- Email: [email protected]
Nasal obstruction in children
G Model
ARTICLE IN PRESS
ANORL-488; No. of Pages 4
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Review
Nasal obstruction in children N. Leboulanger ∗ Service d’ORL et de chirurgie cervico-faciale, hôpital universitaire Necker–Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
a r t i c l e
i n f o
Keywords: Nasal obstruction Children Deformity Neonates Tumor
a b s t r a c t Nasal obstruction is a very frequent symptom in children, with numerous etiologies. Clinical diagnosis is straightforward, but general impact and rare etiologies should be explored for. Complementary examinations are guided by diagnostic orientation. Although not usually a severe condition, nasal obstruction may be life-threatening in neonates and infants. An exhaustive list of etiologies is impossible and would not be useful, but it is worth distinguishing infantile nasal obstruction and nasal obstruction in older children, as causes differ greatly. This is the topic of the present update. © 2015 Elsevier Masson SAS. All rights reserved.
1. Introduction Nasal obstruction is a very frequent symptom in children and a frequent cause of ENT consultation. While older children can express and describe their discomfort, for infants it is the family that has to be interviewed. The interview should particularly determine day- and night-time symptoms (obstruction, rhinorrhea, epistaxis, snoring, etc.), assess duration and impact (on function, growth, feeding and sleep), and look for associated signs (fever, cough, weight-loss, etc.). Physical examination should be as complete as possible and also systematically comprises flexible endoscopy; this is now feasible in almost all children, including neonates, with the development of small-caliber endoscopes. Imaging is not systematic and is reserved to certain cases according to the etiologic orientation emerging from interview and clinical examination. Likewise, other examinations, such a acoustic rhinometry or rhinomanometry, should not be systematic, and may be difficult to perform in children. Etiology is too varied to be easily listed. However, nasal obstruction in neonates and under 2-year-olds is worth distinguishing from that of older children, up to adolescence when the pathology becomes adult-form. Neonates, in particular, breathe exclusively through the nose until the age of about 3 months; severe obstruction at that age thus has great clinical impact and may, as in choanal atresia, even be life-threatening if not treated in the first instants of extra-uterine life. The present article sets forth the main causes of nasal obstruction in children according to frequency, severity and
∗ Tel.: +33 1 71 39 67 91; fax: +33 1 71 39 67 00. E-mail address: [email protected]
specific presenting symptoms, categorizing them as nasal obstruction in young versus older children. 2. Nasal obstruction in neonates and infants Until 3 months of age, neonates have exclusively nasal respiration [1]. Any obstruction therefore leads to varying difficulty: at meal times or at rest only, or so severe as to be life-threatening. Primary care is straightforward: removing the obstacle and fitting a Mayo or Guédel cannula. But this can only be a temporary solution: the cannula is unstable and poorly tolerated even by infants, as it prevents normal feeding and may cause painful hemorrhagic ulceration of the lips and base of the tongue; it should not be maintained longer than 24 hours. Alternative treatment should meanwhile be quickly initiated. 2.1. Neonatal rhinitis Neonatal rhinitis by definition concerns under 3-year-olds, without underlying pathology. Symptomatology ranges from simple intermittent obstruction to respiratory distress requiring hospital admission. Etiology is unknown, but may be multifactor: viral, inflammatory, vascular, drug-related, traumatic, etc. [2]. Clinical examination finds bilateral congestive nasal mucosa, but with bilaterally conserved permeability, thereby ruling out choanal atresia. Medical treatment is enough to bring relief in the vast majority of cases: physiological saline rinse or, temporarily, with hypotonic saline. Adrenaline solution may be used for a few days: usually, 1 mg adrenaline in 10 ml physiological saline. Medical treatment for gastro-esophageal reflux (posture, thickened milk, proton pump inhibitors) is systematic, although reflux involvement is usually hard to demonstrate. Prognosis is excellent. In case of persistence,
http://dx.doi.org/10.1016/j.anorl.2015.09.011 1879-7296/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Leboulanger N. Nasal obstruction in children. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.09.011
G Model ANORL-488; No. of Pages 4
ARTICLE IN PRESS N. Leboulanger / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
2
Fig. 1. Facial CT, bone window, axial slice: infant; right choanal atresia.
recurrence or clinical doubt, underlying deformity should imperatively be looked for. 2.2. Trauma Obstetric trauma may induce sometimes severe septal deviation in neonates. In general, however, this is well tolerated with rapidly favorable progression due to the plasticity of tissue at this age. Reduction surgery is almost never indicated, except for complete dislocation of the septum with the base totally detached from the columella.
