Pediatric Nasal Obstruction

Navigating the spectrum of pediatric sialorrhea management: A narrative review

OBJECTIVE

This review summarizes the approaches to pediatric sialorrhea management from least-to-most invasive: non-pharmacological management, anticholinergic medications, botulinum neurotoxin, non-invasive surgery, and invasive surgical intervention.

REVIEW METHODS

An electronic literature review identified English-language articles on sialorrhea management in pediatric patients. Publications between 1982 and 2022 were used, with a focus on articles published from 2012 to 2022. Additional augmentation of pharmacologic information was obtained from the latest editions of medical textbooks supplemented with official package inserts of investigated medications.

CONCLUSIONS

Sialorrhea is abnormal in patients greater than four years of age. Severe cases warrant intervention to improve patient quality of life and reduce caregiver burden. Management starts with conservative approaches. Viable candidates begin with non-pharmacological management options. Anticholinergic medications can decrease saliva production, but adverse side effects may outweigh benefits. Botulinum neurotoxin injection of the salivary glands decreases salivary flow rate; however, relief is transient and thus multiple treatments are required. Non-invasive sclerotherapy is an emerging treatment option showing promising results for sialorrhea. In contrast, surgical intervention is reserved as a last-resort treatment for patients with severe symptoms, due to its higher risk for adverse consequences.

IMPLICATIONS FOR PRACTICE

Physicians should be familiar with the different pediatric sialorrhea management options, including advantages and disadvantages, to adequately facilitate shared decision making with caretakers of pediatric patients who require treatment.

The updated role of budesonide in managing children and adolescents with allergic rhinitis

Allergic rhinitis (AR) is a prevalent disease in childhood and adolescence. A type 2 inflammation characterizes AR and, mainly, sustains nasal obstruction. Budesonide aqueous nasal spray (BANS) is an intranasal corticosteroid (INCS) available since the early 1980s. BANS is indicated for treating allergic rhinitis. There is evidence about its efficacy in treating children and adolescents with seasonal and perennial AR. In addition, BANS is safe with negligible local and systemic side effects. Recent guidelines for patients with AR recommend the use of INCS as first line in many situations. In particular, AR patients (and their parents) may assess the perception of symptoms' severity using the Visual Analog Scale (VAS). A score ≥5/10 means uncontrolled symptoms and requires adequate treatment. BANS could appropriately be used in patients with uncontrolled symptoms and/or moderate/severe nasal obstruction. In conclusion, BANS represents a valuable option in managing children and adolescents with AR.

American Rhinologic Society Expert Practice Statement: Indications and Recommendations for Septoplasty in Children

The goal of this American Rhinologic Society Expert Practice Statement (EPS) is to provide recommendations and guidance through evidence-based consensus statements regarding pediatric septoplasty. This EPS was developed following the previously published methodology and approval process. The topics of interest included appropriate indications, safety and efficacy, timing, relevant quality of life instruments, and surgical techniques. Following a modified Delphi approach, six statements were developed, five of which reached consensus and one that did not. These statements and accompanying evidence are summarized along with an assessment of future needs.

"Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?"-A Systematic Review of the Literature

Corrective septal surgery for children with nasal obstruction has historically been avoided due to concern about the impact on the growing nose, with disruption of midfacial growth. However, there is a paucity of data evaluating complication and revision rates post-nasal septal surgery in the pediatric population. In addition, there is evidence to suggest that failure to treat nasal obstruction in children may itself result in facial deformity and/or developmental delay. The aim of this systematic review is to evaluate the efficacy and safety of septal surgery in pediatric patients with nasal obstruction. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. MEDLINE, Embase, and the Cochrane Library were searched. Original studies in pediatric patients (<18 years of age) with nasal obstruction were eligible for inclusion. Patients with cleft lip or palate as their primary diagnosis were excluded. Our primary outcomes were patient-reported outcome measures (PROMs), postsurgical complications, and revision rates. Secondary outcomes included surgical technique, anatomical considerations, and anthropometric measurements. Eighteen studies were included (1,080 patients). Patients underwent septoplasty, septorhinoplasty, rhinoplasty, or a combination of procedures for nasal obstruction. Obstruction was commonly reported secondary to trauma, nasal septal deviation, or congenital deformity. The mean age of the patients was 13.04 years with an average follow-up of 41.8 months. In all, 5.6% patients required revision surgery and there was an overall complication rate of 7.8%. Septal surgery for nasal obstruction in children has low revision and complication rates. However, a pediatric-specific outcome measure is yet to be determined. Larger prospective studies with long-term follow-up periods are needed to determine the optimal timing of nasal surgery for nasal obstruction in the pediatric population.

