Neonatal rhinitis

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InternationalJournal of Pediatric Otorhinolaryngology 39 (1997) 59-65

Neonatal rhinitis Cherie-Ann O. N a t h a n a'*, Allan B. Seid b "Department of Otolarvngology, Head and Neck Surgery, Louisiana State University Medical Center, 1501 Kings Highway, P.O. Box 33932, Shreveport, LA 71130, USA bDepartment of Pediatric Otolaryngology, Children's Hospital and Health Center, 3020 Childrens Way, San Diego, CA 92123-4282, USA

Received 5 January 1996; revised 17 October 1996; accepted 20 October 1996

Abstract

Neonatal rhinitis as a distinct disease entity has not been well-studied. The recognition and treatment of this condition is important since neonates are obligate nasal breathers, and mismanagement of this entity can result in poor feeding or even death from respiratory distress. We undertook a retrospective analysis of 20 patients seen at the Children's Hospital of San Diego over the period 1990-1991. Eighteen patients developed neonatal rhinitis in the months of August to January and only two between February and July. Clinical presentation and an effective management algorithm are discussed. Early recognition on the basis of clinical features followed by a two-step therapeutic trial consisting of conservative therapy and corticosteroid drops are advocated. Based on the above findings we have defined neonatal rhinitis as mucoid rhinorrhea with nasal mucosal edema in the afebrile newborn that results in stertor, poor feeding and respiratory distress which responds promptly to decadron 0.1% drops within a week. We recommend reserving diagnostic procedures for complicated cases that do not respond to the proposed regimen. © 1997 Elsevier Science Ireland Ltd. All rights reserved Keywords: Diagnosis; Neonate; Rhinitis; Steroids; Treatment

* Corresponding author. 0165-5876/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved PI1 S0165-5876(96)01464-4

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1. Introduction

Neonatal rhinitis is an under-recognized, poorly understood disease of newborns. Consequently this condition has not been well-studied and there are few reports in the literature [2,6]. Neonates, in contrast to older infants, are obligatory nasal breathers, which makes them uniquely vulnerable to the problem of potentially life-threatening nasal obstruction [3]. Choanal atresia is a widely known anatomic cause of neonatal nasal obstruction. However the nasal edema seen in neonatal rhinitis in the absence of structural defects, can cause severe respiratory distress in neonates necessitating immediate intervention. The increased airway resistance due to rhinitis has been implicated in sudden infant death syndrome [5]. Recently an increased incidence of neonatal rhinitis was noticed at our institution. We therefore initiated a retrospective study, analyzing charts for clinical and epidemiologic data, therapeutic interventions, outcome and follow-up, where available, to delineate the scope of this disease and to formulate a reliable approach to management.

2. Materials and methods

Twenty patients with a diagnosis of neonatal rhinitis were seen at the Children's Hospital of San Diego between 1990 and 1991. The N I C U at the Children's Hospital of San Diego has approximately 475 admissions per year. The age at which they presented to our institution ranged from birth to 6 months. However, all infants had been noted to have the symptoms of noisy breathing and snorting, rhinorrhea, and difficulty with feeding since birth. Fifteen patients presented to our outpatient clinic for treatment and five were inpatient consultations for airway distress resulting from nasal obstruction in neonates admitted to the hospital. Charts were reviewed for demographic data, mode of delivery, weight at birth, clinical features, associated medical problems, treatment received and outcome. Follow-up was available in seven cases but the logistics of a large metropolitan area precluded a comprehensive follow-up program.

3. Results

A total of 20 patients were diagnosed with neonatal rhinitis over the 2 year period under study. The age at which they were referred to us for management ranged from birth to 6 months. Seventeen of the 20 patients had symptoms since birth. Of the remaining patients, two had symptoms beginning at 3 weeks, and symptoms developed at 6 weeks of age in one patient who was 18 weeks premature. There were 10 females and 10 males in the study population. Six of the patients were white, 2 were black and 10 were Hispanic, while the ethnic background of the remaining two was not determined. Sixteen patients had a birth weight of 7 lb or

