Nasal Obstruction in Children

Primary Care Knowledge Boost. Nasal obstruction in children. Hello everyone, welcome back to Primary Care Knowledge Boost. You're here with Dr Lisa Adams and myself Dr Sarah McDermott. And today we are back with Simone Schaefer for our last ENT episode of the moment, talking all about nasal obstruction. We take the same approach, we use a case to get her take on definitions and differentials.

and approaches to managing nasal obstruction and what kind of cases ear, nose and throat consultants are interested in, which was phenomenally interesting for me. Didn't know very much about this topic, so it was great to cover. Yeah, it was really good. So I hope you enjoy it and we'll be back at the end to share our learning points with you all.

So we have you for our last topic Simone that we're really glad that we've been able to squeeze in so we want to talk about nasal obstruction today thinking a little bit about obstructive breathing in a child. And we thought we'd ask you for this episode, if you had any kind of typical type cases that you would want to outline that we could talk around for this episode.

So I think nasal obstruction, there are a couple of different groups of patients that come. So the one that I would want to see, and I think... deserves a referral to ENT, if that makes sense. You can sort of, they walk into your clinic room or into your GP practice and they are.

You can just, they walk in, the parents haven't even talked to you yet and you think, yeah, okay, that doesn't look particularly good. You can hear them, they're open, they're sitting there looking at you with open mouth. Their nose is... They sound constantly congested, not with acute infection, not necessarily with rhinorrhea either, actually, but just...

constant open mouth breathing, constant sounding congested when they speak. They might struggle to eat because they can't breathe through their nose at all, because they can't eat and breathe at the same time. They snore like a trooper. So parents will say, I can hear them outside of their bedroom. I can hear them in my room. I can hear them downstairs. I can hear them snore. They sound like my partner.

And very often, if you then ask these families in a bit more detail, there will be signs of obstructive sleep apnea. So how I often ask for it is they hear their child snore. And then all of a sudden, nothing. Completely silent. And then a big gasp.

And that is essentially their child having an apnea because most of the time the children won't sleep in their parents' bedroom anymore. So they're not there to sort of watch them and see if they're breathing. If there's any doubt, I often ask parents to make a video. is really helpful. And in the typical obstructive sleep apnea children, you can see them, so you can hear them snore, fall completely silent, and then...

Depending on the severity, you can sort of see the signs of obstructive breathing, so the tequila tug or subcostal recessions. You can see that the body's making an effort to overcome the obstruction. And then the child, as a gasp, repositions themselves. and falls back asleep. And that goes through the night constantly. So those children are very, very obvious they need an ENT review. These are generally children that are slightly younger.

So sort of preschool age children. I'm just thinking of a case. I think it's about three or four. So they're generally that age because that's when you're still really struggling with your adenotonsillar hypertrophy. generally tends to go down when they hit like primary school age or the age of sort of about six. So you have that group of kids. You then have the group of kids that are older.

So maybe preteen or something like that, and still have persistent nasal congestion. And they might have... the congestion, maybe a bit of open mouth breathing still. They might have some additional symptoms like rhinorrhea or sneezing, itching. and essentially people have always thought it will get better as they get older and it's not getting much better and they are far more likely to have underlying allergic rhinitis which i know not all primary care

I think do blood tests or skin prick testing. I think it depends on what your practice does. But anyway, they are far more likely to have an underlying allergic rhinitis. It's quite useful to know that Haustos mite allergy, which is very common in the part of the world that we live, is actually their main symptom is just nasal congestion.

And not like hay fever, which comes with sneezing and itching and redness and all those really typical symptoms that people recognize of a nasal allergy. A house dust might very often just cause nasal congestion. So that's worth bearing in mind. In that group specifically, I get a lot of referrals saying on examination there is a polyp.

And I think this is quite a key point. I'm glad we got to it. Children do not have nasal polyps. So the incidence of a child having a nasal polyp is less than 0.1%.

you could say that if a child has nasal polyps, we almost only see them in children with underlying cystic fibrosis, which they should all have been tested for with their heel prick. So if you have a child that has no... respiratory symptoms and you look in her nose and you think oh could this be a polyp it's not a polyp um and it's probably an inferior terminate it is an inferior terminate and

Again, we've talked about this in between how much of your practice actually comprise of ENT and how little you actually see of it in your training. So I completely get the confusion there because an inferior turbinate in a child that has allergic rhinitis looks pale and enlarged and can look a bit boggy. So an inferior turbinate in... allergic rhinitis becomes much paler and that's why people confuse it for a polyp so why it's relevant is because i