Prevalence and descriptive epidemiology of choanal atresia and stenosis in Texas, 1999-2018

Choanal atresia and stenosis are common causes of congenital nasal obstruction, but their epidemiology is poorly understood. Compared to bilateral choanal atresia/stenosis, unilateral choanal atresia/stenosis is generally diagnosed later and might be under-ascertained in birth defect registries. Data from the population-based Texas Birth Defects Registry and Texas vital records, 1999-2018, were used to assess the prevalence of choanal atresia/stenosis. Poisson regression models were used to evaluate associations with infant and maternal characteristics in two analytic groups: isolated choanal atresia/stenosis (n = 286) and isolated, bilateral choanal atresia/stenosis (n = 105). The overall prevalence of choanal atresia/stenosis was 0.92/10,000, and the prevalence of isolated choanal atresia/stenosis was 0.37/10,000 livebirths. Variables associated with choanal atresia/stenosis in one or both analytic groups included infant sex, pregnancy plurality, maternal race/ethnicity, maternal age, and maternal residence on the Texas-Mexico border. In general, adjusted prevalence ratios estimated from the two analytic groups were in the same direction but tended to be stronger in the analyses restricted to isolated, bilateral defects. Epidemiologic studies of isolated choanal atresia/stenosis should consider focusing on cases with bilateral defects, and prioritizing analyses of environmental, social, and structural factors that could account for the association with maternal residence on the Texas-Mexico border.

Neonatal Nasal Obstruction: A Comprehensive Analysis of Our 20 Years' Experience

Neonates are obligatory nasal breathers hence nasal obstruction is a very important symptom to be evaluated. Although causes can be trivial most of the time, they can be life-threatening in some. Respiratory distress immediately after birth, feeding difficulties, paradoxical cyanosis, and failure to thrive are the most evident symptoms, and determination of unilateral or bilateral involvement guides the rationale for elective or emergency intervention. This study aimed to evaluate the causes, presentation, and management of neonates with nasal obstruction. We collected the data of all the neonates evaluated for nasal obstruction at our hospital over the past 20 years from June 2003 to May 2023 and assessed the strategy of approach for diagnosis and management of those cases. In our study, the commonest cause for neonatal nasal obstruction was found to be choanal atresia and the rarest was iatrogenic. A variety of other causes were also reported. As neonatal nasal obstruction has a multitude of rare causes each carries a unique assessment and treatment plan. History taking and clinical examination are the most important parts of evaluation including endoscopic evaluation in an office-based setup. Imaging studies add to the evaluation of cases of anatomical obstructions and associated anomalies (syndromes). Early diagnosis and swift intervention can be life-saving. The need for follow-up visits and second-stage corrections should be emphasized in getting the best long-term results.

Maxillary Soft Tissue Mass in a Newborn Imposing as Teratoma: Diagnostic Challenges and Management Considerations

Congenital facial teratomas in neonates pose diagnostic challenges, necessitating a multidisciplinary approach for accurate diagnosis and management. We present the case of a four-day-old female infant delivered via Lower Segment Cesarean Section (LSCS) with a protruding nasolabial mass noted since birth. CT brain plain revealed a soft tissue density opacification arising from the left maxilla with an underlying bony outgrowth, suggestive of a benign congenital developmental anomaly most likely teratoma. Further evaluation is warranted to delineate the exact nature and extent of the anomaly. This case underscores the importance of meticulous evaluation and interdisciplinary collaboration in managing congenital anomalies, with surgical intervention potentially required based on individual patient factors. Continued research and collaboration among medical specialities are essential to improve understanding and management strategies for congenital facial teratomas.

