congenital and pediatric nasal obstruction, I explained different conditions and proper management for each one

1. Neonatal nasal
obstruction
Nassr Saif ALBarhi

2. Introduction
 The etiology of neonatal obstruction is diverse.
 Neonates are generally obligate nasal breathers for the 1st few months of life.
 Therefore the can present as acute respiratory emergencies, classically with
cyclical cyanosis, relieved by crying.
 The extend of their problems will alter related to neonate’s ability to breath
orally which depend on their maturity and neurological development.

3.  Thus an oral airway is often sufficient to relieve respiratory distress until
definitive treatment can be undertaken.
 Neonates with nasal obstruction may also present with feeding problems.
 Flexible nasendoscopy is particulary useful and imaging via CT and MRI is of
great value in delinating both nasal and post nasal lesions.

5. Choanal atresia

6. Choanal atresia
 Its rare condition (incidence 1 in 7000 live birth) in which there is complete
obstruction of the posterior choanae on one or both sides.

7.  The blockage is thought to be either bony or membranous in origin, but in
reality a mixed picture is usually seen (70% of cases), with the remainder
being purely bony.
 It is believed to be secondary to persistence of the nasobuccal membrane.
 Bilateral choanal atresia in neonate presents as acute respiratory distress as
neonate are obligate nasal breathers.

8.  Classically, cyclical cyanosis relieved by crying, and placement of an
appropriate sized oral airway resolves the distress.
 Unilateral choanal atresia may present later in life, and there is an inability
to pass a nasogastric tube through one nasal passageway.
 Neonates with choanal atresia will have difficulty with feeding.

9.  Misting upon placement of a metal spatula below the neonate's external
nasal aperture excludes a diagnosis of choanal atresia, and this test can
easily be performed in the clinic setting.

10. If suspected, the diagnosis should be confirmed with flexible nasendoscopy,
and CT scanning should then be performed to determine the extent and nature
of the choanal atresia.
In neonates, often a simple oral airway is well tolerated, in which case
endotracheal intubation can be avoided.

13.  CHARGE syndrome, due to mutations in the CHDl gene on chromosome 8.
 Therefore the minimum investigations in addition to
the nasal CT scan are:
 cardiac echo.
 renal ultrasound scan
 ophthalmology
 audiology review.

14. Surgical management
 The two most common techniques for choanal atresia repair are the
transnasal and transpalatal approaches.
 Transpalatal and transnasal surgery have been shown to have similar
outcom es.
 Transpalatal technique is not as common now, but it can be useful in
craniofacial anomalies where the dimensions of the nose and
postnasal space are limited.
TRANSPALATALAPPROACH

15.  There are two methods described for the endoscopic transnasal approach.
One involves using the zero degree endoscope transnasally, with serial
dilatations using urethral sounds or using powered instruments such as
microdrills.
 In cases where the nasal cavity is toosmall to accommodate both
instruments a posterior septal window is created and expanded, thus
allowing the endoscope through one nostril and the powered instrument
through the other nostril, creating a 'neo-unichoana '
.
TRANSNASALAPPROACH
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16. j
0
USING 120' ENDOSCOPE
 The second transnasal approach
involves a 120-degree endoscope
being placed in the mouth and
positioned in the nasopharynx
behind the soft palate to give a
view of the postnasal space.
 Instruments and the drill can then
be introduced through the nose.
 There are reports in the literature of
high success rates using the
endoscopic endonasal approach with
balloon dilatation for choanal atresia,
although the numbers involved in
these series are still quite small.

17.  The role of nasal stenting post choanal atresia repair is
also debated.
 If used, bilateral nasal stents can be fashioned from
two ivory Portex™ endotracheal tubes cut to length
with the bevelled end of each sitting in the
nasopharynx orientated towards the septum.
 The philtrum is protected by either a small length of
size 12 suction catheter cut to act as a bridging piece
or a further small piece of endotracheal
tube.
 The stents are secured by a circumseptal 'O' prolene
suture and left in situ for up to 6 weeks
Bilateral nasal stents with an endotracheal
tube bridging piece.

18. Regular suction..
 A systematic review with meta-analysis has shown that the success rates for
bilateral choanal atresia repair are similar with and without nasal stents,
and that the use of stents may be associated with more complications .
 There is evidence that regular suctioning to clear secretions and daily
washing with sodium chloride solution results in successful outcomes.
 Authors who do not support using stents stress the need for resection of the
posterior aspect of the vomer and early (1 week post repair) repeat
examination for removal of granulations and dilatation as required .
Bilateral nasalstentswithout
a bridgingpiece

19. Mitomycin C and KTP Laser
 Is thought to reduce granulation tissue and fibrosis by
inhibiting fibroblasts and angiogenesis leading to its use
during stent removal.
 However, several papers have found no benefit in terms of
outcomes whether mitomycin c is used or not.
 However, that mitomycin does have beneficial effects.
 The KTP laser has also been shown to be helpful in
the treatment of granulation tissue which develops
post-aperatively.

20. Piriform aperture stenosis

21.  This abnormality, first described in 1988, is a very rare
condition leading to nasal obstruction in the neonate which
arises due to bony overgrowth of the nasal process of the
maxilla.
 The piriform aperture is the narrowest part of the nasal
airway and so even minimal reduction in diameter here can
cause significant problems.
 Symptoms similar to bilateral choanal atresia occur and
epiphora is also often seen secondary to bony involvement
of the nasolacrimal ducts.

