Nasal Obstruction in the Neonate and Infant Harvey Coates, M.B., M.S. (Otol), FR.C.S.(C), F.A.C.S.
Summary: The neonate is a preferential nasal breather; therefore, nasal obstruction in the neonatal period may cause significant sequelae. Although the uncommon choanal atresia is the main condition to be excluded, many other possible causes exist. A systematic approach to the workings of nasal obstruction in the neonate and infant is outlined so that appropriate management can be instituted. Introduction he
nasal obstruction Table 1.
neonate
is
a
are
outlined in
preferen-
the approximate age of five months. Nasal resistance is very high compared with the resistance of the remainder of the neonatal airway, accounting for as much as 49% of the total airway resistance in infants.2 This appears to be related to the narrow diameter of the neonatal nasal airway; pathologic narrowing of the airway further aggravates the situation. Nasal obstruction may be associated with nasal infections, sleep
problems, feeding difficulty, colic, cyanotic attacks, and epiphora.33
Complete nasal obstruction is a serious, life-threatening condition, requiring an alternate airway as a matter of urgency. Once the airway is secured, then careful examination of the infant’s upper
airway
safely.
The
can
be performed of neonatal
causes
Consultant Otolaryngologist Princess Margaret Hospital for Children & King Edward Memorial Hospital for Women
Perth, Western Australia
Evaluation of the Nasal Airway
History The observations of the nursing staff and parents should be noted in order to establish whether the infant’s obstruction is unilateral or
bilateral, produces a discharge,
or
is associated with snoring or cyanosis. The relationship of the nasal obstruction to crying and feeding should be determined. Details of any medication taken by the mother during pregnancy should be obtained as well as details of any nose drops administered to the infant.
Physical Examination Anterior rhinoscopy may be performed simply by elevating the nasal tip, bulb syringing or suctioning nasal mucus from the nasal cavity gently, and examining the
with
hand-held penor light, headlight, otoscope. Instillation of decongestant nasal drops, such as phenylephrine nose
will enhance examination
additionally enable comparison of the congested and decongested state. Passage of a soft nasal
tial nasal breather until two to
0.25%, and
catheter of 5-6 French gauge to at least 32 mm will exclude choanal atresia. Septal struts made of smooth plastic, measuring 6 mm x 2 mm x 100 mm, are passed upward into the nose 3-4 mm and then slid along the floor to detect any frank septal obstruction, which usually occurs 1.5-2.0 cm from the nares. In educated hands the fiberoptic nasopharyngoscope is additionally useful in visualizing structural or pathologic abnormalities in the nasal cavity and nasopharynx. Care should be taken when using any of these techniques that the infant’s nose is adequately decongested and that the instruments are adequately lubricated to avoid traumatizing the delicate nasal mucosa.
Congenital Causes
-
Nasal Obstruction
a
Choanal atresia, although rare with a reported incidence of 1:8000, causes total nasal obstruc-
Downloaded from cpj.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 16, 2015
tion in the neonate. When bilateral, the infant manifests respira-
tory distress and presents as a medical emergency.~4 Choanal atresia has a female preponderance, is usually unilateral, and is bony in 90% of cases. In bilateral choanal atresia there are strenuous respiratory efforts the infant, with relief only by when crying occurs. The unilateral case, conversely, may remain undetected for years, with unilateral discharge often being the only symptom. In 50% of cases, choanal atresia is associated with other congenital anomalies, such as Treacher Collins and
Figure 1: CT
scan of neonatal choanal atresia. (Arrow indicates pooling of contrast at bony obstruc-
tion.)