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more, 2 were between 6 and 7 lb and the remaining 2 had birth weights of 5 lb 5 oz and I lb 12.5 oz respectively. Fifteen of the neonates were full term vaginal deliveries, 2 were born by cesarean section, and 3 were premature deliveries, of which 2 were only 2 weeks premature and 1 was born at 22 weeks. Fifteen patients in the group had no associated problems while the remaining 5 had associated medical problems which included bronchiolitis, central sleep apnea, gastroesophageal reflux, jaundice and bronchopulmonary dysplasia. Most of the patients diagnosed with neonatal rhinitis were born in the fall and winter months, and the monthly breakdown is shown in Fig. 1. Twelve of the patients were born between November and January, 6 were born between August and October, none between the months of February and May, and 2 in the months of June and July. The symptoms at presentation in all cases included noisy breathing and snorting at or within 1 week of birth, mucoid rhinorrhea and difficulty with feeding. Four patients presented with apneic and cyanotic episodes, although none required cardiopulmonary resuscitation. On examination, all patients had stertor, severe nasal mucosal edema, boggy turbinates, mucoid rhinorrhea and nasal flaring with intercostal retraction on agitation. A 16Fr catheter could be passed with ease in all patients, ruling out choanal atresia. Thirteen patients had been treated earlier with vigorous bulb suctioning, nasal saline drops, and neo-synephrine drops for 3 4 days. On 6 patients we were consulted prior to any treatment. Four patients had received beclomethasone nasal spray for 1 month in addition to the above treatment, and 1 had received nasal drops, the nature of which was not specified in the chart.

2 1 0

i

Jan

i

Fel0 Mar

i

Apt

Ma

n

J I

Aug

Sep

Oct

Nov

Dec

Fig. 1. Distribution of admissions with neonatal rhinitis for each month of the year.

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Within 12 Weeks 29%

1 week or less 10%

2 weeks 28%

4 weeks 19%

3 weeks 14%

Fig. 2. Pie-chart showing time-frames for response in patients with neonatal rhinitis.

The following therapeutic regimen was initiated by us after examination: The vigorous suctioning was discontinued. 1/8% Neosynephrine: 2 drops twice a day in each nostril for 3 days. 0.1% Decadron oplthalmic solution: 2 drops three times a day in each nostril until the symptoms subsided. Nine patients responded within 2 weeks, 6 by 4 weeks and 1 by 5 weeks. Two other patients responded within 12 weeks. There was 1 non-responder who had central sleep apnea, and 1 patient was lost to follow-up (Fig. 2). Response was measured clinically with absence of noisy breathing, no evidence of rhinorrhea and no nasal congestion.

4. Discussion

Neonatal rhinitis is an idiopathic disorder characterized by a constellation of symptoms which includes noisy breathing, mucoid rhinnorhea and unexplained poor feeding. These patients present at birth or soon thereafter, usually in fall and winter seasons, and except for mucosal edema do not have a permanent anatomical structural basis for the obstruction. A marked increase in the incidence of this disease has been noted at our institution over the past few years. It appears that this rise could, at least partially, be explained by an increased awareness among pediatricians and neonatologists. Both sexes were affected equally, in contrast to the male predominance noted by Tolley et al. [6]. The ethnic composition of our patients reflects the ethnic make-up of the city, and race does not appear to be a risk factor. However, neonatal rhinitis does have a strong seasonal variation, with almost all the patients presenting in the fall and winter months.

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Neonatal rhinitis had previously been treated with nasal suctioning, saline instillation and occasionally nasal decongestant drops. However there seems to be an increasing number of patients who do not respond to this approach. We obtained an excellent response with decadron ophthalmic drops (0.1% solution), with the majority of the patients being cured within 4 weeks of treatment. The only non-responder was the patient with central sleep apnea. Four patients, initially treated with beclomethasone spray without any response, were switched to decadron drops, with all responding completely within 5 weeks. We also noted that the patients who respond generally do so within 3 5 days of initiating therapy, and failure to see a response is an indication for a diagnostic evaluation to exclude bony abnormalities. Our approach consists of flexible nasopharyngoscopy and a CT scan of the midface. Cases that undergo uncomplicated resolution would avoid unnecessary diagnostic workup. The potential side effects of steroid drops have not been studied in neonates, and are a cause for concern. We have currently initiated a study to determine whether systemic absorption occurs and if it does, whether it suppresses the hypothalamic pituitary-adrenal axis. No side effects were noted in the patients in our series during the time under study. However since no long term follow-up data is available, it would seem prudent to discontinue therapy as early as possible to lessen the potential side effects. Although beciomethasone spray is efficacious in allergic rhinitis, it was ineffective in 4 patients with neonatal rhinitis, suggesting either decreased local absorption or a decreased delivery of the drug in the spray form compared to nasal drops. Several conditions need to be considered in the differential diagnosis of this condition. It is important to rule out choanal atresia and other structural abnormalities such as craniofacial anomalies, adenoid obstruction, choanal stenosis and congenital syphilis, which are grouped by Derkay and Grundfast [1], under the term NOWCA (nasal obstruction without choanal atresia). Interestingly, four of their fifteen neonates had nasal mucosal edema as the sole cause of obstruction and appear to satisfy the criteria for neonatal rhinitis. Infectious rhinitis would have purulence and fever in combination with other symptoms. Allergic rhinitis would present with sneezing, lacrimation and a seasonal character that responds well to beclomethasone spray and is uncommon in the neonatal period. Nonallergic noninfectious rhinitis can occur in older children with or without eosinophilia. Rhinitis with nasal eosinphilia is commonly associated with polyps and asthma. Those without nasal eosinophilia fall into several categories such as vasomotor rhinitis, mucous rhinitis, endocrine rhinitis, metabolic rhinitis and rhinitis medicamentosa [4]. Our neonates did not appear to fall in the above categories. Thus neonatal rhinitis could be defined as mucoid rhinorrhea, nasal mucosal edema in the afebrile newborn that results in stertor, poor feeding and respiratory distress which responds promptly to decadron 0.1% drops within a week. Based on our observation we suggest the following algorithm for the management of this condition (Fig. 3).