22.  Diagnosis is suggested by the inability to pass a narrow
gauge nasogastric tube or 2.2 mm endoscope through the
anterior nasal vestibule due to the bony obstruction.

23. Diagnosis
 CT scan confirms the diagnosis with an aperture width less
than 11 mm measured on an axial CT at the level inferior
meatus (in a term neonate).
 CT can also demonstrate a single central incisor, which
exists in some affected individuals.
 This single central incisor is associated with an absent
upper frenulum

24.  In this subgroup with a 1 megaincisor ' there is a
suggested. association with holoprosencepaly:
 A rare condition in which the developing forebrain fails to divide
appropriately to form the cerebral hemispheres, diencephalon, and optic
and olfactory bulbs.
These patients should undergo further evaluation for central
nervous system defects with an MRI and particularly the
hypothalamic-pituitary-thyroid axis.

26. Treatment
 Conservative treatment with nasal steroid drops or decongestants (for
up to 2 weeks) and saline irrigation is generally recommended as first-
line treatment.
 If there is severe obstruction, respiratory distress or failure to thrive, surgical
treatment is warranted.
 It has also been found that an aperture of less than 5 mm on CT is
almost always associated with the need for surgical intervention.
 Bilateral nasal stents with an endotracheal tube bridging piece.

27. Surgical management
 Surgery involves either:
 A trans-nasal approach with an alar releasing incision or
 A sub-labial approach with a gingival-buccal sulcus incision and
elevation of the soft tissue and periosteum to expose the piriform
aperture.
 The abnormal bone is drilled away using a diamond burr and the
muco-periosteal flap replaced.

28. Post op follow up..
 Post-operatively nasal stents can be used for up to 4 weeks,
although more recent studies suggest that stenting is not
necessary.
 Complications include:
 Adhesions, Septal perforations and Septal ulceration .
 The use of suctioning, nasal irrigation and treating gastro-
oesophageal reflux minimizes this

29. Midnasal stenosis

30.  Mid nasal stenosis is a rare condition secondary to overgrowth of the
nasal bones halfway along the nasal cavity.
 It usually occurs in association with syndromes characterized by
midfacial hypoplasia.
 Neonates will present in a similar fashion to those with piriform
aperture stenosis or choanal atresia with apnea, cyanosis and
failure to thrive.

31.  Diagnosis:
 Can be confirmed with nasal endoscopy or CT scanning which
will demonstrate isolated bony narrowing of the midpart of the
nasal cavity or narrowing with stenosis of the rest of the nasal
cavity
 Treatment
 Is usually conservative, allowing the child's midface to
grow, such that by the age of 6 months the obstruction is
relieved.
 For those children struggling with significant respiratory
problems or failure to thrive, dilatations or stent placement
can be considered.

33. Nasal agenesis

34.  Complete arhinia is very rare but can occur in isolation or as part of a
syndrome.
 It originates at the fifth week in utero when the nasal placode
fails to canalize to form the nasal passages.
 Presentation at birth with acute respiratory distress occurs.
 Management is initially with an oral airway and tube feeding.

35.  A tracheostomy may be required.
 Definitive surgical treatment usually involves a two-staged
procedure aimed at reconstructing the nasal cavity as well as the
external nose, and is usually delayed until facial development is
almost complete.

36. Congenital nasal cysts

37. Dermoid cyst
 Dermoid cysts arise from the ectoderm and mesoderm and usually
contain all the structures of normal skin.
 They are the most common midline nasal mass, and account
for between 1% and 3% of all dermoids.
 Occasionally these dermoids can become infected and thus
present as an abscess requiring drainage.

38.  Between 4% and 45% of dermoid cysts have an intracranial
component, thus pre-operative imaging with CT (for bony anatomy)
and MRI (to delineate any connection to the centraI nervous system)
is essential.
 These cysts usually present as a slowly growing cystic mid line
mass over the nasal dorsum.
 An associated pit is often seen in any position from the nasal tip
to the glabella, and hair may be present at its opening.

39. Encephalocele and meningocele
 A nasal encephalomeningocoele represents a herniation of meninges
with or without associated brain through bony defects.
 A meningocoele consists of either meninges alone or with CSFand an
encephalocoele contains nervous tissue.
 Their combined incidence is around 1 in 4000 live births and they
have an equal male/female distribution.

40.  Encephalocoeles can be described as frontoethmoidal or basal.
 Frontoethmoidal are usually associated with craniofacial deformity as
they arise either at or anterior to the foramen caecum.
 The basal types present intranasally through defects in the skull
base causing nasal obstruction and widening of the nasal bridge.

41. Nasal gliomas
 Benign midline masses containing glial cells and fibrous and vascular
tissue.
 They are sim ilar to encephalocoeles but have become separated from
the intracranial structures. Around 15% do, however, remain attached
to the brain via a fibrous stalk.
 There is usually no associated abnormality of the brain.
 Presentation is usually early on as a firm, non-compressible, reddish
swelling.

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43. References..
 https://www.statpearls.com/ArticleLibrary/viewarticle/19441
 https://www.cureus.com/articles/86353-surgical-management-of-choanal-
atresia-two-classic-cases-and-review-of-the-literature.
 Scott-brown’s otorhinololaryngology head and neck surgery volume 2.

44. Thank you