurred and this can usually be recognisedbecause it is associated with some deformity of thecartilaginous nasal skeleton.

InfectionRhinitis is common, most episodes being ofviral origin andrunning a benign course over 5-10 days with initial feversubsiding and some purulence to the secretions after a fewdays. The associated nasal obstruction can be distressingand the conservative measures outlined may be requiredbut antibiotics are not needed. When purulent secretionspersist for longer than 10 days and added symptoms ofrecurrence of fever and night time cough develop, thepossibility of sinusitis has to be considered. Although thisis not a well recognised entity in infancy, both the maxil-lary and ethmoid sinuses are present from birth and canbecome infected.6 The diagnosis is clinical since at this ageradiology is generally unhelpful. There is also poor correla-tion between bacteria cultured from nasal secretions andthose organisms causing sinusitis. However these areusually Haemophilus influenzae, Streptococcus pneumoniae orBranhamella catarrhalis in the early stages of sinusitis withlater appearance of anaerobic organisms. Antibiotic treat-ment is indicated as orbital and intracranial complications,although not common at this age, can occur. Amoxycillinis the antibiotic generally recommended.

It is easy to overlook the 'snuffles' of congenital syphilis,especially when there are no other obvious stigmata of thedisease. In its early stages it is clinically indistinguishablefrom the above, although later the purulence may beassociated with nasal excoriation and blood staining. It is adiagnosis that should always be kept in mind.

Persistent or frequently recurrent purulent rhinitisshould trigger suspicion of cystic fibrosis as it can be theearliest manifestation ofthis condition. Foreign bodies alsohave to be borne in mind and are not uncommon ininfancy. Classically they present as a unilateral obstructionwith purulent discharge often with an associated unpleas-ant odour.

Aliergic rhinitisThe voluminous literature on allergic rhinitis is noteworthyfor the lack of any definitive article on it in infancy.

Although not common it occurs with sufficient frequencyto warrant consideration, usually in infants with otherallergic manifestations such as asthma and eczema. In earlyinfancy it is related to ingested allergens, most frequentlymilk but also soya, peanuts, egg white and wheat, but byabout 1 year of age sensitivity to inhalant allergens can bedemonstrated - house dust mite and pets, particularly cats(E Weinberg, personal communication). In infancy it isdifficult to treat. When ingestant allergens can be demon-strated either by skin prick testing or by a radioallergosor-bent test, elimination of them from the diet can producedramatic improvement. The use of oral decongestants forthe nasal obstruction is not particularly effective and tachy-phylaxis soon arises, but topical decongestants are effectiveand these can be combined with intranasal steroids. Forinhalant allergens a useful topical preparation is made upby mixing 20 mg sodium cromoglycate with 10 ml 0-025%oxymetazoline (the late Dr L Shore).

Rhinitis medicamentosaUse of topical nasal decongestants generally produces sucha gratifying response from the nasal mucosa that it is some-times difficult thereafter to avoid overuse and the insidiousonset of increasing rebound congestion, a predicamentknown as rhinitis medicamentosa. In this condition there isprobably a combination of reactive vasodilatation as aconsequence of fatigue in the vasoconstrictor mechanismin the submucosal vessels and the ,B sympathomimetic out-lasting a sympathomimetic effects of the decongestant.Typically tachyphylaxis occurs in which the need fortopical decongestion becomes more frequent as reactivenasal congestion intensifies until a situation of chronicmucosal swelling causes almost continual obstruction.Decongestants have to be stopped and a topical steroiddrop can be substituted. In an infant who is still dependenton the nasal airway some form of nasopharyngeal airwaymay have to be placed for a period until the mucosa hasshrunk enough to restore nasal patency.7

'Upper airway obstruction'In infancy it is often difficult to distinguish purely nasalobstruction from the general picture of upper airwayobstruction and often the two cannot be functionallyseparated. The upper airway is a collapsible structure thepatency of which is determined by the thickness of its softtissue walls and the degree of support offered by bony,cartilaginous, and muscular surrounding structures. Atthis level in the airway there is a negative pressure withinthe lumen during inspiration and anything obstructing freeaccess of air will increase this. This in turn causes the softtissues surrounding the space to collapse, further exacer-bating the obstruction - particularly noteworthy in 'floppy'infants.There is usually minimal lymphoid tissue in and around

the upper airway in early infancy but it soon begins tohypertrophy in response to immunological stimulation.The adenoid is usually the first organ to cause obstructiveproblems and has to be considered even in early infancy.From about 6 months of age adenoid hypertrophy is by farthe commonest cause of nasal obstruction. Evaluation isdifficult as interpretable lateral radiographs have to betaken with the infant relaxed during a nasal inspiration.Direct examination of the adenoid using a flexible fibre-optic endoscope passed through the nasal cavity is the bestmethod of assessing the need for adenoidectomy. In floppyinfants and those with reduced oropharyngeal dimensionseven minimal hypertrophy of the tonsils can producemarked upper airway obstruction and the situation can

288

on April 29, 2022 by guest. P

rotected by copyright.http://adc.bm

j.com/

Arch D

is Child: first published as 10.1136/adc.72.4.287 on 1 A

pril 1995. Dow

nloaded from

Nasal obstruction in infancy 289

arise when consideration has also to be given to tonsillec-tomy in infancy.Adenoidectomy and adenotonsillectomy are not

straightforward procedures in infancy particularly whenthe obstruction necessitating surgery has been severe orprolonged. Many are unable to maintain their airway in thepostoperative period and require either intubation or anasopharyngeal tube. As a general rule infants undergoingthese procedures should be managed in a high care areawith suitable monitoring for at least the first postoperativenight and may need to remain under observation for anextra day or two before discharge.There are also significant lymph nodes within the

retropharyngeal space and inflammatory adenitis can causesignificant enlargement that may present as 'nasal obstruc-tion', usually associated with a fever. If suspected a lateralradiograph will confirm widening of the retropharyngealsoft tissue shadow, although these are notoriously unreli-able when infants are crying or swallowing at the time theyare taken. The best method of examination is digitalpalpation. In the early stages intravenous antibiotics mayproduce resolution - airway support is frequently required- but if there has been progression to abscess formationdrainage is essential.The tendency for nasal obstruction to exacerbate upper

airway obstruction is also a factor that has to be consideredin laryngeal disorders such as laryngomalacia and vocalcord palsy, both inspiratory prolapse disorders. Main-tenance of a clear upper airway may enable other interven-tional procedures to be avoided.

