Nasal Obstruction & Rhinorrhea

Nasal obstruction and rhinorrhea in children, unlike in adults, generally cannot be distinguished from each other. In children it is often difficult, if not impossible, to distinguish rhinitis from sinusitis, hence the phrase “rhinosinusitis.” Because newborns are obligate nasal breathers, neonatal nasal obstruction may be life-threatening.

Differential Diagnosis

• Physiologic
  –Nasal cycle
  –Nasopulmonary reflex
  –Puberty
  –Menstruation and pregnancy
• Congenital
  –Choanal atresia or stenosis
  –Cleft palate
  –Craniofacial syndromes such as Treacher Collins, Crouzon
• Cyst
  –Dermoid, meningocele, or encephalocele
  –Thornwaldt

• Infectious
  –Bacterial rhinosinusitis with Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, staph
  –Viral rhinosinusitis with rhinovirus, adenovirus, coxsackie

• Viral prodrome
  –Measles, mumps, mono, polio
• Fungal (if immunocompromised)
  –Aspergillosis, mucormycosis
• Inflammatory
  –Allergic rhinitis
  –Nasal polyps
  –Adenoid hypertrophy
  –Nasopharyngeal GERD
• Granulomatous
  –Sarcoidosis
  –Wegener syndrome
  –SLE
  –Churg-Strauss syndrome
• Traumatic
  –Foreign body
  –Septal hematoma
  –Septal abscess
• Neoplastic
  –Chordoma
  –Craniopharyngioma
  –Juvenile angiofibroma
  –Olfactory neuroblastoma
• Cystic fibrosis
• Thyroid disease (hypo- or hyper-)
• Ciliary dyskinesia
  –Kartagener, immotile cilia syndrome, etc.
• Chronic rhinitis

Workup and Diagnosis

• History
  –Onset, duration, severity, exacerbating and relieving factors, work of breathing
  –Family history
  –Environmental history: Pets, smoke exposure
• Physical exam
  –Passage of suction catheter to rule out atresia/stenosis
  –Direct rhinoscopy with otoscope, or with nasal speculum and headlight or head mirror
  –Fiberoptic rhinoscopy: Flexible well tolerated, rigid (better optics) only for older children
  –Examine nose before and after decongestion
• Allergy testing
  –In vitro (RAST) better tolerated in young children than in vivo (intradermal, prick skin testing)
  –Nasal cytology
  • Studies
    –Lateral neck X-ray: Useful for adenoid hypertrophy or nasopharyngeal cysts
    –Sinus X-ray: Limited utility, essentially replaced by CT
    –CT scan: Contrast only required if tumor suspected; if sinus surgery anticipated, need coronal views
    –MRI: Excellent for tumors, necessary for congenital cysts (differentiate meningocele from encephalocele); much too sensitive for sinusitis
    –Angiography: Useful for juvenile nasopharyngeal angiofibromas and other tumors requiring preoperative embolization

  Treatment

  • Antibiotics for bacterial rhinosinusitis
    –Endoscopically guided middle meatus cultures correlate well with maxillary sinus contents; routine nasal cultures do not
  • Surgical correction of congenital anomalies
    –Must establish airway (e.g., intubation) if respiratory distress
  • Nasal steroids for rhinitis
  • Allergic rhinitis may need nonsedating antihistamine or even immunotherapy
  • Medications for rhinosinusitis (URI symptoms for >10 days) should include antibiotics (covering β-lactamase organisms), nasal steroids, and topical decongestants (no rebound effect if used with steroids)
  • Adenoidectomy for obstructive adenoid hypertrophy or for chronic or recurrent rhinosinusitis refractory to antibiotic therapy
  • Endoscopic resection of nasal polyps

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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