Congenital bilateral nasal obstruction in neonate: Case report with review of literature for congenital nasal pyriform aperture stenosis (CNPAS) and differential diagnosis and management

Congenital nasal pyriform aperture stenosis is a newly defined clinical entity that causes nasal airway obstruction in neonates due to the narrowing of the pyriform aperture, which is the narrowest and most anterior portion of the nasal airway. As newborns are obligate nasal breathers except when crying, a child with bilateral nasal pyriform aperture obstruction presents as an acute airway emergency, resulting in apnea and cyanosis. This entity should be kept in the differential diagnosis of any neonate or infant presenting with signs and symptoms of upper airway obstruction.

Nasal Disorders

Nasal obstruction, rhinorrhea, and epistaxis are common presenting concerns in primary care clinics. Nasal disorders affect the quality of life for many children and families. Rarely, these complaints may represent a life-threatening condition among infant obligate nasal breathers or cases of unusual pathology. The most common causes of rhinorrhea and nasal obstruction vary by age and include physiologic, infectious, allergic, foreign body, irritant, and traumatic causes. Less commonly, children may have congenital malformations, sinonasal masses, or autoimmune disease. The most common causes of epistaxis are inflammatory, environmental, and traumatic causes and medication misuse, but rarely, children may have predisposing anatomic, hematologic, or vascular abnormalities or even sinonasal tumors. In this article, we provide a thorough review of the common nasal disorders treated every day in primary care clinics and mention briefly some of the rare but serious cases that may be overlooked without considering a full differential diagnosis.

Association between tongue, lips position and breathing in newborns

PURPOSE

To verify the association between breathing nasal expiratory flow and posture of lips and tongue at rest, presence of repeated forward movements of the tongue and maternal complaint of respiratory difficulty in the newborn in the first days of life.

METHOD

A observational study was carried out in 130 babies, in a university hospital. Included newborn with Apgar score greater than or equal to 8 in exclusive breast milk. It was the following data: position of lips and tongue at rest, nasal expiratory flow and maternal complaint of difficulty in breathing in the newborn. The data were subjected to statistical analysis using the tests, Fisher's exact test and the Chi-Square test, adopting a significance level of 5% .

RESULTS

there was a significant association between maternal complaint of newborn difficulty breathing with repeated forward tongue movements and nasal expiratory flow; tongue position with resting lips position at rest, repeated tongue forward movements with nasal expiratory flow and tongue position at rest; nasal expiratory flow exit with tongue position at rest.

CONCLUSION

Symmetrical nasal expiratory flow is associated with an elevated tongue position and closed lips at rest; on the other hand, increased and/or absent nasal expiatory flow in one nostril is associated with maternal complaints of difficulty in breathing, open/ half-open lips position and low tongue position during rest, as well as, repeated forward tongue movements.

Treatment of acute traumatic nasopharyngeal stenosis with balloon dilation in two dogs

CASE HISTORY

Two dogs were referred to Veterinary Specialists Aotearoa for evaluation and treatment after sustaining significant head trauma. Case 1 was a 7-month-old, female Staffordshire Bull Terrier who was hit by a car at low speed. Case 2 was a 2-year old, male neutered German Shepherd who sustained a gunshot wound to the head whilst on duty for the New Zealand Police Dog Unit.

