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The management of neonatal rhinitis
international Journal of Pediatric Otorhinolaryngology, 24 (1992) 253-260 0 1992 Elsevier Science Publishers B.V. All rights reserved 016%5876/92/$05.00
253
PEDOT 00781
The management Neil S. Tolley,
of neonatal rhinitis
Glenn Ford and D. Commins
7’he Hospital for Sick Children, London (UK)
(Received 25 February 1991) (Revised version received and accepted 25 July 1991)
Key words: Neonatal rhinitis; Neonatal nasal obstruction
Abstract Life-threatening upper airway obstruction secondary to neonatal rhinitis is a rare and poorly understood condition. Despite potential lethal effects, there has been no basic scientific research investigating the nature of this curious condition. This paper retrospectively reviews 8 patients suffering from neonatal rhinitis. Both the medical and surgical management of neonatal rhinitis and possible aetiological factors involved are discussed. Increasing clinical awareness of this condition may, therefore, serve as inspiration for future research of both an epidemiological and basic scientific nature.
Introduction Great reliance is placed upon the nasal airway at birth since’ neonates are obligate nasal breathers [S]. Acute respiratory distress or even death may be caused by a blocked nose secondary to developmental disorders such as choanal atresia [l]. Clinically, many neonates have a tendency to be ‘snuffly’ at birth. Factors responsible for this have, however, been under-researched and remained speculative. Hormonal influences, drugs, chemical irritation from birth products, bacterial infection and finally immunological factors may all have a role to play. A retrospective study of 8 patients suffering from upper airway obstruction. secondary to neonatal rhinitis was performed. Information regarding the ethnic origin, sex, age of presentation, route of delivery, nasal microbiology, blood Correspondence
Sussex, UK.
to: N.S. Tolley, Flat 9, Belle Vue Court, Belle View Gardens, Brighton, BN2 2AN, E.
254
eosinophilia, immunoglobulin profile, atopic family history and association with eye symptoms was collected. Such a study might allow common factors to be identified and thereby help expand knowledge of the aetiology. The aim of this paper is to highlight the fact that rhinitis in the newborn can be potentially life-threatening. Occasionally, it may require intensive medical and surgical intervention and should, therefore, be treated with due respect. The medical and surgical management of neonatal rhinitis will be discussed in addition to possible aetiological factors responsible.
Clinical material
Eight patients presenting with nasal obstruction secondary to neonatal rhinitis were seen at The Hospital for Sick Children, Great Ormond Street, London from 1982 to 1990. All patients were investigated by axial and coronal CT scanning allowing a diagnosis of neonatal rhinitis to be made. Seven were born term and one was 33 weeks premature, Two were delivered by caesarean section and six by spontaneous vaginal delivery.
Results
In this group of patients, males were affected more than females by a ratio of 3 : 1. Seven patients presented with symptoms within the first 6 h after birth, one patient was one week old at presentation. Six neonates were Caucasian, two negroid. At presentation, nasal microbiology was performed in 6 of the patients. Staphylococcus aureus was isolated in two patients and no growth was obtained in the remaining 4. Half of the patients had a family history of atopy. In addition, half of the patients had associated conjunctivitis/sticky eye symptoms. A nasal smear and ciliary beat study was performed in one patient. This was found to be normal. One patient responded successfully to a course of antibiotics (penicillin and gentamicin) thereby avoiding the necessity for nasal stenting. The remaining 7 patients were treated surgically by inserting nasal stents. All neonates had a normal immunoglobulin profile and none exhibited a raised blood eosinophil count. Table I summarizes these findings. Figs. 1 and 2 show coronal and axial CT views from a patient suffering with neonatal rhinitis. This can be compared with Figs. 3 and 4 which show CT images in bilateral bony choanal atresia. Distinguishing rhinitis from atresia is naturally fundamental to the management of the patient.