Fig. 2. Right nasal cavity, endoscopic view; nasolacrimal cyst under right inferior turbinate bone.
2.3. Dysgenesis Many childhood facial deformities may induce nasal obstruction. The most frequent is choanal atresia, with estimated incidence around 1/5000 births, bilateral in 30% of cases. When unilateral, it may show few or no symptoms; when bilateral, it causes respiratory distress as of the first instants of life. Once the airways are brought under control, by a Mayo or Guédel cannula or intubation, it is impossible to pass an aspiration probe through the nasal cavities and aspiration withdraws clear thick mucus. CT provides definitive diagnosis (Fig. 1). Complementary assessment should explore for CHARGE syndrome; only cardiac echo is essential ahead of surgery [3]. Treatment is endoscopic and neonatal in bilateral forms and, so far as possible, delayed to the age of about 18–24 months in unilateral forms, for reasons of surgical comfort [4]. Nasolacrimal duct cyst is caused by lacrimal duct imperforation, leading to a small cyst filled with fluid. When obstruction is in the inferior part, the cyst bulges into the nasal cavity under the inferior turbinate bone, and may be obstructive (Fig. 2). Bilateral deformity may induce severely symptomatic obstruction in neonates. Treatment consists in endoscopic marsupialization by cold instruments or laser. There is no recurrence [5]. 2.4. Nasal meningocele Nasal meningocele comprises meningocele as such (meningeal hernia through the base of the skull into the nasal cavities, containing only cerebrospinal fluid [CSF]), meningoencephalocele, containing non-functional cerebral parenchyma, and glioma, ectopic glial tissue, with at most a fibrous cord communicating toward the base of the skull and therefore without CSF. Diagnosis in neonates and infants may be suggested by generally unilateral nasal obstruction with pinkish non-inflammatory, sometimes pulsatile tumefaction on endoscopy. There may be spontaneous CSF leakage, but this is not usual. CT and MRI provide diagnosis (Fig. 3). Biopsy, obviously, is not indicated. The child should be vaccinated against
Fig. 3. Facial CT, bone window, frontal slice: infant; large congenital right nasal meningocele of ethmoid origin. Good visualization of enlargement and ethmoid roof defect without bone lysis.
pneumococcus as soon as possible. The deformity is managed surgically, which can often be endoscopic [6]. It consists in resecting the herniated meninx after sectioning it at the neck, then repairing the base of the skull by cartilage and mucosal graft to restore meningeal impermeability. Very large hernia, secondary to large skull base defect, may require a combined ENT and neurosurgical approach. 2.5. Embryonal tumor Embryonal tumor, or teratoma, locations vary, principally involving the rhinopharynx and soft palate in the head and neck region (Fig. 4). These tumors are of very variable volume, and are mainly discovered during antenatal examination. Most are mature and benign, but the specimens must be fully analyzed by the pathologist to screen for immature malignancy. Complete surgical resection is systematically mandatory. Biological surveillance by ␣ fetoprotein and  HCG assay, which will always have been performed preoperatively, may be useful for deep locations in
Please cite this article in press as: Leboulanger N. Nasal obstruction in children. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.09.011
G Model
ARTICLE IN PRESS
ANORL-488; No. of Pages 4
N. Leboulanger / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
Fig. 4. T1-weighted facial MRI, sagittal slice. Neonate of a few days of age. Large oropharyngeal teratoma (X) pediculated onto the nasal septum (not seen in this image).
