Evaluation of Child with Nose Block, Snoring and Restless Sleep

With increasing awareness about sleep apnea child is increasingly being refereed to otorhilnolaryngologist (E N T specialists) by pediatricians to evaluate the cause of nose block, snoring and restless sleep.

Nasal blockage is the sensation of reduced air flow either through one nostril (unilateral) or both nostrils (bilateral).

It is common thinking amongst people that blocked nose (congested or stuffy nose) is because of thick mucus and they try to blow it out. But it is wrong thinking.

Image attributesflickr photos/flatiron32 creative commons

Nasal block is a common complaint in children and it usually resolves without treatment. However it may cause a significant problem with abnormalities in teeth and face as well as heart and lung of child. Nasal block can interfere with the ears, hearing, and speech development. In first few months of life it can interfere with feeding and cause life threatening problems.

Thus every nasal block and mouth breathing in children should be evaluated carefully and potential serious causes must be considered in the differential diagnosis.

Causes of Nose Block

There are many different causes of nasal obstruction. Some causes are present at birth (congenital), oOther causes are acquired later in life.

Infectious/inflammatory mucosal swelling

  • Allergic rhinitis
  • Chronic rhino-sinusitis

Structural problems

  • Enlarged Adenoids
  • Deviated nasal septum (DNS)
  • Enlarged turbinate
  • Nasal polyps

Foreign Body nose

Congenital

  • Posterior choanal stenosis/atresia
  • Encephalocele/meningoencephalocele
  • Craniofacial deformities
  • Dermoids/Craniopharyngiomas/Teratomas/Chordomas
  • Nasoalveolar and Nasopharyngeal (Tornwaldt’s) cysts

Evaluation of a child with nose block

The goals of the evaluation are to determine specific causes of problems, the severity of the obstruction, and the presence of associated medical complications.

This is achieved by thorough history of symptoms and clinical examination of nose along with endoscopic examination of nose and nasopharynx.

Examination of nose of a young child can be done by simply tilting the tip of the nose upwards or using an otoscope.  An extensive examination of nose is often difficult and not possible.

Following diagnostic tests based on clinical findings may be advised:-

  • Allergy skin tests
  • Blood tests (such as CBC)
  • Sputum culture and throat culture
  • X-rays of the sinuses, Nasopharynx and chest
  • Serum total IgE

Differential diagnosis

Rhintis –

Nasal mucosa is thin pinkish lining that covers inside of the nose.  Swelling or inflammation of this mucosa can be caused by allergies, irritants (smoke and pollution), infection, hormonal (vasomotor rhinitis) and abuse of nasal drops (rhinitis medicamentosa).

Careful history and evaluation of the nose (nasal endoscopy for detailed examination) is all that is required to find out the likely diagnosis. Sometimes, additional tests may be advised to confirm the cause.

Usually medical treatment along with antibiotics and steroid nasal spray are required along with preventive measures to avoid allergen/irritants.

Allergy shots are successful treatment method. SLIT skin tests and sometimes blood tests are used to make allergy-inducing substances specific to an individual patient.

Chronic sinusitis is evaluated by CT scan during the quiet periods. A very conservative approach is followed as far as children are concerned. If patient fails to respond to medical treatment endoscopic sinus surgery may be necessary.

Deviated Nasal Septum (DNS)

Nasal septum is mid line partition which divides the nose into two halves. Child may be born with a deviated septum, or may develop after injury to nose.

Clinical examination by headlight and mirror is enough to conform the diagnosis, nasal endoscopy may be done for detailed examination of nose to rule out other anatomical abnormalities inside the nose and nasopharynx.

Sometimes DNS does not cause any symptoms but if it is severe enough to block the nasal passage it is to be corrected with surgery of septum (septoplasty)

Adenoid Enlargement

Second most common cause of nose blockage is enlarged or hypertrophied adenoids. Adenoids are lymphoid tissue similar to tonsils situated at back space of nose.

Adenoids are not directly visible and mirror examination or nasal endoscopy is required to see it. X-ray of nasopharynx may be done to see the enlarged adenoids.

If adenoids are blocking nasal airway leading to sleep apnea it has to be removed surgically.

You can read more about tonsils and adenoids in previous post

Foreign Body Nose–

A common cause of nasal obstruction in the younger child is an object (foreign body) placed in the nose (such as peanut, seeds, beads, button cell).

Characteristic history usually raises strong suspicion. Child usually comes with a foul smelling drainage from the nose on the side of the foreign object.

Removal can be done in the office without anesthesia but occasionally, if the foreign body has been present a long time, a short general anesthesia is necessary to remove it.

Congenital  Malformations

Choanal atresia (back opening of the nose is blocked with either tissue or bone), if bilateral (both sides are involved) surgical repair is needed immediately to allow the child to breath normally. If only unilateral (one sided) the diagnosis may be made much later in life.

Tumors such as nasal dermoids, chordoma and craniopharyngiomas most often present during infancy and early childhood however, they may be missed early in life.

Summary:

In summary, chronic nasal obstruction in children is a common symptom that requires careful evaluation, 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 hearing, facial growth as well as cardiac and pulmonary systems.

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