Discussion
Despite the fact that rhinitis is a common manifestation amongst neonates, it is somewhat surprising that little research has been conducted into investigating its
255 TABLE Summary
1 of the clinical findings in the 8 patients suffering from neonatal rhinitis
Both the serum eosinophil count and immunoglobulin profile were found to be normal studied. SVD = spontaneous vaginal delivery. LSCS = lower segment caesarean section.
in all patients
Patient
Sex
Age at birth
Age at onset of symptoms
Age at nasal stenting
Nose swab
Eye symptoms
Atopic family histoo
K.H. B.T.
M M
SVD (33/52) SVD (Term)
6 h 1 week
4 months 6 weeks
No growth
Yes Yes
M.L. K.G. S.J.
M F M
SVD (Term) SVD (Term) SVD (Term)
6h 6 h 6 h
3 days 2 weeks 3 days
S. aureus S. aureus No growth
M.S. K.A.
M F
SVD (Term) LSCS (Term)
6 h 6 h
4 days 4 days
No growth _
OS.
M
LSCS (Term)
6 h
Treated with antibiotics only
No growth
No Yes (No No No Yes (No No Yes (No Yes (No
growth) No Yes Yes growth) No No growth) No growth)
cause. In addition, there are few references in the literature which address this condition. The deficiencies and limitations of a retrospective study are acknowledged by the authors, however it must be stressed that severe upper airway obstruction secondary to rhinitis is rare. Despite these limitations, it has been possible to collect an appreciable series from which some interesting findings have been made apparent. Firstly, 50% of patients had associated eye symptoms. Chlamydial infection has previously been linked with rhinitis and conjunctivitis in the newborn IS]. Chlamydial infection would be expected to be transmitted during delivery via the vaginal route. Despite this, half of the patients displaying rhinitis and conjunctivitis were delivered by caesarean section. Secondly, 50% of patients had a family history of atopy which suggests immunological factors might have a role to play. Lending support to this, Ingall and colleagues have reported that allergic rhinitis can present in early infancy [3]. In addition, Van Asperen and co-workers observed that non-infective rhinitis presented below the age of one year in over 50% of children they studied [Ill. Our finding that males were 3 times more likely to contract severe neonatal rhinitis, is in keeping with the higher preponderance of allergy induced disorders seen in males compared to females [9]. The finding that IgE levels were not raised in any of the patients does not exclude allergy as a major causative factor since 40-50% of children with allergic rhinitis do not have elevated IgE levels [9]. Finally, respiratory distress usually occurred some 6 h following delivery. This might be in keeping with the establishment of an infective rhinitis secondary to bacterial or viral invasion of the nasal mucous membranes. Immunological factors
Fig. 1. Coronal CT image of a patient suffering from neonatal rhinitis. Complete occlusion of the nasal airway can be seen secondary to gross swelling of the mucous membranes.
may, in turn, predispose the child to such infection. The finding in one patient that nasal stenting was avoided, possibly as a consequence of antibiotic treatment is particularly interesting in this respect. However, such a finding could equally be coincidental. Physiological factors may also be important. The normal asymmetry in nasal airflow between the two nostrils, otherwise known as the nasal cycle, is a well described phenomenon [4,10]. This cycle is regulated by the action of central sympathetic tone upon venous erectile tissue within the nasal turbinates [2]. Studies have shown that children may not display this ‘cycling’ phenomenon [121. Such an effect may consequently lead to a significant increase in nasal resistance at regular intervals during the day. Immaturity in the development of central autonomic controlling centres might, therefore, be a factor that could result in nasal obstruction. One finding against this, is that neonatal rhinitis does not appear to be a condition that responds particularly well to vasoconstrictor drops. Mugliston
Fig. 2. Axial CT image of the same patient
in Fig. 1. Again,
mucosal
congestion
is well shown.