which clinical examination is difficult and imaging hard to interpret [7]. 3. Nasal obstruction in older children 3.1. Inflammatory pathology By far the most frequent cause of nasal obstruction in children older than about 18 months is rhinopharyngitis, an acute, usually viral inflammation of the rhinopharyngeal mucosa and particularly of the adenoid vegetation. Diagnosis is easy: infection, fever, rhinorrhea, nasal obstruction, snoring, etc. Treatment is medical and symptomatic (physiological saline rise and antipyretics), with rapidly favorable results. Antibiotic therapy is not indicated, even in case of purulent secretion. In case of frequent recurrence, underlying adenoid hypertrophy should be screened for, with correction of risk factors, primarily smoking by the parents [2]. Allergic rhinitis may cause acute or chronic nasal obstruction. Diagnosis is usually easy, associating obstruction, rhinorrhea, anosmia, pruritus and sneezing. Identifying and eliminating the culprit allergen(s) may be more difficult. 3.2. Adenoid hypertrophy Adenoid vegetation hypertrophy is a very frequent cause of nasal obstruction in children between the ages of 18 months and about 5 years, or sometimes younger or older. It is multifactorial, and mainly secondary to a disease of adaptation. It may induce nasal obstruction with obstructive sleep apnea syndrome (OSAS), iterative rhinopharyngitis and chronic rhinorrhea. Positive diagnosis is made on flexible endoscopy, which is feasible at any age and allows visualization of the obstructed choanae. Rhinopharyngeal X-ray involves radiation and is imprecise; it is no longer indicated: flexible endoscopy is preferable [8]. In case of symptomatic hypertrophy occurring outside episodes of superinfection, adenoidectomy is indicated. 3.3. Foreign bodies Foreign bodies are frequent in children, in the nasal cavities as in the outer ear. These may be bits of toys, little pebbles, seeds, etc. Partial nasal obstruction may be revelatory of a longstanding foreign body when associated with unilateral purulent rhinorrhea. In most cases, if the foreign body is discovered early on, it can be removed in consultation. The principle is to avoid making too
3
Fig. 5. 10-year-old with severe post-traumatic right septal deviation; the anterior part of the septum is clearly visible.
many attempts, so as not to frighten the child or cause mucosal lesions that might bleed and lead to edema. Removal is facilitated by anterior swabbing with Xylocaine Naphazoline followed by use of small otologic instruments. In some rare cases, surgery under general anesthesia may be needed [9]. 3.4. Septal deviation Congenital or acquired septal deviation may cause nasal obstruction, in children as in adults (Fig. 5). The added difficulty in children lies in gauging the functional impact experienced, possible consequences for the quality of sleep (clinical and possibly polygraphic OSAS screening), and choice of surgical technique if indicated. In principle, septoplasty is possible at any age, but is never implemented before 6–7 years and rarely before 15–16. When performed before adolescence, clinical indications should be very well-founded and surgery should be very limited, comprising only resection of an obstructing spur or realignment of the septum with minimal cartilage resection so as not to impair nasal pyramid growth. Facial CT is systematic before surgical planning [10]. As in adults, childhood nasal obstruction may also be caused by a number of benign or malignant tumoral pathologies. 3.5. Benign tumoral pathology Antrochoanal polyp of Killian mostly occurs in adolescence, but sometimes as early as 5 or 6 years. It is a single, large polyp, macroscopically regular and non-hemorrhagic, developing on the anterolateral mucosa of a maxillary sinus. Growth is slow and progressive, leading to uni- then bilateral obstruction when the polyp fills the rhinopharynx. CT finds complete opacity of the affected maxillary sinus and nasal cavity, depending on extension. There is no bone lysis. Treatment is exclusively surgical, by endoscopy, consisting in complete resection of the polyp and its base. Recurrence, however, is frequent [11]. Sinonasal polyposis can occur in children, although much less frequently then in adults. It is frequently associated with cystic fibrosis or primary ciliary dyskinesia; these should systematically be screened for when sinonasal polyposis is discovered in a child, and the advice of a pediatric pneumologist should be sought. Treatment is as in adults, taking account of the difficulty of administering long-course nasal corticosteroids in children [12]. Angiofibroma or nasopharyngeal angiofibroma is a benign richly vascularized tumor typically originating in the posterior lateral part
Please cite this article in press as: Leboulanger N. Nasal obstruction in children. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.09.011
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ARTICLE IN PRESS
ANORL-488; No. of Pages 4
N. Leboulanger / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
4
of a nasal cavity, at the sphenopalatine foramen. It is rare, affecting only preadolescent boys. Pathogeny is unknown. It is mainly revealed by iterative epistaxis and progressive nasal obstruction. Endoscopy finds a clear pinkish tumor with superficial vascular lacing. Work-up comprises facial CT and MRI to determine anatomic conditions and possible extension. Any clinical suspicion of angiofibroma contraindicates biopsy, due to risk of hemorrhage. Treatment consists in primary embolization followed by surgical resection within 48 hours, usually on an endonasal approach. Progress in imaging, embolization and endonasal instrumentation has greatly improved prognosis [13].