Charge syndromes; polydactyly; colobomata; facial, nasal, and palatal defects; congenital heart disease; tracheoesophageal fistula ; and craniosynostosis.55
Diagnosis is by failure of a 6 French-gauge feeding catheter more than 32 mm the posterior choanae. This can be confirmed by a com(CT) scan of puted tomography the choanae,66 which will demonstrate the bony atresia (Figure 1). The bilateral case is managed by securing an oral airway and by breaking down the atretic area with laser, drill, or curette transnasally, or via the
to
pass
through
transseptal or transpalatal route. A Silastic nasopharyngeal tube is left in situ for up to six weeks to prevent restenosis. Restenosis is the main problem with a transnasal route, while palatal fistula is a complication of the transpalatal approach. In the unilateral case, surgery may be delayed until the child is six to seven years old. Partial removal of the posterior bony septum at the time of choanal atresia repair is a useful
surgical approach
to
prevent
restenosis of the choana.’ Posterior choanal stenosis is similar in its presentation to choa-
nal atresia.
Diagnosis is by CT and
management is conservative, awaiting normal growth of the nasal cavities. Anterior nasal stenosis is uncommon in neonates. Such stenosis typically occurs at the bony inlet or pyriform aperture. This is the narrowest section of the nasal
cavity and, therefore, most susceptible to changes in the air flow and nasal resistance with mucosal swelling.’ The stenosis may be either congenital or traumatic. Diagnosis evaluation reveals a shelf-like projection just inside the nasal passage obstructing the
Figure 2: Method of manipulation of deviated
nasal septum. (Downward pressure on palate and medial pressure to septum.)
Downloaded from cpj.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 16, 2015
nasal tant
cavity. The use of decongesdrops to differentiate true
anatomical obstruction from mucosal edema is important. CT will confirm the diagnosis. Management is initially by medical therapy (topical steroid drops), with surgery reserved for those few cases that do not improve with nasal growth by six months.9 Midline nasal masses in the infant meningoencephaloceles, gliomas, and dermoids can also cause nasal obstruction. These pose an additional problem as intracranial connections are a possi-
-
bility ; biopsy or attempted surgical
resection may well cause meningitis or other intracranial complicaCT tions. and magnetic resonance imaging (MRI) examination will delineate such intracranial extension. Meningoencephaloceles1o are herniations of both glial tissue and meninges through defects in the skull. Sixty percent are situated over the nasal dorsum, 30% are intranasal, and the remainder are a combination of the above. The glioma, in contrast, is brain tissue isolated from its meningeal connections; a fibrous attachment to the intracranial structures is present in 20% of cases. Dermoid cysts occur in the nasal midline; a fistulous tract and protruding hair may be present externally in
The diagnosis is enhanced by the clinical examination looking for other stigmata of congenital syphi-
lis, such
as flattened nasal dorsum frontal bossing, and is confirmed by FTA-ABS serology. Treatment is with saline and steroid nasal drops and penicillin. Chlamyor
dia, acquired by passage through infected birth canal, can also
an
nasal obstruction and rhinitis in the neonate.12 Cow’s milk allergy may present in the one- to two-month-old infant cause
with excessive mucus production. Usually this responds within one to two days following cessation of the cow’s milk or milk protein formula and substitution of soy protein formula. Adenoid hypertrophy is usually not seen before the age of 12 months but may present in the infantwith snoring and even obstructive sleep apnea. Diagnosis is by lateral radiograph of the nasopharflexible nasoand/or ynx
pharyngoscopy.
many cases. Other anatomic reasons for nasal obstruction include nasal deformities associated with the cleft lip and various degrees of nasal
agenesis.
Inf lammatory The most common inflammacause of nasal obstruction in neonates and infants is upper re-
tory
tract infection; respiratory difficulties are especially
spiratory common
if underlying physical ob-
struction, such as a septal deviation, exists. Management measures include
bulb syringing and suctioning, decongestant nasal drops or nasal saline drops, together with a broad-spectrum antibiotic
such
as
amoxicillin
if
purulent changes Congenital syphilis, popularly occur.
known
as
profuse,
&dquo;snuffles,&dquo; presents
occasionally
as a
blood-
stained, mucopurulent discharge before the age of six weeks.&dquo; Osteitis and osteochondritis of the nasal bones and cartilages may cause
collapse of the nasal bridge.
Downloaded from cpj.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 16, 2015
Management
requires careful adenoidectomy appropriate monitoring for apnea postoperatively.