Craniofacial anomaliesCraniofacial anomalies are associated with very variablenasal airway patency both as to cause and severity ofobstruction. If obstructed the potential sites that have to beevaluated are the 'nasal valve' area anteriorly, hypertrophicturbinates in narrowed nasal cavities, posterior choanalstenosis and reduced dimensions to the nasopharynx thatmay be compounded by adenoid hypertrophy. A combina-tion of endoscopic and radiological examination with bothgood lateral plain films and computed tomograms shouldenable determination of which areas are predominantlyaffecting the airway. For many some form of surgical pro-cedure can then be devised to attempt to increase patency.These are not always successful and the potential for devel-oping cardiac complications from chronic upper airwayobstruction may mean that tracheostomy has to be con-sidered, although there are some parents who prefer a longterm nasopharyngeal airway but these have potential tocause nasal cartilage deformity.

Midline nasal massesThe commonest 'tumour' involving the nose is thehaemangioma. Although these are usually external, as theyexpand during the first year of life, any intranasal compo-nent may cause nasal obstruction necessitating surgicalintervention. Otherwise the majority completely involuteover the next three to four years without the need for anytreatment.

Within the nasal cavity the commonest tumour is theencephalocoele which arises when the embryologicalforamen caecum fails to close and cranial contents herniate

through the defect. They are classified as encephalocoeleswhen the content is both dura and brain tissue and asgliomas when either only a fibrous connection extendsintracranially or complete separation has occurred.Computed tomography delineates those cases in which theroof of the nasal cavity is intact, when the mass can beexcised intranasally, from those in which there is a defect.8When a defect is present local policy varies. Some neuro-surgeons advocate an intracranial approach for all cases,surgery that has devastating consequences for the sense ofsmell and frequently precipitates epilepsy, while othersprefer primary intranasal excision only proceeding tointracranial surgery when a true encephalocoele is demon-strated.Even more rare are neoplastic masses in the infant nasal

cavity. At this age these are usually teratomatous malfor-mations,9 true neoplasms usually presenting at a slightlyolder age.

ConclusionNasal obstruction in infancy can be very distressing forparents but its severity is often underestimated by physi-cians as it is generally at its worst at night when the infantsare sleeping but at its best when they are in our consultingrooms. It is a complaint to which, in general, we need to bemore sensitive because significant nasal obstruction canpose a very real danger in infancy. The severity of theobstruction when it is at its worst needs to be determinedand in particular whether or not it is associated withepisodes of obstructive apnoea - a very definite indicationfor urgent intervention. At this age arousal mechanisms areoften poorly developed and infants can very rapidly desat-urate down to the levels at which cardiac arrhythmias arise.

Although most nasal obstruction in infancy is not of thisorder of severity and generally responds to simple conser-vative measures, when some of the conditions outlinedneed to be considered diagnosis requires a combination ofhistory, examination, and investigation. Here the problemlies in trying to find the skills and equipment needed. Theinfant nose is a highly specialised area of practice and timeinvested in persuading a colleague in the ear, nose, andthroat department to develop such an interest will be wellrewarded and thereafter the more such cases are referredthe greater the expertise that will develop in their manage-ment.

C A J PRESCOTTDepartment of Otolaryngology and Head and Neck Surgery,Glasgow Royal Infirmary,University NHS Trust,Glasgow G4 OSF

1 Benjamin B. Evaluation of choanal atresia. Ann Otol Rhinol Larynol 1985; 94:429-32.

2 Pirsig W. Surgery of choanal atresia in infants and children: historical notesand updated review. Int J Pediatr Otorhinolarynhol 1986; 11: 153-70.

3 Brown OE, Myer CM, Manning SC. Congenital nasal pyriform aperturestenosis. Laryngoscope 1989; 99: 86-91.

4 Gray LP. Septal manipulation in the neonate: method and results. Int JPediatr Otorhinolaryngol 1985; 8: 195-209.

5 Kent SE, Reid AP, Nairn ER, Brain DJ. Neonatal septal deviations. Y R SocMed 1988; 81: 132-5.

6 Giebink GS. Childhood sinusitis: pathophysiology, diagnosis and treatment.Pediatr Infect DisY 1994; 13S: 55-8.

7 Osguthorpe JD, Reed S. Neonatal respiratory distress from rhinitis medica-mentosa. Laryngoscope 1987; 97: 829-31.

8 Barkovich AJ, Vandermarck P, Edwards MSB, Cogen PH. Congenital nasalmasses: CT and MR imaging features in 16 cases. American Journal ofNeuroradiology 1991; 12: 105-16.

9 Alter AD, Cove JK. Congenital nasopharyngeal teratoma: report of a caseand review of the literature. J Pediatr Surg 1987; 22: 179-81.

on April 29, 2022 by guest. P

rotected by copyright.http://adc.bm

j.com/

Arch D

is Child: first published as 10.1136/adc.72.4.287 on 1 A

pril 1995. Dow

nloaded from