and Mitchell described one patient in whom the clinical condition deteriorated following their use and improved once they were withdrawn [7]. In neonatal rhinitis, if nasal obstruction is secondary to engorgement of the venous erectile tissue, this would be expected to respond well to vasoconstrictor medication in the usual fashion. If however obstruction was secondary to inflammatory oedema from whatever cause, vasoconstrictors would not be expected to be as effective. Hypothyroidism and disorders of ciliary function have also been reported as causing nasal congestion [9]. Abnormalities of mucus seen in cystic fibrosis can also contribute to the clinical picture of neonatal rhinitis. These factors must not, therefore, be forgotten when assessing such patients. CT scanning is mandatory to distinguish this condition from choanal atresia. Vasoconstrictor drops and nasal suction prior to scanning is important lest an underlying atresia be missed and the wrong diagnosis be made [6]. Treatment must be directed at providing a satisfactory nasal airway. This may be accomplished by medical or surgical means as symptoms dictate. For reasons previously outlined, topical vasoconstrictor drops are avoided. Topical steroids (Betnesol O.l%, Glaxo), however, may prove useful.
258
Fig. 3. A coronal CT image of a patient suffering from bony choanal atresia is shown for comparison purposes. Note how the anterior nasal cavity is free of the mucosal congestion shown in Fig. 1.
The surgical management of rhinitis involves the insertion of nasal stents in exactly the same fashion as in cases of choanal atresia. This has been described recently and will not be elaborated upon further [61. Regular suction clearance of the stents is vital. They must be flushed with l/2 ml of saline in each limb, half hourly and then cleared of secretions with suction apparatus. Eventually, the frequency of suction clearance may be diminished as clinical conditions dictate. The administration of Betnesol through such stents on a thrice daily basis may be performed, but is probably futile. Stents remain is situ for 2-3 weeks and must be removed in hospital under medical supervision with strict monitoring for at least 48 h. It cannot be stressed more highly, that supervision of the stents and regular suction night and day is mandatory. Parents cannot be allowed to take their child home until full suction apparatus and training have been ensured. Clearly, much needed research is required before the aetiology of this curious condition can be elucidated. This must include studies of an epidemiological
Fig. 4. Axial CT image of the same patient in Fig. 3. The bony atresia of mucosal congestion is also shown.
plate is clearly
seen. An absence
nature looking into factors such as food allergy in addition to performing research of a basic scientific nature.
References Derkay, C.S. and Grundfast, K.M., Airway compromise from nasal obstruction in neonates and infants, Int. J. Pediatr. Otorhinolatyngol., 19 (1990) 241-249. Eccles, R., The central rhythm of the nasal cycle, Acta Otolaryngol., 86 (1978) 464-468. Ingall, M., Glaser, J., Meltzer, R.S. and Dreyfuss, E.M., Allergic rhinitis in early infancy, Pediatrics. 35 (1965) 108. Kayser, R.. Die exacte Messung der Luftdurchgangigkeit der Nase, Arch. Laryngol. Rhino]., 3 (1895) 101.-120. Kent, S.E. and Mathews, R.S., Chlamydial rhinitis neonatorum, J. Laryngol. Otol., 101 (1987) 1193-1197. Morgan, D.W. and Bailey, C.M., Current management of choanal atresia, Int. J. Pediatr. Otorhinolaryngol., 19 (1990) I-13.
260 7 Mu&ton, T.A.H. and Mitchell, D.B., Nasal obstruction in healthy neonates, Br. Med. J., 289 (1984) 1659-1670. 8 Osguthorpe, J.D. and Shirley, R., Neonatal respiratory distress from rhinitis medicamentosa, Laryngoscope, 97 (19871829-831. 9 Siegel, S.C., Wahn, II. and Backman, A., Rhinitis in children. In: N. Mygind and B. Weeke (Eds.), Allergic and Vasomotor Rhinitis: Clinical Aspects, Munksgaard, Copenhagen, Denmark, 1985, pp. 50-52. 10 Stoksted, P., Rhinometric measurements for determination of the nasal cycle, Acta Otolaryngol., Suppl. 109 (1953) 159-175. 11 Van Asperen, P.P., Andrew, S.K. and Mellis, G.M., A prospective study of the clinical manifestations of atopic disease in infancy, Acta Paed. Stand., 73 (1984) 80. 12 Van Cauwenberge, P.B. and Deleye, L., Nasal cycle in children, Arch. Otolaryngol., 110 (1984) 108-110.