Neoplasms
septal deformity may cause respiratory distress and feeding diffi-
vere
with
Hemangiomas lymphangiomas of the
common
Iatrogenic Mechanical
trauma
from in-
induce mucosal edema. Foreign bodies are a rare cause of nasal obstruction in infants. Direct nasal obstruction in neonates may be caused by the misuse of nasal decongestant drops with a rebound rhinitis medicamentosa effect. In general, decongestant drops should be restricted to five days’ use only or alternated with normal saline or topical steroid
drops. Secondary nasal obstruction has been reported in infants with fetal alcohol syndrome. 13 Midface growth abnormalities, nasal hypoplasia, and other congenital abnormalities have been associated with this syndrome. In the immediate postpartum period, infants born to mothers who take narcotics or antihypertensives may suffer nasal obstruction; this medication-related mucosal edema usually resolves with conservative
management.
Early cleft-palate repair
in in-
fants with Treacher Collins syndrome and other craniofacial anomalies may lead to nasal obstruction and significant airway compromise. Delayed cleft-palate repair, together with tracheotomy, may be necessary in these children.
Metabolic One of the manifestations of congenital hypothyroidism is nasal congestion. Usually other classical features of congenital hypothyroidism are also present. 14
hemangiothe
benign
most neo-
the infant. 15 may be seen on the external nose or on the mucosal surface of the anterior septum and turbinates. Although there are several histologic types, their clinical appearance and behavior are similar. The majority of these hemangiomas resolve spontane-
plasms seen Hemangiomas
strumentation, including nasotracheal or nasogastric tubes, may
and are
in
few patients require carbon dioxide, laser therapy, or surgical excision. Malignant tumors of the nose are rare.
ously. Very
Rhabdomyosarcomas are occasionally seen in the first year of life. Management consists of wide local excision and multiple-drug chemotherapy protocols, including actinomycin D, vincris-
cyclophosphamide, cisplatinum.l6 tine,
culties due to nasal
obstruction;
secondary blockage
of the
tion.l7
REFERENGES 1.
Taylor M. Physiology of the nose, paranasal sinuses and nasopharynx. In: English GM, ed. Otolaryngology. Vol 2. Hagerstown, MD: Harper and Row;
2.
Godfrey S. Nasal resistance in infancy. Resp Physiol. 1978;34:233-246. Gray LP. Relationship of septal deformity to snuffly noses, poor feeding, sticky eyes and blocked naso-lacrimal ducts. Int J Pediatr Otorhinolaryngol.
1979.
3.
and
Stocks J,
1980;2:201-215. 4.
Black ital
Trauma 5.
Duncan NO, Miller RH, Catlin FI. Choanal atresia and associated anomalies. Int J Pediatr Otorhinolaryngol.
6.
Brown
trauma
during vaginal delivery. Gray3 examined the septal configuration of 2,380 consecutive newborns; he noted the septum was straight in half of neonates delivered by caesarean section but only in one quarter of those with persistent oc-
cipitoposterior presentation delivered vaginally, implying that significant nasal septal deformity occurred during delivery. Diagnostically, the columella may be displaced, the tip deviated, and the alae asymmetric. The passage of the plastic stents mentioned previously may be impeded on the side of the obstruction. The majority of the nasal septal deviations noted are minor and spontaneously correct
RJ, Pracy R, Evans JNG. Congenposterior choanal atresia. Clin Otol.
1983;8:251-255.
may occur infrom intrauterine trapartum pressure, but more commonly occurs
Septal
naso-
lacrimal ducts with sticky eyes may also occur. Such cases should be corrected in a conservative fashion by the use of nasal septal manipulation as a bedside procedure (Figure 2). There is seldom a role for formal operative reduc-
within
a
month of birth. Se-
Downloaded from cpj.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 16, 2015
1988;15:129-135. OE, Smith T, Armstrong E,
Grundfast K. The evaluation of choanal atresia by computed tomography. Int J Pediatr Otorhinolaryngol. 1968;12:85-98.
