Pediatric Nasal Obstruction

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Key points

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    Newborns with bilateral congenital nasal obstruction will present very early to the physician with desaturations with feeding.

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    Nasal dermoids, gliomas, and encephaloceles are the most common causes of midline nasal masses. A positive Furstenberg sign is diagnostic of an encephalocele.

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    Chronic rhinosinusitis and allergic rhinitis overlap significantly and, untreated, can lead to a significant decrease in quality of life.

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    Intervention is always needed for removal of nasal foreign bodies to prevent

History

As with other disease processes, obtaining an accurate history, including laterality, is very important to narrow the differential diagnoses (Box 1) for nasal obstruction. Newborns with bilateral congenital nasal obstruction will present soon after birth with desaturations or blue spells because they are unable to coordinate feeding and breathing. Left untreated, this results in failure to thrive. Unilateral congenital nasal obstruction typically presents later in life, as feeding is typically

Physical examination

The physical examination should begin with observation for retractions, nasal flaring, visible nasal obstructive masses or other midline defects, and the presence of mouth breathing. If there are signs of respiratory distress, such as cyanosis, labored breathing, or substernal or subcostal retractions, airway management should be initiated. This management may include supplemental oxygen, noninvasive ventilation, or even intubation. Management of feeding through a nasogastric tube may be

Imaging

Computed tomography (CT) and/or MRI, alone or in combination, are the most common modalities used to assess pediatric nasal obstruction. CT is best used to evaluate the bony skeleton, and MRI is best used to evaluate the soft tissue as well as the extent of intracranial involvement. One advantage of MRI over CT is the lack of radiation exposure. However, in young or uncooperative children, sedation may be required. In pediatric patients who have undergone implant procedures (eg, cochlear

Differential diagnosis

As demonstrated in Box 1, there are a multitude of causes for pediatric nasal obstruction. The authors discuss the most commonly encountered causes next.

Choanal Atresia

Embryologically, there are 5 recognizable facial structures (frontonasal prominence, right and left maxillary prominence, and right and left mandibular prominence) that become evident around 4 weeks’ gestational age.1 Over the next few weeks, these prominences rotate to fuse in the midline. The nasal pits continue to invaginate toward the pharynx and oral cavity to create a connection between the nasal cavity and the pharynx during weeks 6 to 7. If the nasal cavity is not in continuity with the

Allergic Rhinitis

Allergic rhinitis is one of the most common causes of pediatric nasal obstruction, which affects 8% to 16% of children and is immunoglobulin E mediated.20, 21 Children will typically complain of itchy and watery eyes, nasal obstruction, clear rhinorrhea, chronic fatigue, and sometimes cough. Depending on the duration of disease before treatment, children can become primary mouth breathers and develop facial abnormalities associated with mouth breathing and lack of nasal airflow.22 Anterior

Structural Nasal Defects

Whether from previous trauma or natural growth, another common cause of nasal obstruction is a deviated septum. Septal deviation rates, depending on the location of the deviation, range from 0.7% to 28.7% in children.30 Nasal septal deviation is more prevalent in older children and adults, which may be due to the increased incidence of external trauma experienced later in life.31 Regardless of the mechanism of injury, septoplasty has been advocated in children older than age 6; but recent

Juvenile Nasopharyngeal Angiofibroma

Juvenile nasopharyngeal angiofibromas present with recurrent epistaxis and unilateral nasal obstruction. They are only seen in males and typically present during adolescence. Even though this is considered a benign tumor, it can be very locally destructive. Nasal endoscopy will reveal a vascular mass near the posterior attachment of the middle turbinate, at the opening of the sphenopalatine foramen. Imaging can reveal (Fig. 6) an anterior bowing of the posterior maxillary sinus wall

Summary

Pediatric nasal obstruction is a common complaint, and the diagnosis and treatment of conditions causing this symptom varies. In infants and newborns, several congenital lesions may contribute to feeding and respiratory complaints. In older children, infectious causes, such as sinusitis and allergic rhinitis, are common and are treated medically, in a manner almost identical to adult treatment of these entities. Both trauma and neoplastic disease are alternative causes that can be diagnosed

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    Disclosure: Dr M.M. Smith has nothing to disclose. Dr S.L. Ishman is a consultant for Medtronic.

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