253
PEDOT 00781
The management Neil S. Tolley,
of neonatal rhinitis
Glenn Ford and D. Commins
7’he Hospital for Sick Children, London (UK)
(Received 25 February 1991) (Revised version received and accepted 25 July 1991)
Key words: Neonatal rhinitis; Neonatal nasal obstruction
Abstract Life-threatening upper airway obstruction secondary to neonatal rhinitis is a rare and poorly understood condition. Despite potential lethal effects, there has been no basic scientific research investigating the nature of this curious condition. This paper retrospectively reviews 8 patients suffering from neonatal rhinitis. Both the medical and surgical management of neonatal rhinitis and possible aetiological factors involved are discussed. Increasing clinical awareness of this condition may, therefore, serve as inspiration for future research of both an epidemiological and basic scientific nature.
Introduction Great reliance is placed upon the nasal airway at birth since’ neonates are obligate nasal breathers [S]. Acute respiratory distress or even death may be caused by a blocked nose secondary to developmental disorders such as choanal atresia [l]. Clinically, many neonates have a tendency to be ‘snuffly’ at birth. Factors responsible for this have, however, been under-researched and remained speculative. Hormonal influences, drugs, chemical irritation from birth products, bacterial infection and finally immunological factors may all have a role to play. A retrospective study of 8 patients suffering from upper airway obstruction. secondary to neonatal rhinitis was performed. Information regarding the ethnic origin, sex, age of presentation, route of delivery, nasal microbiology, blood Correspondence
Sussex, UK.
to: N.S. Tolley, Flat 9, Belle Vue Court, Belle View Gardens, Brighton, BN2 2AN, E.
254
eosinophilia, immunoglobulin profile, atopic family history and association with eye symptoms was collected. Such a study might allow common factors to be identified and thereby help expand knowledge of the aetiology. The aim of this paper is to highlight the fact that rhinitis in the newborn can be potentially life-threatening. Occasionally, it may require intensive medical and surgical intervention and should, therefore, be treated with due respect. The medical and surgical management of neonatal rhinitis will be discussed in addition to possible aetiological factors responsible.
Clinical material
Eight patients presenting with nasal obstruction secondary to neonatal rhinitis were seen at The Hospital for Sick Children, Great Ormond Street, London from 1982 to 1990. All patients were investigated by axial and coronal CT scanning allowing a diagnosis of neonatal rhinitis to be made. Seven were born term and one was 33 weeks premature, Two were delivered by caesarean section and six by spontaneous vaginal delivery.
Results
In this group of patients, males were affected more than females by a ratio of 3 : 1. Seven patients presented with symptoms within the first 6 h after birth, one patient was one week old at presentation. Six neonates were Caucasian, two negroid. At presentation, nasal microbiology was performed in 6 of the patients. Staphylococcus aureus was isolated in two patients and no growth was obtained in the remaining 4. Half of the patients had a family history of atopy. In addition, half of the patients had associated conjunctivitis/sticky eye symptoms. A nasal smear and ciliary beat study was performed in one patient. This was found to be normal. One patient responded successfully to a course of antibiotics (penicillin and gentamicin) thereby avoiding the necessity for nasal stenting. The remaining 7 patients were treated surgically by inserting nasal stents. All neonates had a normal immunoglobulin profile and none exhibited a raised blood eosinophil count. Table I summarizes these findings. Figs. 1 and 2 show coronal and axial CT views from a patient suffering with neonatal rhinitis. This can be compared with Figs. 3 and 4 which show CT images in bilateral bony choanal atresia. Distinguishing rhinitis from atresia is naturally fundamental to the management of the patient.