7.
Morgan DW, Bailey CM.
8.
agement of choanal atresia. Int J Pediatr Otorhinolaryngol. 1990;19:1-13. Myer CM, Cotton RT. Nasal obstruc-
Current
man-
tion. In: A Practical Approach to Pediatric Otolaryngology. Chicago, IL: Year Book; 1988:84-104. 9.
10.
Myer CM, Manning SC. Congenital nasal pyriform aperture stenosis. Laryngoscope. 1989;99:86-91. Cinnamond MJ. Congenital anomalies Brown OE,
of the nose. In: Scott-Brown’s Otolaryngology. 5th ed. London, UK: Butterworth;
1987:218-225. 11.
12.
Derkay CS, Grundfast KM. Airway compromise from nasal obstruction in neoand infants. Int J Pediatr nates Otorhinolaryngol. 1990;19:241-249. Belenkey WM. Nasal obstruction and
rhinorrhoea. In: Bluestone CD, Stool SE, eds. Pediatric Otolaryngology. 2nd ed. Philadelphia, PA: W.B. Saunders;
1990:657-671. 13. Usowicz AG, Edabi M, Curry C. Upper airway obstruction with fetal alcohol 14.
1986;140:1039. Am syndrome. J Dis Child. Tachman ML, Guthrie Jr GP. Hypothy-
roidism : diversity of presentation. Endocr Rev. 1984;5:456. 15. Batsakis J. Tumors of the Head and Neck. Baltimore, MD: William and Wilkins;
Otolaryngology.
delphia,
PA: W.B.
2nd ed. Phila-
Saunders; 1990:780-
792. 17.
1974:250. 16.
Pediatric
StanjevichJF, Lore Jr. JM. Tumors of the paranasal sinuses, and nasophar-
nose,
ynx. In: Bluestone CD, Stool SE, eds.
Downloaded from cpj.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 16, 2015
LP.
Septal manipulation in the Int J Pediatr Otorhinolaryngol. 1985;8:195-209. Gray,
neonate:
method and results.
Summary: The neonate is a preferential nasal breather; therefore, nasal obstruction in the neonatal period may cause significant sequelae. Although the uncommon choanal atresia is the main condition to be excluded, many other possible causes exist. A systematic approach to the workings of nasal obstruction in the neonate and infant is outlined so that appropriate management can be instituted. Introduction he
nasal obstruction Table 1.
neonate
is
a
are
outlined in
preferen-
the approximate age of five months. Nasal resistance is very high compared with the resistance of the remainder of the neonatal airway, accounting for as much as 49% of the total airway resistance in infants.2 This appears to be related to the narrow diameter of the neonatal nasal airway; pathologic narrowing of the airway further aggravates the situation. Nasal obstruction may be associated with nasal infections, sleep
problems, feeding difficulty, colic, cyanotic attacks, and epiphora.33
Complete nasal obstruction is a serious, life-threatening condition, requiring an alternate airway as a matter of urgency. Once the airway is secured, then careful examination of the infant’s upper
airway
safely.
The
can
be performed of neonatal
causes
Consultant Otolaryngologist Princess Margaret Hospital for Children & King Edward Memorial Hospital for Women
Perth, Western Australia
Evaluation of the Nasal Airway
History The observations of the nursing staff and parents should be noted in order to establish whether the infant’s obstruction is unilateral or
bilateral, produces a discharge,
or
is associated with snoring or cyanosis. The relationship of the nasal obstruction to crying and feeding should be determined. Details of any medication taken by the mother during pregnancy should be obtained as well as details of any nose drops administered to the infant.
