Respiratory System (6)

DR.HUSSAM ALDAOUKI
 Disorders of the Nose
 Most neonates are obligatory nose breathers .
 Nasal congestion is common in the 1st year of life
 The internal nasal airway doubles in size in the 1st 6 months of life.
 Nose is important in warming & humidification of inspired air .
 Nasal mucosa is ciliated
 Nasal secretions contain lysozyme, IgA, lactoferrin , histamine & glycoproteins (Viscid)
 CHOANAL ATRESIA
 Is the most common congenital anomaly of the nose.
 It is either unilateral or bilateral .
 The septum is either bony (90%), membranous (10%), or mixed.
 Incidence : 1: 7.000 live births .
 50% of cases have other congenital anomalies e.g. CHARGE syndrome
(coloboma, heart disease, atresia choanae, retarded growth and development
or CNS anomalies or both, genital anomalies or hypogonadism or both, and
ear anomalies or deafness or both).
 C/P of CHOANAL ATRESIA
 Newborn infants have a variable ability to breathe through their mouths, so nasal
obstruction does not produce the same symptoms in every infant.
 Manifestations of CA is depend on whether it is uni- or bilateral.
 Unilateral CA :
 may be asymptomatic for a prolonged period until 1st attack of RTI when unilateral
nasal discharge or persistent nasal obstruction may occur.
 Bilateral CA :
 is usually symptomatic at birth. Infants who are able to breathe through their mouths,
will experience difficulty & cyanosis
 during sucking or feeding; whereas those who have difficulty with mouth breathing
make vigorous attempts to inspire (often sucking their lips) and develop cyanosis, this
distressed newborn then cry(which relieves cyanosis by opening the mouth) so
become calmer,then repeat the cycle again after closing their mouths.
 Investigation of CHOANAL
ATRESIA
 CA may be suspected by simple measures e.g. inability to pass a
firm catheter through each nostril 3–4 cm into the nasopharynx .
 Absence of air flow after approximation of piece of cotton near each
nostril.
 fiberoptic Rhinoscopy .
 CT of head.
 Treatment of CHOANAL
ATRESIA
 Unilateral obstruction can be treated by surgery several years later.
 Bilateral obstruction should be treated promptly by keeping the
mouth open through establishing an airway, which can be done by the
"feeding nipple" through making a large holes at its tip, then the infant
can be fed by gavage.
 Intubation or tracheostomy may be required if these measures are
failed till operative management.
 NASAL POLYPS
 Benign pedunculated tumors usually formed from edematous,
chronically inflamed nasal mucosa.
 They are usually arise from the ethmoidal sinus .
 Commonly associated with cystic fibrosis, chronic sinusitis, allergic rhinitis,
and low vit D level.
 Samter's triad: Nasal polyps, aspirin sensitivity & asthma
 NASAL POLYPS
 Etiology :
 Cystic fibrosis: Commonest cause in children
 Allergic rhinitis
 Sinusitis
 C/P NASAL POLYPS
 hyponasal speech : nasal polyps may cause enlargement & deformity
of the nose & also it can completely obstruct the nasal passages .
 Mouth breathing .
 profuse unilateral mucoid or mucopurulent discharge .
 Rhinorrhea .
 Epistaxis.
 Investigation of Nasal Polyps
 fiberopticRhinoscopy or flexible Nasopharyngoscopy
(reveals a glistening , gray, grapelike masses squeezed between nasal
turbinates and septum).
 CT scan may also be required before surgery.
 Treatment of Nasal Polyps

 Intranasal steroid sprays, and sometimes systemic steroids, may

provide some shrinkage of nasal polyps with symptomatic relief.
 Decongestants are usually ineffective.
 Doxycycline (100 mg daily) is also effective.
 Surgery is required when there is no response to medical Rx.
 EPISTAXIS
 Bleeding from the nose.