of 18–24 months, enables simple and rapid diagnostic orientation. An exhaustive list of etiologies would not be useful and would be difficult to draw up but, for clinical purposes, this simple distinction suffices: deformity predominates in younger children, and infection or tumor in older children.
3.6. Malignant tumoral pathology
[1] Trabalon M, Schaal B. It takes a mouth to eat and a nose to breathe: abnormal oral respiration affects neonates’ oral competence and systemic adaptation. Int J Pediatr 2012;2012:207605. [2] Garabédian EN, Bobin S, Monteil JP, Triglia JM. ORL de l’enfant. 2e éd. Paris: Flammarion; 2006 [446 p]. [3] Blake KD, Prasad C. CHARGE syndrome. Orphanet J Rare Dis 2006;1:34. [4] Teissier N, Kaguelidou F, Couloigner V, Franc¸ois M, Van Den Abbeele T. Predictive factors for success after transnasal endoscopic treatment of choanal atresia. Arch Otolaryngol Head Neck Surg 2008;134(1):57–61. [5] Lecavalier M, Nguyen LH. Bilateral dacryocystoceles as a rare cause of neonatal respiratory distress: report of 2 cases. Ear Nose Throat J 2014;93(1):E26–8. [6] Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal versus open repair of anterior skull base CSF leak, meningocele, and encephalocele: a systematic review of outcomes. J Neurol Surg A Cent Eur Neurosurg 2013;74(4):239–50. [7] Paradis J, Koltai PJ. Pediatric teratoma and dermoid cysts. Otolaryngol Clin North Am 2015;48(1):121–36. [8] Feres MF, Hermann JS, Cappellette M, Pignatari SS. Lateral X-ray view of the skull for the diagnosis of adenoid hypertrophy: a systematic review. Int J Pediatr Otorhinolaryngol 2011;75(1):1–11. [9] Claudet I, Salanne S, Debuisson C, Maréchal C, Rekhroukh H, Grouteau E. [Nasal foreign body in infants]. Arch Pediatr 2009;16(9):1245–51. [10] Lawrence R. Pediatric septoplasy: a review of the literature. Int J Pediatr Otorhinolaryngol 2012;76(8):1078–81. [11] Ayache S, Chatelain D, Denimal F, Deschepper B, Deramond H, Benhaïm T, et al. [A rare case of nasal and buccal obstruction in a child: the antrochoanal polyp of Killian]. Arch Pediatr 2005;12(10):1492–5. [12] de Winter-de Groot KM, van Haren Noman S, Speleman L, Schilder AG, van der Ent CK. Nasal nitric oxide levels and nasal polyposis in children and adolescents with cystic fibrosis. JAMA Otolaryngol Head Neck Surg 2013;139(9):931–6. [13] Cloutier T, Pons Y, Blancal JP, Sauvaget E, Kania R, Bresson D, et al. Juvenile nasopharyngeal angiofibroma: does the external approach still make sense? Otolaryngol Head Neck Surg 2012;147(5):958–63. [14] Gerth DJ, Tashiro J, Thaller SR. Pediatric sinonasal tumors in the United States: incidence and outcomes. J Surg Res 2014;190(1):214–20.