Physical Examination Anterior rhinoscopy may be performed simply by elevating the nasal tip, bulb syringing or suctioning nasal mucus from the nasal cavity gently, and examining the
with
hand-held penor light, headlight, otoscope. Instillation of decongestant nasal drops, such as phenylephrine nose
will enhance examination
additionally enable comparison of the congested and decongested state. Passage of a soft nasal
tial nasal breather until two to
0.25%, and
catheter of 5-6 French gauge to at least 32 mm will exclude choanal atresia. Septal struts made of smooth plastic, measuring 6 mm x 2 mm x 100 mm, are passed upward into the nose 3-4 mm and then slid along the floor to detect any frank septal obstruction, which usually occurs 1.5-2.0 cm from the nares. In educated hands the fiberoptic nasopharyngoscope is additionally useful in visualizing structural or pathologic abnormalities in the nasal cavity and nasopharynx. Care should be taken when using any of these techniques that the infant’s nose is adequately decongested and that the instruments are adequately lubricated to avoid traumatizing the delicate nasal mucosa.
Congenital Causes
-
Nasal Obstruction
a
Choanal atresia, although rare with a reported incidence of 1:8000, causes total nasal obstruc-
Downloaded from cpj.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 16, 2015
tion in the neonate. When bilateral, the infant manifests respira-
tory distress and presents as a medical emergency.~4 Choanal atresia has a female preponderance, is usually unilateral, and is bony in 90% of cases. In bilateral choanal atresia there are strenuous respiratory efforts the infant, with relief only by when crying occurs. The unilateral case, conversely, may remain undetected for years, with unilateral discharge often being the only symptom. In 50% of cases, choanal atresia is associated with other congenital anomalies, such as Treacher Collins and
Figure 1: CT
scan of neonatal choanal atresia. (Arrow indicates pooling of contrast at bony obstruc-
tion.)
Charge syndromes; polydactyly; colobomata; facial, nasal, and palatal defects; congenital heart disease; tracheoesophageal fistula ; and craniosynostosis.55
Diagnosis is by failure of a 6 French-gauge feeding catheter more than 32 mm the posterior choanae. This can be confirmed by a com(CT) scan of puted tomography the choanae,66 which will demonstrate the bony atresia (Figure 1). The bilateral case is managed by securing an oral airway and by breaking down the atretic area with laser, drill, or curette transnasally, or via the
to
pass
through
transseptal or transpalatal route. A Silastic nasopharyngeal tube is left in situ for up to six weeks to prevent restenosis. Restenosis is the main problem with a transnasal route, while palatal fistula is a complication of the transpalatal approach. In the unilateral case, surgery may be delayed until the child is six to seven years old. Partial removal of the posterior bony septum at the time of choanal atresia repair is a useful
surgical approach
to
prevent
restenosis of the choana.’ Posterior choanal stenosis is similar in its presentation to choa-
nal atresia.
Diagnosis is by CT and
management is conservative, awaiting normal growth of the nasal cavities. Anterior nasal stenosis is uncommon in neonates. Such stenosis typically occurs at the bony inlet or pyriform aperture. This is the narrowest section of the nasal
cavity and, therefore, most susceptible to changes in the air flow and nasal resistance with mucosal swelling.’ The stenosis may be either congenital or traumatic. Diagnosis evaluation reveals a shelf-like projection just inside the nasal passage obstructing the
Figure 2: Method of manipulation of deviated
nasal septum. (Downward pressure on palate and medial pressure to septum.)
