Nasal breathing and olfaction (sense of smell) disorders in young children
The etiology and pathogenesis of nasal breathing and olfaction (sense of smell) disorders in young children is obstruction of the nasal cavity or nasopharynx with the impaired nasal breathing in infants and children in the first years of life can be congenital or acquired. Congenital obstruction of the nasopharynx is presented in the form of complete and incomplete choana or nasal cavity atresia, malformations or hypoplasia of the nasopharynx. Acquired obstruction of the nasal cavity may be due to granulomatous diseases (tuberculosis, syphilis, scleroma), diphtheria, trauma or the result of unqualified adenotomy.
Difficulty in nasal breathing occurs when obstruction of the nose in case of rhinitis, nasopharyngitis, foreign body, tumor, hematoma, abscess of the nasal septum or its deviation. Causes of obstruction can also be hypertrophy of the turbinates, thickening and deviation of the nasal septum, sinusitis, allergic rhinitis, nasal polyps, adenoid vegetations, retropharyngeal abscess.
Changing the mucous membrane of the nasal cavity due to excessive entrainment by local application of vasoconstrictors in infants can cause severe nasal obstruction, difficulty in nasal breathing and discomfort. Vasoconstrictors, when they are used unnecessarily, cause back effects, which leads to vasodilation of nasal vascular-rich mucous membrane and an increase in edema. The mucous membrane becomes even more inflamed and thickens, which is manifested by swelling of the nasal concha and increased secretion.
Among other reasons for the difficulty of nasal breathing and the appearance of discharge from the nose may be called hyperthyroidism, which causes changes in the mucous glands. Discharge are thicker than usual, however, with rhinoscopy, only the edematous mucosa is often determined. Even if there are no nasal secretions during the examination of the child and the middle nasal passages are not changed, if hypothyroidism is suspected, the function of the thyroid gland should be investigated.
Clinical presentation of nasal breathing and olfaction (sense of smell) disorders in young children
With prolonged obstruction of the nasal cavity in newborns and infants, sucking is disturbed and they are underfed. The child usually is capricious at packing in bed, snores in sleep, sleeps with the open mouth. The obstruction of the nasal cavity in combination with the infection is usually accompanied by purulent discharge, which intensifies with the progression of obstruction. When examining the nasal cavity, its anatomical constriction is determined of a different nature (depending on the cause) or edematous inflamed tissue.
Diagnosis of nasal breathing and olfaction (sense of smell) disorders in young children
Full bilateral choanal atresia, when the innate septum completely disconnects the nasal cavity and nasopharynx, is usually determined already at birth or during the first hours of life, as it is accompanied by severe asphyxia not yet able to breathe through the mouth of the newborn and inspiratory dyspnoea.
When unilateral imperforate choanae asphyxia attacks can only occur during the feeding of the child, they are less pronounced. Unilateral choanal atresia in a newborn are not always diagnosed, as it is accompanied by minimal symptoms. Sometimes stagnant phenomena occur in the nasal cavity with the subsequent development of rhinitis, sinuititis and, possibly, exudative inflammation of the middle ear.
Nasal breathing and sense of smell with hereditary and other forms of deviated nasal septum are disturbed relatively often. The upper part of the nasal septum, starting from the level of the middle nasal concha, belongs to the olfactory area. It is pertinent to emphasize that not only olfactory but also other nerves innervating the nasal septum (nerves of the autonomic nervous system, etc.) participate in the act of smell, therefore any injury of the nasal septum, especially its olfactory region, leads to disruption of the sense of smell.
The cause of the sense of smell disorders is usually the deviated nasal septum in the upper part (from the place of contact with the middle nasal cavity - the region of the olfactory gap - and above). Small diviation in the posterior part of septum and the presence of crests and thorns do not usually lead to a smell disturbance, since there are no obstacles to the correct air current. In upper part deviated nasal septum, the air current during inspiration is forcibly directed along an unusual bed - the lower nasal passage (rather than arcuate upward, as in the norm). In a number of cases, the middle nasal concha and the deviated nasal septum closely adjoin each other, completely covering the olfactory gap, which causes hyposmia or anosmia on the side of the narrowed half of the nose. Sometimes the sense of smell is disturbed on both sides or on the side opposite to the deviation (due to the compensatory increase in the other nasal concha). In some cases, olfaction disorders depends not only on the direct narrowing of the nasal cavity in connection with the deviation, but also on the attachment of inflammatory phenomena in its cavity. The cause of the sense of smell disorders is established by examining the nasal cavity and using appropriate methods of investigation.
The diagnosis of nasal obstruction confirmed the impossibility to enter the rubber catheter through the nose into the nasopharynx. Normally, a small amount of methylene blue, introduced into the nose, should be determined visually in the nasopharynx, which does not happen when the posterior pharyngeal wall is blocked.
Radiographs with contrast substances introduced into the nose and nasopharynx help not only to diagnose, but also to determine the degree, type, location of the obstruction of the nasal cavity.