Childhood malignant tumor is dominated by 3 different anatomopathologic types. Revelation is broadly similar: chronic, asymmetric, slowly progressive nasal obstruction often associated with iterative epistaxis, pain, adenopathies, neurologic signs, impaired general health, etc. Alveolar or poorly differentiated embryonal rhabdomyosarcoma is the most frequent, and has the best prognosis. Locoregional growth is generally fast, with rapidly progressive obstruction or facial deformation. Imaging finds a tissue lesion, often lytic, and screens for parameningeal extension, which is relatively frequent and of adverse prognosis. Treatment is medical (chemotherapy and possibly radiation therapy), with surgical resection of residual tumor when possible [14]. Undifferentiated rhinopharyngeal carcinoma and nonHodgkins malignant lymphoma are diagnosed on biopsy of the nasal lesion or lymph-node extension, which is frequent. Treatment is basically medical. 4. Conclusion Nasal obstruction in children is a very frequent symptom, with benign etiology in the vast majority of cases. It may, however, be threatening in neonates and infants, or involve pathologies that must be identified and explored. The distinction between nasal obstruction in young and older children, with an arbitrary threshold
Disclosure of interest The author declares that he has no competing interest. References
Please cite this article in press as: Leboulanger N. Nasal obstruction in children. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.09.011
ARTICLE IN PRESS
ANORL-488; No. of Pages 4
European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Review
Nasal obstruction in children N. Leboulanger ∗ Service d’ORL et de chirurgie cervico-faciale, hôpital universitaire Necker–Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
a r t i c l e
i n f o
Keywords: Nasal obstruction Children Deformity Neonates Tumor
a b s t r a c t Nasal obstruction is a very frequent symptom in children, with numerous etiologies. Clinical diagnosis is straightforward, but general impact and rare etiologies should be explored for. Complementary examinations are guided by diagnostic orientation. Although not usually a severe condition, nasal obstruction may be life-threatening in neonates and infants. An exhaustive list of etiologies is impossible and would not be useful, but it is worth distinguishing infantile nasal obstruction and nasal obstruction in older children, as causes differ greatly. This is the topic of the present update. © 2015 Elsevier Masson SAS. All rights reserved.
1. Introduction Nasal obstruction is a very frequent symptom in children and a frequent cause of ENT consultation. While older children can express and describe their discomfort, for infants it is the family that has to be interviewed. The interview should particularly determine day- and night-time symptoms (obstruction, rhinorrhea, epistaxis, snoring, etc.), assess duration and impact (on function, growth, feeding and sleep), and look for associated signs (fever, cough, weight-loss, etc.). Physical examination should be as complete as possible and also systematically comprises flexible endoscopy; this is now feasible in almost all children, including neonates, with the development of small-caliber endoscopes. Imaging is not systematic and is reserved to certain cases according to the etiologic orientation emerging from interview and clinical examination. Likewise, other examinations, such a acoustic rhinometry or rhinomanometry, should not be systematic, and may be difficult to perform in children. Etiology is too varied to be easily listed. However, nasal obstruction in neonates and under 2-year-olds is worth distinguishing from that of older children, up to adolescence when the pathology becomes adult-form. Neonates, in particular, breathe exclusively through the nose until the age of about 3 months; severe obstruction at that age thus has great clinical impact and may, as in choanal atresia, even be life-threatening if not treated in the first instants of extra-uterine life. The present article sets forth the main causes of nasal obstruction in children according to frequency, severity and
∗ Tel.: +33 1 71 39 67 91; fax: +33 1 71 39 67 00. E-mail address: [email protected]