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As a first step, one needs to confirm that there is no choanal atresia by passing a 16Fr catheter. If clinical examination is consistent with neonatal rhinitis further work-up can be delayed and the following treatment instituted. A three-day trial of gentle, skilled nasal suction and saline instillation, with neosynephrine (1/8%) 2 drops three times a day in each nostril is instituted next. If the patient does not improve or deteriorates on the above regimen, discontinue neosynephrine and start decadron, 2 drops of 0.1% solution, three times a day in each nostril for 2 weeks, with a taper over the last 5 days. If the patient does not show any improvement in 5 days we recommend flexible nasopharyngoscopy and/or CT scan to rule out structural causes of the obstruction. In the absence of any structural abnormalities we suggest continuing the steroid drops for 8 12 weeks, and then gradually tapering off over 2 weeks. All the responders in our series (18 out of 20) were symptom free by 12 weeks.

Noisy Breathing Snorting, Stertor Rhinorrhea Nasal Congestion

I Gentle Bulb Suctioning Neosynephnne (1/8%) Nasal Drops 2 Drops BID x 3 Days Nasal Saline Drops

F

!

IMPROVEMENT

Continue

Above Rx

I

NO I M P R O V E M E N T Continue Gentle Bulb Suctioning Continue Nasal Saline Drops D1C Neosynepherine

InstillDecadron Ophthalmic Solution (0.1%): 2 Drops TID x One Week

I IMPROVEMENT

Taper Decadron Drops Over One Week

SLOW IMPROVEMENT*

Continue Decadron Drops x One Month Continue Nasal Saline Drops

Fig. 3. Algorithm for the diagnosis and management of neonatal rhinitis.

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A high index o f suspicion is needed for early recognition o f this potentially serious condition, which responds dramatically to simple medical measures. N e o n a tal rhinitis can be treated effectively by this approach, and does not warrant surgical measures or other interventions such as prolonged stent placement recomm e n d e d by Tolley et al. [6].

5. Conclusion A literature search on neonatal rhinitis reveals a limited fund o f knowledge. A greater understanding is imperative for better diagnosis and treatment o f this condition as neonates are obligate nasal breathers and prompt, precise m a n a g e m e n t o f this entity is necessary to prevent p o o r feeding and death from respiratory distress. We propose a m a n a g e m e n t algorithm that relies on diagnosing this condition on the basis o f clinical features and response to a therapeutic trial. This would avoid the expensive diagnostic w o r k - u p for patients with uncomplicated neonatal rhinitis. We instituted d e c a d r o n nasal drops in these patients with excellent results. We do not r e c o m m e n d placing stents as most o f these patients respond to the simple measures outlined above. The etiology o f neonatal rhinitis remains an enigma and further studies are needed to elucidate its p a t h o p h y s i o l o g y and the safety o f long term use o f steroid drops in its treatment.

References [1] Derkay, C.S. and Grundfast, K.M. (1990) Airway compromise from nasal obstruction in neonates and infants. Int. J. Ped. Otorhinolaryngol. 19, 241 249. [2] Fuller, R.A. (1988) Upper respiratory obstruction in the neonate: a case of neonatal rhinitis. Ped. Nuts. 14(1), 30--31. [3] Osthugorpe, J.D. and Shirley, R. (1987) Neonatal respiratory distress from rhinitis medicamentosa. Laryngoscope 97, 829- 831. [4] Pearlman, D.S. (1988) Chronic rhinitis in children. J. Allergy Clin. Immuol. 81(5 part 2), 962 966. [5] Schafer, A.T., Lembe, R. and AIthoff, H. (1991) Airway resistance of posterior nasal pathway in sudden infant death victims. Eur. J. Ped. 150, 595 598 [6] Tolley, N.S., Ford, G. and Commins, D. (1992) The management of neonatal rhinitis. Int. J. Ped. Otorhinolaryngol. 24, 253 260.