Congenital nasal defects often combined with a cleft palate and harelip. Congenital atresia and synechia in the nasal cavity (connective tissue, cartilaginous or bone) look like bridges between the walls of the nasal cavity, covering in some degree the lumen of the nasal passages. X-ray examination with a contrast agent inserted into the nose helps to establish the localization of the constriction. To the obstruction of the nasal cavity and obstruction of nasal breathing can lead to damage during labor (with a narrow pelvis), when there is a fracture of the nasal bones, hematoma or abscess, deviated nasal septum.
Nnasal bones fracture in infants confirmed crepitus on palpation. Usually a nasal trauma is accompanied by a swelling and a hemorrhage into the thickness of its mucous membrane. Radiographically fracture of the nose is not determined in all cases, because it does not always visible signs of it on X-ray and it is difficult to differentiate between nasal bone trauma and fractured.
Septal hematoma can appear during childbirth, but it often occurs in young children from falls, since the core of the nose has not yet acquired the usual hardness. Hematoma develops as a result of a sharp injury with the separation of perichondria from injured cartilage. On the mucosa gaps are not always visible. Characterized by progressive obstruction of the nasal cavity, sometimes mucous or bloody discharge from the nose. At rhinoscopy in the front part of the nasal septum the swelling of blue-red color is bilaterally defined, at touching with a probe it soft and becomes dark-purple. Aspiration of its contents with a thick needle with a large opening sometimes confirms the presence of blood, but this may not happen if there are blood clots in the cavity. Anemization in this case has little effect on the obstruction of the nasal cavity and, consequently, on nasal breathing.
The result of injury at birth (passage through the narrow birth canal) or later injury may be the deformation of the nasal septum with the development of single or bilateral obstruction of its cavity, because it is offset from the cartilage of the nasal septum from the maxillary crest with subsequent mechanical obstruction.
Rhinoscopy revealed the different displacement of the nasal septum, but often one side with thickening it in the lower Department from the opposite side. The base of the nasal septum is usually extended due to a thickened alveolar crest and the displacement of the cartilage. Sometimes visible breaks in the mucous membrane of the nose. Arising subsequently compensatory hypertrophy of the turbinate can also lead to obstruction of the nasal cavity. With diagnosis help of anamnestic data, including of birth (data on the size of the pelvis, the nose bleeding in the newborn, external nasal deformity, swelling of soft tissues). Rhinoscopy often reveal a dislocation and a fracture of the cartilaginous part of the nasal septum. To study the posterior of the nasal cavity produce anemisation of the mucous membrane.
When nasal foreign body in young children is characterized by unilateral obstruction of nasal breathing, mucous and muco-purulent unilateral purulent discharge with an unpleasant odor, recurrent nosebleeds. With rhinoscopy, the edematous mucous membrane of the nasal cavity is determined, after anemization, a foreign body is detected.
X-ray examination is advisable if the foreign body is radiopaque, in this case it looks like a dark place on the roentgenogram. When manipulating around a foreign body, nosebleeds may occur; in infants such actions usually performed under general anesthesia. Foreign body in the nose often find on the front end of the inferior turbinate.
Adenoid vegetations sometimes develop already in early childhood and are characterized by a disturbance in the growth of the skeleton of the face: the upper jaw lengthens, becomes a high and narrow palate, an adenoid facial expression appears (half-open mouth, drooping lower jaw, nasolabial fold flattening). In infants diagnosed more often specify digital examination of the nasopharynx.
Sinusitis in young children is not always manifested purulent nasal discharge. For chronic sinuititis, which can be already at the age of 2 years, characterized by hyperemia and swelling of the mucous membrane, sometimes mucopurulent discharge in the middle nasal passages. In young children it is retropharyngeal abscess, accompanied by disturbances of nasal breathing, dysphagia, nasal. When the soft palate is lifted by the spatula on the back wall of the pharynx the bulging is determined, soft to the touch.
Scleroma in infants is rare and differs by the narrowing of the vestibule of the nose due to the infiltration of its wings, which are hard to touch and protruded. Infiltrates can be found in the area of the nasopharynx arch and the choan. The diagnosis is refined with the help of the Borde-Gangu reaction with the scleral antigen.
For differential diagnosis, a test for microflora, fungi, sometimes serological testing for syphilis, skin testing for tuberculosis is performed.
Difficulty of nasal breathing often occurs with allergies at an early age, which is difficult to recognize during formation. Allergic manifestations in children of this age group can mimic the signs of numerous diseases - from rhinitis to bronchopulmonary pathology. The diagnosis of an allergic disease should not be made to a child unless a complete allergological study is performed, although it is very difficult to perform it at an early age.
Carefully collected history helps to identify predisposition to seasonal, all-the-year-round or episodic manifestations of allergy, in order to distinguish it from other, non-allergic diseases. Allergic diseases in young children significantly reduce the resistance to bacterial infections. Banal rhinitis can be primary or secondary in the development of allergic rhinitis.