specific presenting symptoms, categorizing them as nasal obstruction in young versus older children. 2. Nasal obstruction in neonates and infants Until 3 months of age, neonates have exclusively nasal respiration [1]. Any obstruction therefore leads to varying difficulty: at meal times or at rest only, or so severe as to be life-threatening. Primary care is straightforward: removing the obstacle and fitting a Mayo or Guédel cannula. But this can only be a temporary solution: the cannula is unstable and poorly tolerated even by infants, as it prevents normal feeding and may cause painful hemorrhagic ulceration of the lips and base of the tongue; it should not be maintained longer than 24 hours. Alternative treatment should meanwhile be quickly initiated. 2.1. Neonatal rhinitis Neonatal rhinitis by definition concerns under 3-year-olds, without underlying pathology. Symptomatology ranges from simple intermittent obstruction to respiratory distress requiring hospital admission. Etiology is unknown, but may be multifactor: viral, inflammatory, vascular, drug-related, traumatic, etc. [2]. Clinical examination finds bilateral congestive nasal mucosa, but with bilaterally conserved permeability, thereby ruling out choanal atresia. Medical treatment is enough to bring relief in the vast majority of cases: physiological saline rinse or, temporarily, with hypotonic saline. Adrenaline solution may be used for a few days: usually, 1 mg adrenaline in 10 ml physiological saline. Medical treatment for gastro-esophageal reflux (posture, thickened milk, proton pump inhibitors) is systematic, although reflux involvement is usually hard to demonstrate. Prognosis is excellent. In case of persistence,
http://dx.doi.org/10.1016/j.anorl.2015.09.011 1879-7296/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Leboulanger N. Nasal obstruction in children. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.09.011
G Model ANORL-488; No. of Pages 4
ARTICLE IN PRESS N. Leboulanger / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
2
Fig. 1. Facial CT, bone window, axial slice: infant; right choanal atresia.
recurrence or clinical doubt, underlying deformity should imperatively be looked for. 2.2. Trauma Obstetric trauma may induce sometimes severe septal deviation in neonates. In general, however, this is well tolerated with rapidly favorable progression due to the plasticity of tissue at this age. Reduction surgery is almost never indicated, except for complete dislocation of the septum with the base totally detached from the columella.
Fig. 2. Right nasal cavity, endoscopic view; nasolacrimal cyst under right inferior turbinate bone.
2.3. Dysgenesis Many childhood facial deformities may induce nasal obstruction. The most frequent is choanal atresia, with estimated incidence around 1/5000 births, bilateral in 30% of cases. When unilateral, it may show few or no symptoms; when bilateral, it causes respiratory distress as of the first instants of life. Once the airways are brought under control, by a Mayo or Guédel cannula or intubation, it is impossible to pass an aspiration probe through the nasal cavities and aspiration withdraws clear thick mucus. CT provides definitive diagnosis (Fig. 1). Complementary assessment should explore for CHARGE syndrome; only cardiac echo is essential ahead of surgery [3]. Treatment is endoscopic and neonatal in bilateral forms and, so far as possible, delayed to the age of about 18–24 months in unilateral forms, for reasons of surgical comfort [4]. Nasolacrimal duct cyst is caused by lacrimal duct imperforation, leading to a small cyst filled with fluid. When obstruction is in the inferior part, the cyst bulges into the nasal cavity under the inferior turbinate bone, and may be obstructive (Fig. 2). Bilateral deformity may induce severely symptomatic obstruction in neonates. Treatment consists in endoscopic marsupialization by cold instruments or laser. There is no recurrence [5]. 2.4. Nasal meningocele Nasal meningocele comprises meningocele as such (meningeal hernia through the base of the skull into the nasal cavities, containing only cerebrospinal fluid [CSF]), meningoencephalocele, containing non-functional cerebral parenchyma, and glioma, ectopic glial tissue, with at most a fibrous cord communicating toward the base of the skull and therefore without CSF. Diagnosis in neonates and infants may be suggested by generally unilateral nasal obstruction with pinkish non-inflammatory, sometimes pulsatile tumefaction on endoscopy. There may be spontaneous CSF leakage, but this is not usual. CT and MRI provide diagnosis (Fig. 3). Biopsy, obviously, is not indicated. The child should be vaccinated against
Fig. 3. Facial CT, bone window, frontal slice: infant; large congenital right nasal meningocele of ethmoid origin. Good visualization of enlargement and ethmoid roof defect without bone lysis.