Discussion
Despite the fact that rhinitis is a common manifestation amongst neonates, it is somewhat surprising that little research has been conducted into investigating its
255 TABLE Summary
1 of the clinical findings in the 8 patients suffering from neonatal rhinitis
Both the serum eosinophil count and immunoglobulin profile were found to be normal studied. SVD = spontaneous vaginal delivery. LSCS = lower segment caesarean section.
in all patients
Patient
Sex
Age at birth
Age at onset of symptoms
Age at nasal stenting
Nose swab
Eye symptoms
Atopic family histoo
K.H. B.T.
M M
SVD (33/52) SVD (Term)
6 h 1 week
4 months 6 weeks
No growth
Yes Yes
M.L. K.G. S.J.
M F M
SVD (Term) SVD (Term) SVD (Term)
6h 6 h 6 h
3 days 2 weeks 3 days
S. aureus S. aureus No growth
M.S. K.A.
M F
SVD (Term) LSCS (Term)
6 h 6 h
4 days 4 days
No growth _
OS.
M
LSCS (Term)
6 h
Treated with antibiotics only
No growth
No Yes (No No No Yes (No No Yes (No Yes (No
growth) No Yes Yes growth) No No growth) No growth)
cause. In addition, there are few references in the literature which address this condition. The deficiencies and limitations of a retrospective study are acknowledged by the authors, however it must be stressed that severe upper airway obstruction secondary to rhinitis is rare. Despite these limitations, it has been possible to collect an appreciable series from which some interesting findings have been made apparent. Firstly, 50% of patients had associated eye symptoms. Chlamydial infection has previously been linked with rhinitis and conjunctivitis in the newborn IS]. Chlamydial infection would be expected to be transmitted during delivery via the vaginal route. Despite this, half of the patients displaying rhinitis and conjunctivitis were delivered by caesarean section. Secondly, 50% of patients had a family history of atopy which suggests immunological factors might have a role to play. Lending support to this, Ingall and colleagues have reported that allergic rhinitis can present in early infancy [3]. In addition, Van Asperen and co-workers observed that non-infective rhinitis presented below the age of one year in over 50% of children they studied [Ill. Our finding that males were 3 times more likely to contract severe neonatal rhinitis, is in keeping with the higher preponderance of allergy induced disorders seen in males compared to females [9]. The finding that IgE levels were not raised in any of the patients does not exclude allergy as a major causative factor since 40-50% of children with allergic rhinitis do not have elevated IgE levels [9]. Finally, respiratory distress usually occurred some 6 h following delivery. This might be in keeping with the establishment of an infective rhinitis secondary to bacterial or viral invasion of the nasal mucous membranes. Immunological factors
Fig. 1. Coronal CT image of a patient suffering from neonatal rhinitis. Complete occlusion of the nasal airway can be seen secondary to gross swelling of the mucous membranes.
may, in turn, predispose the child to such infection. The finding in one patient that nasal stenting was avoided, possibly as a consequence of antibiotic treatment is particularly interesting in this respect. However, such a finding could equally be coincidental. Physiological factors may also be important. The normal asymmetry in nasal airflow between the two nostrils, otherwise known as the nasal cycle, is a well described phenomenon [4,10]. This cycle is regulated by the action of central sympathetic tone upon venous erectile tissue within the nasal turbinates [2]. Studies have shown that children may not display this ‘cycling’ phenomenon [121. Such an effect may consequently lead to a significant increase in nasal resistance at regular intervals during the day. Immaturity in the development of central autonomic controlling centres might, therefore, be a factor that could result in nasal obstruction. One finding against this, is that neonatal rhinitis does not appear to be a condition that responds particularly well to vasoconstrictor drops. Mugliston
Fig. 2. Axial CT image of the same patient
in Fig. 1. Again,
mucosal
congestion
is well shown.
