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A 5 1/2 year old girl is referred by her pediatrician because of a lifelong history of difficulty breathing through her nose accompanied by snoring and restless sleep. You are asked to evaluate a cause and make recommendations as to possible treatment.
Nasal obstruction is a common complaint in children. It usually is a self limiting condition and resolves without treatment and maybe only a minor inconvenience. It can however, be quite uncomfortable for the child and may cause a significant problem with dento-facial abnormalities and cardiopulmonary such as pulmonary hypertension and cor pulmonale. Also, several rare but potentially life threatening conditions may be the cause of the nasal obstruction and must be considered in the differential diagnosis.
Snoring may be only minor annoyance, however, it may indicate obstructive sleep apnea and it is a symptom that requires investigation. Sleep apnea is defined as the cessation of airflow during sleep (usually for 10 seconds are greater). Obstructive sleep apnea is caused by mechanical obstruction in the upper airway. Adenoid hyperplasia is the most common cause of this problem in the pediatric population other causes are as listed:
The goals of the evaluation are to determine specific causes of problems, the severity of the obstruction, and the presence of associated medical complications. Lifelong symptoms suggest congenital malformation or early acquired disease or injury. The general well-being of the child, including growth and development, must be determined. Pertinent past history include birth trauma, early childhood trauma, previous hospitalizations, medications, and surgical history. Related symptoms must be actively investigated. Sleep history may often reveal loud irregular snoring, restless sleep, abnormal sleep position, and nocturnal mouth breathing. Enuresis may also be present. The duration and frequency of the apneic spells is important. Swallowing difficulties may be noted. Voice quality (degree of nasality) and clarity, daytime hypersomnolence, and school/behavioral difficulties should be evaluated. History of rhinorrhea, epistaxis and allergy should be noted.
A complete examination of the head and neck is performed. Resting mouth position is noted. "Adenoid facies" is characterized by an open mouth, dull facial appearance, and short upper lip. This is nonspecific for chronic nasal obstruction and adenoid enlargement may be only one of the causes. Other craniofacial anomalies may be associated with these symptoms including cleft palate, Down syndrome, etc. Dental malocclusion supports the diagnosis of long standing significant nasal obstruction. Consultation with the pedodontist or orthodontist may be necessary. Tonsillar hypertrophy, macroglossia and oropharyngeal masses should be evaluated.
Evaluation of the voice quality includes as assessment of nasality and clarity. Having the child to speak words that enhance nasality such as lemon, milkman, Mickey Mouse, ninety nine, bananas are normally nasal transmitted words and words such as baseball and Jack are normally non-nasal transmitted words. The ears should be evaluated as otitis media certainly is associated with nasal obstruction problems. Bony nasal anomalies, external masses, pits, etc. should be evaluated. Anterior rhinoscopy is relatively easy to perform in a small child. The otoscope with a large speculum is ideal for this purpose. The nasal speculum is rarely needed and may be uncomfortable and frighten the small child. The posterior nasal cavity may be seen with this technique if minimal anterior disease is present. Posterior rhinoscopy and nasopharyngoscopy will require a topical decongestant and local anesthetic and insertion of either a rigid telescope or flexible fiberoptic nasopharyngoscope in a cooperative child. This may be difficult to do younger than age 4. A long thin cotton pledget soaked in a 1:1 solution of 2% Pontocaine (tetracaine) and 1:1000 epinephrine is used. Afrin solution may be substituted for the epinephrine. It is generally placed along the inferior turbinate until it extends from the nasal vestibule to the posterior nasal cavity. Five to ten minutes should be allowed for the anesthetic and decongestant effect. The 2.7mm rigid telescope or the 3mm flexible scope are both well tolerated in children. Using a video monitor may improve the child's acceptance of this procedure.
In children suspected of cardiopulmonary complications auscultation of the heart and lungs may reveal abnormalities.
Based on the physical examination, radiologic and laboratory testing may be required. A lateral radiograph of the airway is helpful only if a nasopharynx has not be adequately visualized. Sinus x-rays may be useful to rule out sinusitis. If a congenital or acquired deformity or tumor is suspected, CT scan of the midface of the coronal and axial sections are helpful. If there is a strong likelihood of significant sleep apnea a chest x-ray and echocardiogram are useful.
Polysomnography is a multichannel sleep recording of multiple physiological variables. It is useful and valid in determining the severity of sleep disturbances. However, it requires the use of a sleep laboratory, is expensive, and is impractical for large scale screening. Only if the diagnosis is questionable form the physical exam or history is this considered useful. An audiotape of the patient sleep brought in by the parent is easy and inexpensive but less accurate.