 The most common site of bleeding is the Kiesselbach plexus, an area in

the anterior septum.
 Etiology of EPISTAXIS
 Idiopathic (Spontaneous)
 Epistaxis digitorum
 Foreign body
 Trauma
 Tumors (Juvenile nasal angio fibroma)
 Rhinites , sinusites ,
 irritants ( GERD, smoking)
 Nasal polyps
 Septal deviation & perforation
 Vascular malformation
 Cocaine, topical steroids
 Etiology of EPISTAXIS
 B. General :
 Bleeding tendency(thrombocytopenia, coagulopathy, liver disease)
 Hypertension
 Fever
 Drugs: (NSAIDs, aspirin , anticoagulant agents).
 EPISTAXIS
C/P :
 Nose-bleeds usually occurs without warning from one nostril or both.
 The blood may be swallowed and become apparent only when the child vomits or passes blood in the stools.
Treatment :
 Most Epistaxis stop spontaneously within a few minutes. However, the following steps should be
followed
1. Compress the nares, keep the child quiet in upright position with head tilted forward.
2. Apply cold compresses on the nose.
3. Apply epinephrine locally.
4. Put anterior nasal pack; if the bleeding is posterior, put another & posterior pack.
5. Severe bleeding may require admission for blood transfusion and for
- otolaryngologic evaluation to exclude local lesions by nasal endoscopy, CT or MRI with surgical
intervention if needed.
- Hematological evaluation may also required to exclude bleeding tendency.
 Prevention of Recurrence of Epistaxis

 After control of bleeding, to prevent further bleeding & if the bleeding site is identified,
 It can be obliterated by cautery with silver nitrate followed by application of antiseptic
nasal cream.
 Other measures include: discouragement of nose picking, stop nasal steroid sprays,
attention to nasal infections and allergies, apply saline drops or petrolatum (vaseline)
to the septum, & humidification of bedroom during winter or dry environment.
 FOREIGN BODY IN NOSE
 It usually occur in toddlers.
C/P :
 Unilateral obstruction, sneezing & relatively mild discomfort or pain.
 Unilateral nasal obstruction with mucopurulent discharge with foul smell odor .
 Mouth breathing and epistaxis.
 Signs of local obstruction and discomfort may increase with time because some FBs
are hygroscopic, i.e. ↑ in size when they absorb water.
 generalized body odor, called Bromhidrosis!.
 Investigation of Foreign body in
Nose
 Nasal speculum or wide otoscope placed in the nose after removal of
the purulent secretions,
 long standing FB can become embedded in granulation tissue or
mucosa and appear as nasal mass.
 Lateral skull X-ray can reveal the FB if it is radiopaque.
 Complication of Foreign body
in Nose
 Posterior dislodgement .
 FB aspiration .
 infection (including tetanus).
 septal perforation, especially with disc batteries that may occur within
hours.
 Treatment of Foreign body in
Nose
 Unskilled attempts may force the FB deeper with risk of aspiration.

 Removal may require local (or sometimes general) anesthesia & done
by nasal forceps, Katz catheter, or suction with antibiotic cover.

 “Mother kiss” approach has been successful in acute situations through

occlusion of unaffected nostril and then blowing into the child’s mouth
(with a complete seal over the mouth) to dislodge.
 FOREIGN BODIES IN THE AIRWAY
 Aspiration of foreign bodies into the trachea and bronchi is relatively common.
 The majority of children who aspirate foreign bodies are under 3 years of age.
 Patients with developmental delay or with older siblings are at increased risk.
 Foreign bodies commonly tend to lodge in right-sided airways .
 Many foreign bodies are not radiopaque.
 The most common foreign bodies aspirated by young children are food (especially
nuts) and small toys.
FOREIGN BODIES IN THE AIRWAY

 C/P :
 Many children who aspirate foreign bodies have clear histories of choking, witnessed
aspiration
 However, a proportion of patients have a negative history because the aspiration
went unrecognized.
 cough
 localized wheezing
 unilateral absence of breath sounds
 stridor
 Hemoptysis (bloody sputum)
FOREIGN BODIES IN THE AIRWAY

 Investigation :
 Radiographic studies (X-RAY) will reveal the presence of radiopaque
objects and can also identify focal air trapping, especially on expiratory
views or decubitus films.
 Many foreign bodies are not radiopaque. Thus when foreign body
aspiration is suspected, expiratory or lateral decubitus chest radiographs
may identify air trapping on the affected, dependent side.
 Rigid bronchoscopy, typically performed by an otolaryngologist.
 Flexible bronchoscopy
 Foreign Body Aspiration
 Prevention :
 Common foods, including peanuts or other nuts, popcorn, uncooked
carrots, or any foods difficult to break into small pieces, are at risk to be
aspirated by infants and children, particularly before molar teeth have
erupted.
 Older siblings should be counseled to keep small toys separate and not
present younger children with small parts.