Quite reasonably, if people see a polyp, especially if they only see it on one side or think it's a polyp and they see it on one side, you'll refer to ENT. And if you don't see polyps, then you're much more likely to start management in primary care. So that's why it's quite reasonable to know that actually what you're looking at is very likely the inferior turbinate being pale and enlarged in a child that has underlying allergic rhinitis, which you can then start managing in primary care.

in the first instance yeah really useful you mentioned skin prick testing is that quite useful if we've got somebody if we've got a child who's getting a lot of congestion and we've been managing it with variable levels of response is it a useful test to see so i so yeah in in our setting we only the um immunologist

can order skin prick testing. I do ROS testing, but that doesn't really matter that much. I think it's useful to sort of explain to parents and patients what their diagnosis is and what their prognosis is. So they often come with saying, oh, well, I've used a nasal steroid spray and it worked for a little bit and then it stopped or I stopped using it and then it came back. Which all makes sense if I can tell you that you have an underlying allergy.

and therefore whatever medication we throw at you it's never going to be curative it's just going to reduce your symptoms and as soon as you stop it your symptoms will come back and even whilst you're on it it might not cure your symptoms because we're not curing your allergy and i think that that can be quite useful to have in writing that actually you have an allergy this is the cause of all your issues and i can't fix that for you

So that's why I think it has a place. It's not necessarily to make the diagnosis because it can be quite straightforward when you have the history and the examination to say, well, you're going to have allergic rhinitis. But to sort of have that. for patient expectation management can be quite useful. Really helpful. Have you got any other types of patient that you want to talk about in terms of nasal obstruction? Yeah, I guess, but you will see them far more than I do.

are then the younger children that have nasal obstruction just because they're young and they live in the northwest of England where the weather is always terrible and we all sit inside on top of each other. You're bringing a lovely picture. Yeah, I mean, I have a child that goes to full-time nursery, so I know what it's like. Yeah, and in those people really...

Having a blocked nose and maybe even with some snoring with it in the absence of obstructive sleep apnea and the absence of significant open mouth breathing or any of those other symptoms, that just takes time. I always tell people children on average have about six to ten episodes of upper respiratory tract infections a year in this part of the world.

which are generally clustered between sort of say September, March, September, April. So if you have six to 10 upper respiratory tract infections in about seven, eight months. That means every three weeks your child has a cold. That is just brutal. But it is what it is. So they're constantly snotty. They might constantly have a bit of a cough. But... After they've hit sort of three years of age, that will stop again. And the evidence of any surgical intervention, so adenoid...

removal for recurrent upper respiratory tract infections is very minimal. So it's not listed as an indication for surgery because the effect of it is not enough to warrant the risks. And steroid nasal sprays are licensed only in children over the age of three. So that's not going to be much help of you there either. So it's in essence that conversation similar to AOM. You just have to get through this or move to Spain. Fair enough. Yeah.

For those children that are the ones that you do want to see the symptoms of OSA, the apneic episodes or the open mouth breathing, the very noisy breathing, is there a way of... Because that waiting list of average of 12 months is quite tricky when the child is suffering so much. Is there a way of navigating that at the moment for those types of children?

hard situation to be in I think at the moment so officially the guidelines that we have for the northwest of England and Wales would say that we should aim to see children with symptoms of OSA within three months. which currently definitely isn't happening. So whilst they're waiting, there's no harm if the child is over the age of three to give them some steroid nasal spray, although we know it's not going to cure it. It might just help with...

reducing their symptoms. And there is some evidence, especially for sort of mild to moderate sleep apnea, that Montelukast reduces the symptoms. I don't know how often Montelukast is prescribed in primary care, I must say. There is some evidence to say that it helps reduce endotonsular hypertrophy. So that's something to consider whilst they're waiting. And I think if they're, because we get...

a lot of referrals for obstructive sleep apnea. It's far more common to have your adenoids and tonsils removed for OSA than it is for current tonsillitis. So we get a lot of referrals. So if you're truly concerned about your... that child so you've seen a video and the child is really recessing or tugging that really helps putting that in your letter to say or if they're concerns about schooling so you get that a lot as well where

They're OSAs to such a degree that they obviously can't focus at school. We've had children.

on quite a regular basis where there are concerns about ADHD, for example, because they're not focusing at school and you resolve their obstructive sleep apnea and their behavior improves. So if there are any sort of... concerns around that like the severity of the osa the the impact that it has on a child's daily life and then that is useful information for me to know yeah that's very helpful i think i remember when i was a trainee that

people used to like or used to include in their referral letters if their tonsils if this is more for tonsils rather than adenoids and so they used to refer to them as kissing so you can see them kissing is that useful information in a referral letter or is it more just about the breathing and the clinical the impact of the the symptoms on them so it helps in a sense that

sort of it helps us guide to say okay well then it's very likely they need their adenoids and tonsils removing but then again if you have a child with clear symptoms of OSA with no tonsil hypertrophy I would see them. just as much okay yeah should try and get myself digging a hole about tonsils there because that is right i might as well clarify i've got an expert um so your adenoids are a type of tonsil right um the tonsil

at the back of your throat? What are they called? So you have your adenoids, you have your tonsils on the side of your throat, and then you have a tongue tonsil, so a tongue base. Yeah, yeah. But essentially all you can see on clinical examination are the tonsils in your mouth. You can only see adenoids.