Downloaded from cpj.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 16, 2015
nasal tant
cavity. The use of decongesdrops to differentiate true
anatomical obstruction from mucosal edema is important. CT will confirm the diagnosis. Management is initially by medical therapy (topical steroid drops), with surgery reserved for those few cases that do not improve with nasal growth by six months.9 Midline nasal masses in the infant meningoencephaloceles, gliomas, and dermoids can also cause nasal obstruction. These pose an additional problem as intracranial connections are a possi-
-
bility ; biopsy or attempted surgical
resection may well cause meningitis or other intracranial complicaCT tions. and magnetic resonance imaging (MRI) examination will delineate such intracranial extension. Meningoencephaloceles1o are herniations of both glial tissue and meninges through defects in the skull. Sixty percent are situated over the nasal dorsum, 30% are intranasal, and the remainder are a combination of the above. The glioma, in contrast, is brain tissue isolated from its meningeal connections; a fibrous attachment to the intracranial structures is present in 20% of cases. Dermoid cysts occur in the nasal midline; a fistulous tract and protruding hair may be present externally in
The diagnosis is enhanced by the clinical examination looking for other stigmata of congenital syphi-
lis, such
as flattened nasal dorsum frontal bossing, and is confirmed by FTA-ABS serology. Treatment is with saline and steroid nasal drops and penicillin. Chlamyor
dia, acquired by passage through infected birth canal, can also
an
nasal obstruction and rhinitis in the neonate.12 Cow’s milk allergy may present in the one- to two-month-old infant cause
with excessive mucus production. Usually this responds within one to two days following cessation of the cow’s milk or milk protein formula and substitution of soy protein formula. Adenoid hypertrophy is usually not seen before the age of 12 months but may present in the infantwith snoring and even obstructive sleep apnea. Diagnosis is by lateral radiograph of the nasopharflexible nasoand/or ynx
pharyngoscopy.
many cases. Other anatomic reasons for nasal obstruction include nasal deformities associated with the cleft lip and various degrees of nasal
agenesis.
Inf lammatory The most common inflammacause of nasal obstruction in neonates and infants is upper re-
tory
tract infection; respiratory difficulties are especially
spiratory common
if underlying physical ob-
struction, such as a septal deviation, exists. Management measures include
bulb syringing and suctioning, decongestant nasal drops or nasal saline drops, together with a broad-spectrum antibiotic
such
as
amoxicillin
if
purulent changes Congenital syphilis, popularly occur.
known
as
profuse,
&dquo;snuffles,&dquo; presents
occasionally
as a
blood-
stained, mucopurulent discharge before the age of six weeks.&dquo; Osteitis and osteochondritis of the nasal bones and cartilages may cause
collapse of the nasal bridge.
Downloaded from cpj.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 16, 2015
Management
requires careful adenoidectomy appropriate monitoring for apnea postoperatively.
Neoplasms
septal deformity may cause respiratory distress and feeding diffi-
vere
with
Hemangiomas lymphangiomas of the
common
Iatrogenic Mechanical
trauma
from in-
induce mucosal edema. Foreign bodies are a rare cause of nasal obstruction in infants. Direct nasal obstruction in neonates may be caused by the misuse of nasal decongestant drops with a rebound rhinitis medicamentosa effect. In general, decongestant drops should be restricted to five days’ use only or alternated with normal saline or topical steroid
drops. Secondary nasal obstruction has been reported in infants with fetal alcohol syndrome. 13 Midface growth abnormalities, nasal hypoplasia, and other congenital abnormalities have been associated with this syndrome. In the immediate postpartum period, infants born to mothers who take narcotics or antihypertensives may suffer nasal obstruction; this medication-related mucosal edema usually resolves with conservative
management.
Early cleft-palate repair
in in-
fants with Treacher Collins syndrome and other craniofacial anomalies may lead to nasal obstruction and significant airway compromise. Delayed cleft-palate repair, together with tracheotomy, may be necessary in these children.
Metabolic One of the manifestations of congenital hypothyroidism is nasal congestion. Usually other classical features of congenital hypothyroidism are also present. 14
hemangiothe
benign
most neo-
the infant. 15 may be seen on the external nose or on the mucosal surface of the anterior septum and turbinates. Although there are several histologic types, their clinical appearance and behavior are similar. The majority of these hemangiomas resolve spontane-
plasms seen Hemangiomas
strumentation, including nasotracheal or nasogastric tubes, may
and are
in
few patients require carbon dioxide, laser therapy, or surgical excision. Malignant tumors of the nose are rare.
ously. Very
Rhabdomyosarcomas are occasionally seen in the first year of life. Management consists of wide local excision and multiple-drug chemotherapy protocols, including actinomycin D, vincris-
cyclophosphamide, cisplatinum.l6 tine,
culties due to nasal
obstruction;
secondary blockage
of the
tion.l7
REFERENGES 1.