The degree of disturbance that is considered "enough" obstruction to warrant surgery has not been established. If the diagnosis of adenoid hypertrophy with significant obstruction is made the use of polysomnography is not necessary because of the cost and difficulty in obtaining the exam. However, if the percent of obstruction is not well established, a polysomnogram will confirm the percent of obstruction and determine the severity.
In the patient described above, the differential diagnosis and possible treatment plan is discussed as follows:
Nasal septal deformities are seen at birth in over 6% babies in one large study. This trauma may occur from intrauterine positioning or from vaginal delivery. Prolonged labor and primiparous mothers have a higher incidence of nasal traumatic deformity. Although controversy still exist over whether nasal deformities in children can be safely corrected without disrupting the normal nasal growth pattern, this concern is being overcome by the increased recognition that prolonged nasal obstruction can result in significant dental, orthodontic, facial and palatal abnormalities in the growing child. A sublabial approach to septoplasty in children has provided excellent exposure and involves in removing minimal septal cartilage as well as morselized cartilage. No significant short term or long term morbidity was noted in ten children followed for 5 years. A reasonable approach is to favor early repair in the severely affected child in whom complications are present (obstructive apnea) or in whom complications are very likely if long-term obstruction continues.
At birth, the normal adenoid is usually small enough that the infant (who is an obligate nasal breather for the first few weeks of like, may adequately breathe without respiratory distress). Frequent exposure to recurrent upper respiratory infections very early in life may lead to early obstructive adenoid hyperplasia. Physical exam may confirm the presence of an enlarged but not necessarily obstructing adenoid pad. Often, the adenoids are large and cause mucociliary stasis, which results in enlarged adenoids becoming functionally and totally obstructive. Adenoidectomy is not controversial and will almost relieve the obstruction. If significant tonsillar hyperplasia is also present, the tonsils should be removed at that time. Adenoidectomy should be performed using a mirror to visualize the nasopharynx during surgery in order to insure complete removal of all adenoid tissue particularly in the posterior choanae. If a submucous cleft palate or an occult submucous cleft palate is identified, the surgery must be weighed against possible complications. A sleep study or dental evaluation may be helpful in this decision. Adenoidectomy in the presence of the above palatal abnormality could leave the child with severe VPI, requiring speech rehabilitation or additional surgery for correction. A partial adenoidectomy with preservation of a central mass of adenoids may sometime be useful in these cases.
Congenital malformations and tumors most often present during infancy and early childhood however, they may not be identified until later in childhood. These tumors include nasal dermoids, encephaloceles, meningoencephaloceles, chordomas, teratomas, craniopharyngiomas and nasoalveolar and nasopharyngeal (Tornwaldt's) cysts. Congenital malformations such as choanal stenosis and rarely unilateral atresia may also be missed early in life. Bilateral choanal atresia is usually identified in the neonatal period. Radiologic evaluation of the nose and nasopharynx by CT scanning is helpful in establishing the diagnosis as well as the extent of disease. In this 5 year old, choanal stenosis or atresia would be repaired by transpalatal approach with prolonged stenting.
Chronic rhino-sinusitis may be present early childhood and can cause nasal obstruction and sleep disturbances. The finding of purulent secretions in the middle meatus is diagnostic. Plain sinus x-rays may be helpful. Medical treatment with antibiotics and possibly topical steroids may be helpful. Treatment failures may require surgery. Coronal CT scan is necessary prior to surgical approach. Endoscopic sinus surgery shows some promise in childhood but is much more limited than in adult patients.
Allergic rhinitis, chronic hypertrophic rhinitis and nasal polyposis are also causes of nasal obstruction of long duration in a child. A detailed history and physical exam would help exclude these possibilities. Nasal polys should prompt a search for cystic fibrosis. Other signs of nasal allergies may also be present. Rhinitis medicamentosa by an overzealous parent may be a possibility. Topical nasal steroids, systemic decongestants and/or antihistamines may be helpful. In the unresponsive patient allergic testing and immunotherapy may be necessary.
Whatever the cause and surgical approach appropriate anesthesia consultation should be obtained. Preoperative and postoperative narcotics and sedatives are contraindicated in patients who have obstructive sleep apnea. During the induction of anesthesia, the airway may become compromised. On rare occasions, relief of a long standing upper airway obstruction may result in acute pulmonary edema postoperatively. It may be necessary for the post operative child to spend one night in the pediatric intensive care unit following relief of chronic upper airway obstruction.
In summary, chronic nasal obstruction in children is a common symptom that requires careful and thoughtful evaluation in order to arrive at a correct diagnosis and treatment plan. Both the diagnostic evaluation and the treatment must take into account not only the nature and severity of the primary disease, but also the possible adverse effects on facial growth as well as cardiac and pulmonary systems. Careful perioperative management can be as important as the surgical procedure itself.