If you do a nasendoscopy, you can only see the tongue tonsil if you do a laryngoscopy, really. So yeah, and it's all part of sort of that circle of lymphoid tissue at the back of your nose and your throat as part of your sort of first defense against... infections that we breathe in.

thank you yeah um i thought yeah i thought it was a term um do you have any take-home points that you want the listeners um to remember about nasal obstruction specifically so yeah i think for nasal obstruction Consider the diagnosis of allergic rhinitis, even if they don't have symptoms like sneezing, itching, redness, etc. Don't worry about nasal polyps in children.

Ask about sleep patterns and what those sleep patterns, what consequence they have on the child's day-to-day life. That's absolutely amazing. Thank you so, so much, Simone. It's been wonderful to cover. Very good. So Lisa, now that it's just the two of us and it's been a little while since we've recorded these, what would you say your learning points are?

Yeah, so like you said up front in the intro, I think this one is probably the one that I knew least about as well out of the four topics. So I think it was quite useful for her to go through quite...

clearly what it would look like to see nasal obstruction in a child. I've written down that you can hear them, they've got an open mouth, they sound constantly congested, they're struggling to eat, they snore. I think those are quite... nice to have laid out in front of you and also her description of what the the obstruction at night sounds like the apneas i think was quite useful to have kind of laid out as well and then the other bit that i've kind of written is the

about the allergic rhinitis again I think I was I think I was really on allergic rhinitis because I said the last one as well but I think I just found it really interesting Yeah, definitely. It's not necessarily something high up in the differentials and there's not a huge amount we can be doing in general practice either. So having something that we could potentially target, I think is really useful to know. Yeah, that was a big learning point.

for me is that okay was it that's good yeah um and then i'd written down that yeah i was also interested to hear that children do not have nasal polyps they just do not they do not have nasal polyps it's not a thing unless they have cystic fibrosis which you would know about um they don't have a nasal polyp So I thought that was a big learning point. Yeah, no, I think I'm trying to think if I've ever thought a child has one. Can't really think. I've definitely seen some very congested noses.

But yeah, I really liked the learning point for me about the usefulness of videos. So parents will often come in with a audio recording of the noise, but actually what... In fact, as soon as we recorded this episode, I used that in clinic where I said record a video because we need to be really useful to see if they are getting any increased work of breathing.

during during those so are they having to really suck in are they recessing are they um yeah all the signs for for increased labored breathing in children um it was really interesting and getting that proof

and yeah the impact on behavior you see as well i thought was interesting to kind of go through that yeah it is because you think about it and from the the adult point of view and the fact that we've got like your upper scores and you're like for your adults and how much impact it can have on daily life and work

and things like that it's fairly similar for children the impact that that would have on schooling particularly in the older children is quite significant I did like her reassurance that for ones that aren't acute severe ones that lower level issues their tonsillar hypertrophy recedes when they become school age so if it if it isn't quite hitting referral criteria or criteria needing surgery that that hopefully will will help just that time.

So yeah, another point after we recorded this episode that you might be also wondering about is the safe use of topical steroids in children of different ages and considerations around the licensing there. So we asked her about this afterwards.

Simone's really helpfully sent us a nice link that you can use that we'll add to the episode description and it talks about how memetazone's licensed from three years of age and above and avamist slash fruticazone is licensed from the age of six years and upwards you can check out the link about the safe use of them there

So she also mentioned that if long term treatment with nasal steroids is required for symptom control, and by long term, she's meaning six months and above, she'd recommend referral to ear, nose and throat or paediatric allergy services, depending on which.

which you think might be more appropriate. We also wanted to check about, we didn't get... hugely into the area of allergy because it's a huge topic we did talk about it can be quite useful to check about allergy but a diagnosis of allergic rhinitis is primarily a clinical one Allergy testing can provide the required evidence to support the diagnosis and therefore manage patients' and parents' expectations of treatment, but it's primarily clinical, so we'll leave it there for this episode.

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