Choanal atresia is the most common congenital anomaly of the nose and consists of a bony or membranous septum between the nose and pharynx, either unilateral or bilateral. Bilateral choanal atresia classically presents in neonates as cyclic cyanosis because neonates are preferential nose breathers. Airway obstruction and cyanosis are relieved when the mouth is opened to cry and recurs when the calming infant reattempts to breathe through the nose. Some newborns show respiratory difficulty while feeding only. Nearly half of infants with choanal atresia have other congenital anomalies as a part of the CHARGE association (coloboma, congenital heart disease, choanal atresia, retardation, genitourinary defects, ear anomalies). Unilateral choanal atresia may go undiagnosed until later in life and presents with symptoms of unilateral nasal obstruction and discharge.
Nasal polyps typically appear as bilateral, gray, glistening sacs originating from the ethmoid sinuses and may be associated with clear or purulent nasal discharge. Nasal polyps are rare in children younger than 10 years of age but, if present, warrant evaluation for an underlying disease process, such as cystic fibrosis or primary ciliary dyskinesia. Triad asthma is asthma, aspirin sensitivity, and nasal polyps with chronic or recurrent sinusitis.
Foreign bodies are seen more commonly in young children who place food, small toys, stones, or other things in their nose. The index of suspicion should be raised by a history of unilateral, purulent nasal discharge, or foul odor. The foreign body can often be seen on examination with a nasal speculum.
Management of allergic rhinitis is based on disease severity, impact of the disease on the patient, and the ability of the patient to comply with recommendations. Treatment modalities include allergen avoidance, pharmacologic therapy, and immunotherapy. Environmental control and steps to minimize allergen exposure, similar to preventive steps for asthma, should be implemented whenever possible (see Table 78-3).
Intranasal corticosteroids are the most potent pharmacologic therapy for treatment of allergic and nonallergic rhinitis. These include beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone, mometasone, and triamcinolone. These topical agents work to reduce inflammation, edema, and mucus production. They are effective for symptoms of nasal congestion, rhinorrhea, itching, and sneezing but less helpful for ocular symptoms. Nasal corticosteroid sprays have been used safely in long-term therapy. Deleterious effects on adrenal function or nasal membranes have not been reported when these agents are used appropriately. The most common adverse effects include local irritation, burning, and sneezing, which occur in 10% of patients. Nasal bleeding from improper technique (spraying the nasal septum) can occur. Rare cases of nasal septal perforation have been reported.