and Mitchell described one patient in whom the clinical condition deteriorated following their use and improved once they were withdrawn [7]. In neonatal rhinitis, if nasal obstruction is secondary to engorgement of the venous erectile tissue, this would be expected to respond well to vasoconstrictor medication in the usual fashion. If however obstruction was secondary to inflammatory oedema from whatever cause, vasoconstrictors would not be expected to be as effective. Hypothyroidism and disorders of ciliary function have also been reported as causing nasal congestion [9]. Abnormalities of mucus seen in cystic fibrosis can also contribute to the clinical picture of neonatal rhinitis. These factors must not, therefore, be forgotten when assessing such patients. CT scanning is mandatory to distinguish this condition from choanal atresia. Vasoconstrictor drops and nasal suction prior to scanning is important lest an underlying atresia be missed and the wrong diagnosis be made [6]. Treatment must be directed at providing a satisfactory nasal airway. This may be accomplished by medical or surgical means as symptoms dictate. For reasons previously outlined, topical vasoconstrictor drops are avoided. Topical steroids (Betnesol O.l%, Glaxo), however, may prove useful.
258
Fig. 3. A coronal CT image of a patient suffering from bony choanal atresia is shown for comparison purposes. Note how the anterior nasal cavity is free of the mucosal congestion shown in Fig. 1.
The surgical management of rhinitis involves the insertion of nasal stents in exactly the same fashion as in cases of choanal atresia. This has been described recently and will not be elaborated upon further [61. Regular suction clearance of the stents is vital. They must be flushed with l/2 ml of saline in each limb, half hourly and then cleared of secretions with suction apparatus. Eventually, the frequency of suction clearance may be diminished as clinical conditions dictate. The administration of Betnesol through such stents on a thrice daily basis may be performed, but is probably futile. Stents remain is situ for 2-3 weeks and must be removed in hospital under medical supervision with strict monitoring for at least 48 h. It cannot be stressed more highly, that supervision of the stents and regular suction night and day is mandatory. Parents cannot be allowed to take their child home until full suction apparatus and training have been ensured. Clearly, much needed research is required before the aetiology of this curious condition can be elucidated. This must include studies of an epidemiological
Fig. 4. Axial CT image of the same patient in Fig. 3. The bony atresia of mucosal congestion is also shown.
plate is clearly
seen. An absence
nature looking into factors such as food allergy in addition to performing research of a basic scientific nature.
References Derkay, C.S. and Grundfast, K.M., Airway compromise from nasal obstruction in neonates and infants, Int. J. Pediatr. Otorhinolatyngol., 19 (1990) 241-249. Eccles, R., The central rhythm of the nasal cycle, Acta Otolaryngol., 86 (1978) 464-468. Ingall, M., Glaser, J., Meltzer, R.S. and Dreyfuss, E.M., Allergic rhinitis in early infancy, Pediatrics. 35 (1965) 108. Kayser, R.. Die exacte Messung der Luftdurchgangigkeit der Nase, Arch. Laryngol. Rhino]., 3 (1895) 101.-120. Kent, S.E. and Mathews, R.S., Chlamydial rhinitis neonatorum, J. Laryngol. Otol., 101 (1987) 1193-1197. Morgan, D.W. and Bailey, C.M., Current management of choanal atresia, Int. J. Pediatr. Otorhinolaryngol., 19 (1990) I-13.
260 7 Mu&ton, T.A.H. and Mitchell, D.B., Nasal obstruction in healthy neonates, Br. Med. J., 289 (1984) 1659-1670. 8 Osguthorpe, J.D. and Shirley, R., Neonatal respiratory distress from rhinitis medicamentosa, Laryngoscope, 97 (19871829-831. 9 Siegel, S.C., Wahn, II. and Backman, A., Rhinitis in children. In: N. Mygind and B. Weeke (Eds.), Allergic and Vasomotor Rhinitis: Clinical Aspects, Munksgaard, Copenhagen, Denmark, 1985, pp. 50-52. 10 Stoksted, P., Rhinometric measurements for determination of the nasal cycle, Acta Otolaryngol., Suppl. 109 (1953) 159-175. 11 Van Asperen, P.P., Andrew, S.K. and Mellis, G.M., A prospective study of the clinical manifestations of atopic disease in infancy, Acta Paed. Stand., 73 (1984) 80. 12 Van Cauwenberge, P.B. and Deleye, L., Nasal cycle in children, Arch. Otolaryngol., 110 (1984) 108-110.