There are no any pathognomonic signs in the nasal cavity to distinguish the allergic etiology of rhinitis from bacterial, but purulent or mucopurulent discharge from the nose with polymorphonuclear cells and bacteria suggest an infection. Cytological examination of nasal secretions is an effective diagnostic method, but the isolated culture can not always confirm the etiological factor of the disease. In infection antibiotic therapy is effective .
Allergic rhinitis, unlike banal, is accompanied by sneezing attacks, the allocation of profuse transparent secretion from the nose, itching in the nose, swelling, cyanosis of the inferior nasal turbinate. After anemizatoin of turbinate swelling is almost not reduced.
Vasomotor rhinitis with vegetovascular response (apparently of a reflex origin) is manifested by vasodilation, hyperemia, hypersecretion, hypertrophy of the nasal mucosa. The etiology of it, strictly speaking, is unknown, although it is established that stress intensifies the symptoms, and individual sensitivity is affected not only by emotions, but also by changing weather conditions. The norm is characterized by a balance of stimulation of the sympathetic and parasympathetic nerves of the nasal mucosa.
In vasomotor rhinitis, additional parasympathetic stimulation is noted, the mucous membrane of the nose is pale, hyperemia appears, and later hypertrophy, discharge is transparent and watery, obstruction of the nasal cavity and rhinorrhea can both be combined and exist separately from each other.
Thus, a careful interpretation of the data of anamnesis, examination, the appropriate additional diagnostic studies are helpful for differential diagnosis and correct diagnosis.
Treatment of nasal breathing and olfaction (sense of smell) disorders in young children
Therapy of nasal breathing disturbance in young children should be aimed at eliminating the reason of the nasal cavity obstruction or a specific pathology. Before the diagnosis is made, it is inappropriate to use both congestive and decongestive agents, aerosols and other drugs.
When bilateral choanal atresia and other diseases involving asphyxia at birth, to ensure breathing through the mouth, the child's chin is glued to the chest with a strip of adhesive patch or an air duct is inserted into the mouth. Accumulating nasal mucus (rhinitis, sinusitis and other pathology) was removed by aspiration.
In acute inflammatory diseases of the nose and paranasal sinuses or exacerbation of chronic process indicated antibacterial therapy and restorative treatment. Surgical intervention in young children is limited, however, by indications do adenotomy, polipotomiyu, sinus puncture, and other operations.
Complications of nasal breathing and olfaction (sense of smell) disorders in young children
The most common complication of prolonged obstruction of the nasal cavity is hearing impairment as a result of exudative inflammation of the middle ear, therefore it is important to make an accurate diagnosis for the purposeful treatment. In classical cases, the tympanic membrane of the child usually bulges out, tense, dull, often amber in color, can be thickened. When a child blows his nose, covers his nose, mouth, inflates his cheeks, air bubbles may appear in the middle ear, which can lead to infection.
Tests using tuning forks to diagnose disorders of sound conduction associated with exudative otitis media, feasible in younger children with sufficient persistence doctor.
Weber's test is performed by placing a tuning fork on maxillary incisors or on the midline of the skull. In a child with an impaired sound-conducting sound lateralised in a weakly hearing ear. With the help of the Rinne test, bone and air conduction are studied, placing the tuning fork in turn against the external auditory canal and the mastoid process. The test is considered positive if the patient hears longer for air conduction than for bone conduction (normal), a negative test indicates a loss of sound conductivity (bone conduction is longer than air conductivity).
Audiometric studies in children with exudative inflammation of the middle ear often indicate a hearing impairment, with bone conduction being normal, and air conduction is lowered. On the tympanogram, it is possible to graphically represent the compliance of the tympanic membrane after insertion of the probe into the external auditory canal. The middle ear, filled with serous fluid, is characterized by a weak compliance of the tympanic membrane with both positive and negative pressure on it, which at maximum compliance will be reflected in the scheme as a straight line.
Impedance measurements give an idea of the resistance of the eardrum, along with timpanometry provides a more complete understanding of the nature of middle ear disease.
Other most frequent complication of long-term obstruction of the nasal cavity - sinusitis. It is characterized by purulent discharge, especially in the morning. In adults, such common symptoms as pain, chills, headache are more common. In children other symptoms are more important: rhinorrhea, persistent cough, inflammation of the middle ear, they have hemolytic streptococcus, pneumococcus and staphylococcus from the microbes.
Diaphanoscopy is ineffective in children under the age of 12 due to underdevelopment of their maxillary and latticular sinuses, which are most often involved in the inflammatory process. On examination, a thickened edematous mucous membrane of the nose and dense, thick purulent discharge are found in the middle nasal passage and along the nasal cavity.
X-ray examination usually reveals a thickening of the mucous membrane, diffuse darkening of the sinuses, sometimes an air-liquid level.