pneumococcus as soon as possible. The deformity is managed surgically, which can often be endoscopic [6]. It consists in resecting the herniated meninx after sectioning it at the neck, then repairing the base of the skull by cartilage and mucosal graft to restore meningeal impermeability. Very large hernia, secondary to large skull base defect, may require a combined ENT and neurosurgical approach. 2.5. Embryonal tumor Embryonal tumor, or teratoma, locations vary, principally involving the rhinopharynx and soft palate in the head and neck region (Fig. 4). These tumors are of very variable volume, and are mainly discovered during antenatal examination. Most are mature and benign, but the specimens must be fully analyzed by the pathologist to screen for immature malignancy. Complete surgical resection is systematically mandatory. Biological surveillance by ␣ fetoprotein and  HCG assay, which will always have been performed preoperatively, may be useful for deep locations in
Please cite this article in press as: Leboulanger N. Nasal obstruction in children. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.09.011
G Model
ARTICLE IN PRESS
ANORL-488; No. of Pages 4
N. Leboulanger / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
Fig. 4. T1-weighted facial MRI, sagittal slice. Neonate of a few days of age. Large oropharyngeal teratoma (X) pediculated onto the nasal septum (not seen in this image).
which clinical examination is difficult and imaging hard to interpret [7]. 3. Nasal obstruction in older children 3.1. Inflammatory pathology By far the most frequent cause of nasal obstruction in children older than about 18 months is rhinopharyngitis, an acute, usually viral inflammation of the rhinopharyngeal mucosa and particularly of the adenoid vegetation. Diagnosis is easy: infection, fever, rhinorrhea, nasal obstruction, snoring, etc. Treatment is medical and symptomatic (physiological saline rise and antipyretics), with rapidly favorable results. Antibiotic therapy is not indicated, even in case of purulent secretion. In case of frequent recurrence, underlying adenoid hypertrophy should be screened for, with correction of risk factors, primarily smoking by the parents [2]. Allergic rhinitis may cause acute or chronic nasal obstruction. Diagnosis is usually easy, associating obstruction, rhinorrhea, anosmia, pruritus and sneezing. Identifying and eliminating the culprit allergen(s) may be more difficult. 3.2. Adenoid hypertrophy Adenoid vegetation hypertrophy is a very frequent cause of nasal obstruction in children between the ages of 18 months and about 5 years, or sometimes younger or older. It is multifactorial, and mainly secondary to a disease of adaptation. It may induce nasal obstruction with obstructive sleep apnea syndrome (OSAS), iterative rhinopharyngitis and chronic rhinorrhea. Positive diagnosis is made on flexible endoscopy, which is feasible at any age and allows visualization of the obstructed choanae. Rhinopharyngeal X-ray involves radiation and is imprecise; it is no longer indicated: flexible endoscopy is preferable [8]. In case of symptomatic hypertrophy occurring outside episodes of superinfection, adenoidectomy is indicated. 3.3. Foreign bodies Foreign bodies are frequent in children, in the nasal cavities as in the outer ear. These may be bits of toys, little pebbles, seeds, etc. Partial nasal obstruction may be revelatory of a longstanding foreign body when associated with unilateral purulent rhinorrhea. In most cases, if the foreign body is discovered early on, it can be removed in consultation. The principle is to avoid making too
3
Fig. 5. 10-year-old with severe post-traumatic right septal deviation; the anterior part of the septum is clearly visible.