CLINICAL FINDINGS

The dog in Case 1 suffered numerous facial fractures which caused collapse of the ventral nasal meatus and dorsal nasopharyngeal wall. The dog in Case 2 had extensive osseous and soft tissue damage to the nose, nasopharynx and cervical region with severe narrowing of the ventral meatuses, nasopharyngeal meatus and rostral nasopharynx due to multiple fracture fragments and shrapnel pieces. A diagnosis of traumatic nasopharyngeal stenosis was made in each case by computed tomography. Mechanical balloon dilation was used to treat the stenosis in both dogs. The balloon dilations were performed using a 12-mm balloon dilation catheter inserted in an antegrade fashion. In the first dog, the procedure was performed blind and was repeated three times with 5 and 9-day intervals between dilations. In the second dog, the procedure was performed under endoscopic guidance and again, was repeated three times with a 7-day interval between dilations. Clinical success was reported in both patients following treatment and the second dog also underwent a follow-up computed tomography scan which confirmed resolution of the stenosis.

DIAGNOSIS

Traumatic nasopharyngeal stenosis that was successfully treated with balloon dilation.

CLINICAL RELEVANCE

Findings suggest that balloon dilation may be an effective technique for the treatment of traumatic nasopharyngeal stenosis in dogs. Multiple dilation procedures are likely required, but the procedure can ultimately result in long term clinical resolution.

Opening up on airways: the purported effect of nasorespiratory obstruction on dentofacial growth

Nasorespiratory obstruction has been purported to influence dentofacial growth adversely. This has sparked considerable debate for decades with a resurgence in interest in 'airway friendly orthodontics' among both general and specialist dental practitioners. This critical review aims to evaluate the current literature relating to two questions: does nasorespiratory obstruction alter dentofacial growth, and does early intervention targeted at alleviating nasorespiratory obstruction improve dentofacial growth? The strength of association between nasorespiratory obstruction, mouth breathing and a long face is weak. The common methodological flaws in research include unblinded and cross-sectional study designs, a lack of adequate controls, inadequate follow-up, subjective assessments and inadequate statistical power. Vertical dentofacial growth has a strong genetic influence, which implies a relatively minor contribution of environmental factors including airway obstruction. The current evidence does not support recommending procedures, such as adenotonsillectomy and maxillary expansion, with the singular aim of negating a hyperdivergent (vertical) dentofacial growth pattern. In light of low-quality evidence, both the World Health Organization guidelines and ethical principles dictate that greater emphasis is placed on avoiding harm and wastage of resources over alternative options. These findings call for quality improvement in undergraduate and postgraduate curricula and continuing professional development for health professionals.

Rhinitis Phenotypes

Rhinitis is an umbrella term of a group of upper airway diseases with nasal symptoms and signs with different etiologies and various clinical features or traits. It can be classified into different "phenotypes," based on these observable traits. A proper differential diagnosis is necessary to adequately manage the disease. The objective of this review is to clarify the concept of rhinitis phenotypes while analyzing the clinical features and/or traits of each in order to determine a proper differential diagnosis and appropriate treatment.

Neonatal nasal obstruction

PURPOSE

Congenital nasal obstruction can be a significant cause of respiratory distress in the newborn, given that they are considered to be obligate nasal breathers. Several different causes have been described, which can be broadly classified as anatomical/malformative, non-tumoral masses and cysts, benign and malignant neoplasia, inflammatory/infectious, traumatic/iatrogenic, and miscellaneous. The purpose of this review is to provide updated and useful clinical information for teams involved in neonatal care, especially in a hospital setting.

METHODS

A review of the available literature was performed. Studies were sourced from PubMed with searching of relevant headings and sub-headings and cross-referencing.

RESULTS

The most common etiology is inflammatory, which can have different precipitating factors or be idiopathic, a condition known as neonatal rhinitis. On the other hand, some less frequent but nonetheless relevant conditions causing severe nasal obstruction include choanal atresia, midnasal stenosis, and pyriform aperture stenosis. Some cystic lesions, such as dacryocystoceles with intranasal mucocele, can also produce significant obstruction. Diagnosis usually requires a nasal endoscopy and in some cases imaging such as computed tomography. Management includes different medical and surgical strategies and will greatly depend on the etiology and the severity of symptoms.

CONCLUSION

Congenital nasal obstruction can be a significant cause of respiratory distress in the newborn. The wide spectrum of differential diagnoses requires a thorough knowledge of nasal anatomy, physiology, and pathology; as well as different management strategies.

