Consultation with the Specialist: Diagnosis and Management of the Newborn and Young Infant Who Have Nasal Obstruction

Abstract

1. Susannah Q. Olnes, MD* 2. Richard H. Schwartz, MD* 3. Robert S. Bahadori, MD† 1. 2. *Department of Pediatrics. 3. 4. †Section of Otolaryngology, Inova Fairfax Hospital for Children, Falls Church, VA. Because neonates may be obligate nasal breathers until they are at least 2 months old, nasal obstruction, particularly if bilateral and complete, can cause severe respiratory distress quickly. Nasal airway problems far less consequential than total nasal obstruction can be worrisome in the neonate and young infant. Their nasal passages may exhibit as much as 50% of the total airway resistance, and the degree of obstruction often worsens when the infant has an upper respiratory tract infection. Focal obstruction can occur in the nasal vestibule or in any of the three anatomic regions of the nose: nasal piriform aperture, mid-nasal cavity, or the posterior choanae. Most cases of nasal obstruction in the neonate and young infant are due to generalized nasal airway obstruction associated with neonatal rhinitis, viral upper respiratory tract infections, and possibly milk/soy allergies. A relatively unrecognized, but important percentage of neonatal nasal obstruction is due to gastroesophageal reflux disease (GERD), with secondary inflammation of the posterior nasal passages (reflux rhinitis). Less common causes of generalized neonatal/young infant nasal obstruction include rhinitis medicamentosa due to the overuse of topical vasoconstrictor nose drops and maternal ingestion of drugs such as methyldopa, tricyclic antidepressants, or propranalol. Trauma from nasal prongs or nasogastric tubes may produce unilateral or bilateral nasal obstruction. With the exception of posterior choanal atresia, the challenging differential diagnosis and management of the neonate who has nasal obstruction is described in only a few English language pediatric journal articles. There are several reviews of the subject in the subspecialty literature. Syphilitic snuffles, although an infrequent cause of nasal obstruction, merits particular mention because it sometimes is misdiagnosed. The watery nasal secretions associated with snuffles are teeming with spirochetes and highly contagious. Chlamydial rhinitis can produce similar clinical symptoms. Successful management of nasal obstruction in the neonate or young …