many attempts, so as not to frighten the child or cause mucosal lesions that might bleed and lead to edema. Removal is facilitated by anterior swabbing with Xylocaine Naphazoline followed by use of small otologic instruments. In some rare cases, surgery under general anesthesia may be needed [9]. 3.4. Septal deviation Congenital or acquired septal deviation may cause nasal obstruction, in children as in adults (Fig. 5). The added difficulty in children lies in gauging the functional impact experienced, possible consequences for the quality of sleep (clinical and possibly polygraphic OSAS screening), and choice of surgical technique if indicated. In principle, septoplasty is possible at any age, but is never implemented before 6–7 years and rarely before 15–16. When performed before adolescence, clinical indications should be very well-founded and surgery should be very limited, comprising only resection of an obstructing spur or realignment of the septum with minimal cartilage resection so as not to impair nasal pyramid growth. Facial CT is systematic before surgical planning [10]. As in adults, childhood nasal obstruction may also be caused by a number of benign or malignant tumoral pathologies. 3.5. Benign tumoral pathology Antrochoanal polyp of Killian mostly occurs in adolescence, but sometimes as early as 5 or 6 years. It is a single, large polyp, macroscopically regular and non-hemorrhagic, developing on the anterolateral mucosa of a maxillary sinus. Growth is slow and progressive, leading to uni- then bilateral obstruction when the polyp fills the rhinopharynx. CT finds complete opacity of the affected maxillary sinus and nasal cavity, depending on extension. There is no bone lysis. Treatment is exclusively surgical, by endoscopy, consisting in complete resection of the polyp and its base. Recurrence, however, is frequent [11]. Sinonasal polyposis can occur in children, although much less frequently then in adults. It is frequently associated with cystic fibrosis or primary ciliary dyskinesia; these should systematically be screened for when sinonasal polyposis is discovered in a child, and the advice of a pediatric pneumologist should be sought. Treatment is as in adults, taking account of the difficulty of administering long-course nasal corticosteroids in children [12]. Angiofibroma or nasopharyngeal angiofibroma is a benign richly vascularized tumor typically originating in the posterior lateral part
Please cite this article in press as: Leboulanger N. Nasal obstruction in children. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.09.011
G Model
ARTICLE IN PRESS
ANORL-488; No. of Pages 4
N. Leboulanger / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2015) xxx–xxx
4
of a nasal cavity, at the sphenopalatine foramen. It is rare, affecting only preadolescent boys. Pathogeny is unknown. It is mainly revealed by iterative epistaxis and progressive nasal obstruction. Endoscopy finds a clear pinkish tumor with superficial vascular lacing. Work-up comprises facial CT and MRI to determine anatomic conditions and possible extension. Any clinical suspicion of angiofibroma contraindicates biopsy, due to risk of hemorrhage. Treatment consists in primary embolization followed by surgical resection within 48 hours, usually on an endonasal approach. Progress in imaging, embolization and endonasal instrumentation has greatly improved prognosis [13].
of 18–24 months, enables simple and rapid diagnostic orientation. An exhaustive list of etiologies would not be useful and would be difficult to draw up but, for clinical purposes, this simple distinction suffices: deformity predominates in younger children, and infection or tumor in older children.
3.6. Malignant tumoral pathology
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Childhood malignant tumor is dominated by 3 different anatomopathologic types. Revelation is broadly similar: chronic, asymmetric, slowly progressive nasal obstruction often associated with iterative epistaxis, pain, adenopathies, neurologic signs, impaired general health, etc. Alveolar or poorly differentiated embryonal rhabdomyosarcoma is the most frequent, and has the best prognosis. Locoregional growth is generally fast, with rapidly progressive obstruction or facial deformation. Imaging finds a tissue lesion, often lytic, and screens for parameningeal extension, which is relatively frequent and of adverse prognosis. Treatment is medical (chemotherapy and possibly radiation therapy), with surgical resection of residual tumor when possible [14]. Undifferentiated rhinopharyngeal carcinoma and nonHodgkins malignant lymphoma are diagnosed on biopsy of the nasal lesion or lymph-node extension, which is frequent. Treatment is basically medical. 4. Conclusion Nasal obstruction in children is a very frequent symptom, with benign etiology in the vast majority of cases. It may, however, be threatening in neonates and infants, or involve pathologies that must be identified and explored. The distinction between nasal obstruction in young and older children, with an arbitrary threshold
Disclosure of interest The author declares that he has no competing interest. References
Please cite this article in press as: Leboulanger N. Nasal obstruction in children. European Annals of Otorhinolaryngology, Head and Neck diseases (2015), http://dx.doi.org/10.1016/j.anorl.2015.09.011