Impact of rapid palatal expansion on the internal nasal valve and obstructive nasal symptoms in children

OBJECTIVE

The aim of this study is to evaluate the impact of rapid palatal expansion (RPE) on the nasal airway subjectively by utilizing patient-reported outcome measures (PROM) and objectively by evaluating validated internal nasal valve (INV) measurements obtained from cone beam computed tomography (CBCT) in pediatrics.

MATERIALS AND METHODS

In this retrospective cohort study, subjects who underwent RPE from March to December 2018 with cone beam CT and Nasal Obstruction Symptom Evaluation (NOSE) scores were included. Exclusion criteria included craniofacial deformity, allergies, asthma, recent nasal trauma, or surgery. INV measurements (angle and cross-sectional area), diastema, midpalatal suture opening, and NOSE scores were evaluated.

RESULTS

Fifty-one subjects met the inclusion criteria with a mean age of 10.1 ± 2.6. Pre-expansion mean NOSE score was 32.55 (moderate) while post-expansion was 13.92 (mild). Mean NOSE score improved significantly by an average of 18.63 following post-expansion (P < 0.0001). The patients' right and left INV angles increased significantly by a mean of 2.42° and 2.65° respectively (P < 0.0001). Right and left INV cross-sectional areas increased significantly by an average of 14.35 mm² (P < 0.0001) and 14.17 mm² (P < 0.0001) respectively. An average expansion of the diastema and the suture was 1.60 mm and 3.05 mm respectively (P < 0.0001), with an average of 6.29 mm of expansion. We found the amount of diastema expansion to correlate with change in NOSE score (R = - 0.32, P = 0.022). Age and diastema showed a negative correlation (R = - 0.44, P = 0.0019), while INV angle and diastema showed a statistically significant positive correlation (R = 0.28, P = 0.048).

CONCLUSIONS

RPE showed improvement in both NOSE scores and objective measures of the INV. This may show the possibility of considering RPE in managing resistant pediatric nasal airways. Future studies should include collaboration with pediatric otolaryngologists, with the inclusion of pediatric patients with persistent nasal obstruction.

Best Practice Recommendations for Pediatric Otolaryngology during the COVID-19 Pandemic

Objective

To review the impact of coronavirus disease 2019 (COVID-19) on pediatric otolaryngology and provide recommendations for the management of children during the COVID-19 pandemic.

Data Sources

Clinical data were derived from peer-reviewed primary literature and published guidelines from national or international medical organizations. Preprint manuscripts and popular media articles provided background information and illustrative examples.

Methods

Included manuscripts were identified via searches using PubMed, MEDLINE, and Google Scholar, while organizational guidelines and popular media articles were identified using Google search queries. Practice guidelines were developed via consensus among all authors based on peer-reviewed manuscripts and national or international health care association guidelines. Strict objective criteria for inclusion were not used due to the rapidly changing environment surrounding the COVID-19 pandemic and a paucity of rigorous empirical evidence.

Conclusions

In the face of the COVID-19 pandemic, medical care must be judiciously allocated to treat the most severe conditions while minimizing the risk of long-term sequelae and ensuring patient, physician, and health care worker safety.

Implications for Practice

The COVID-19 pandemic will have a profound short- and long-term impact on health care worldwide. Although the full repercussions of this disease have yet to be realized, the outlined recommendations will guide otolaryngologists in the treatment of pediatric patients in the face of an unprecedented global health crisis.

Common Pediatric Airway Disorders

Pediatric airway disorders may be congenital (anatomical) or acquired (infectious) and may involve the upper, lower, or entire airway, with obstruction being a common feature. The pathophysiology of upper airway obstruction in infants, children, and adolescents is distinctly different due to the anatomic differences that evolve with growth. Accordingly, clinical presentation and consequences of airway obstruction vary by age. This article reviews the common upper airway disorders by age with a review of classic presentation, recommended diagnostic steps, and management considerations for the general pediatrician. [Pediatr Ann. 2019;48(4):e162-e168.].