Taylor M. Physiology of the nose, paranasal sinuses and nasopharynx. In: English GM, ed. Otolaryngology. Vol 2. Hagerstown, MD: Harper and Row;
2.
Godfrey S. Nasal resistance in infancy. Resp Physiol. 1978;34:233-246. Gray LP. Relationship of septal deformity to snuffly noses, poor feeding, sticky eyes and blocked naso-lacrimal ducts. Int J Pediatr Otorhinolaryngol.
1979.
3.
and
Stocks J,
1980;2:201-215. 4.
Black ital
Trauma 5.
Duncan NO, Miller RH, Catlin FI. Choanal atresia and associated anomalies. Int J Pediatr Otorhinolaryngol.
6.
Brown
trauma
during vaginal delivery. Gray3 examined the septal configuration of 2,380 consecutive newborns; he noted the septum was straight in half of neonates delivered by caesarean section but only in one quarter of those with persistent oc-
cipitoposterior presentation delivered vaginally, implying that significant nasal septal deformity occurred during delivery. Diagnostically, the columella may be displaced, the tip deviated, and the alae asymmetric. The passage of the plastic stents mentioned previously may be impeded on the side of the obstruction. The majority of the nasal septal deviations noted are minor and spontaneously correct
RJ, Pracy R, Evans JNG. Congenposterior choanal atresia. Clin Otol.
1983;8:251-255.
may occur infrom intrauterine trapartum pressure, but more commonly occurs
Septal
naso-
lacrimal ducts with sticky eyes may also occur. Such cases should be corrected in a conservative fashion by the use of nasal septal manipulation as a bedside procedure (Figure 2). There is seldom a role for formal operative reduc-
within
a
month of birth. Se-
Downloaded from cpj.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 16, 2015
1988;15:129-135. OE, Smith T, Armstrong E,
Grundfast K. The evaluation of choanal atresia by computed tomography. Int J Pediatr Otorhinolaryngol. 1968;12:85-98.
7.
Morgan DW, Bailey CM.
8.
agement of choanal atresia. Int J Pediatr Otorhinolaryngol. 1990;19:1-13. Myer CM, Cotton RT. Nasal obstruc-
Current
man-
tion. In: A Practical Approach to Pediatric Otolaryngology. Chicago, IL: Year Book; 1988:84-104. 9.
10.
Myer CM, Manning SC. Congenital nasal pyriform aperture stenosis. Laryngoscope. 1989;99:86-91. Cinnamond MJ. Congenital anomalies Brown OE,
of the nose. In: Scott-Brown’s Otolaryngology. 5th ed. London, UK: Butterworth;
1987:218-225. 11.
12.
Derkay CS, Grundfast KM. Airway compromise from nasal obstruction in neoand infants. Int J Pediatr nates Otorhinolaryngol. 1990;19:241-249. Belenkey WM. Nasal obstruction and
rhinorrhoea. In: Bluestone CD, Stool SE, eds. Pediatric Otolaryngology. 2nd ed. Philadelphia, PA: W.B. Saunders;
1990:657-671. 13. Usowicz AG, Edabi M, Curry C. Upper airway obstruction with fetal alcohol 14.
1986;140:1039. Am syndrome. J Dis Child. Tachman ML, Guthrie Jr GP. Hypothy-
roidism : diversity of presentation. Endocr Rev. 1984;5:456. 15. Batsakis J. Tumors of the Head and Neck. Baltimore, MD: William and Wilkins;
Otolaryngology.
delphia,
PA: W.B.
2nd ed. Phila-
Saunders; 1990:780-
792. 17.
1974:250. 16.
Pediatric
StanjevichJF, Lore Jr. JM. Tumors of the paranasal sinuses, and nasophar-
nose,
ynx. In: Bluestone CD, Stool SE, eds.
Downloaded from cpj.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 16, 2015
LP.
Septal manipulation in the Int J Pediatr Otorhinolaryngol. 1985;8:195-209. Gray,
neonate:
method and results.
