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M. Gümüşsoy and İ. Çukurova
22.9 Systemic Causes
22.9.1 Cystic Fibrosis
It is the most common autosomal recessive genetic disease in Caucasians. Water
and salt transport in the cell membrane is disrupted, and there is a change in the
composition of the uid secreted from the respiratory tract, pancreas, gastrointestinal tract, sweat glands, and other exocrine tissues. Because cystic brosis is a disease that affects more than one system, it manifests itself with very different clinical
signs and symptoms. Recurrent lung infections during childhood and adolescence,
purulent sputum production, nasal congestion, nasal polyposis, chronic and persistent rhinosinusitis, asthma, clubbing of ngers, hemoptysis, biliary cirrhosis, meconium ileus, diabetes mellitus, delayed puberty, and infertility are among the ndings
suggestive of cystic brosis. In addition to these clinical ndings, measuring 100mg
of sweat chloride concentration above 60mEq/L in three separate periods conrms
the diagnosis. Its treatment can be achieved with a multidisciplinary approach.
Medical treatment (corticosteroids) and surgical treatment may be required in
patients with polyps in the nasal cavity. The monitoring and treatment team should
include a pulmonologist, gastroenterologist, metabolism and nutrition specialist,
dietitian, physiotherapist, and microbiologist. Depending on the complications that
arise, assistance from other branches is provided, thus prolonging the patients’ quality and duration of life [59–61].
22.9.2 Primary Ciliary Dyskinesia
It is characterized by chronic sinopulmonary infections starting from the neonatal
period due to disorders in the structure and functions of cilia. It is characterized by
ciliary immotility and ciliary dyskinesia. It is an autosomal recessive disease. There
is a congenital disability in the structure and function of motile cilia. An increased
incidence of infertility and situs in versus characterizes impairment in mucociliary
ltration. Increased mucus and bacterial load in the airways is typical. While the
diagnosis of cystic brosis can often be made at the age of one, in primary ciliary
dyskinesia, if there is cardiac pathology, it may be delayed until the age of four or
six if there is no [62].
For a denitive diagnosis, the nasal biopsy sample should be evaluated by
video microscopy for cilia function and by electron microscopy for ultrastructural cilia defect. The diagnosis must be conrmed by genetic evaluation. It is
essential to have a history of recurrent respiratory tract infections, sinusitis and
otitis attacks, cardiac pathology with bronchiectasis, or a history of a relative
diagnosed with primary ciliary dyskinesia. In cases where nasal polyps are seen
together with chronic rhinosinusitis in children, the most common differential
diagnosis is cystic brosis and rarely direct rhinosinusitis. Ciliary dyskinesia
should be considered [63].
ab
22 Nasal Congestion inChildren
305
22.10 Trauma/Iatrogenic Causes
22.10.1 Nasal Trauma-Septal Hematoma
Septal deformity in children is often seen after trauma and can occur anytime. The
nose and mandible are the facial bones most frequently traumatized. During newborns and childhood, fractures are not seen as often as in older children since most
of the nasal skeleton has not developed and is cartilaginous. Therefore, nasal fractures are very rare in children under ve. Instead of fractures in the nasal bones,
septal hematoma, abscess, or septum deviation are more common. Septal hematoma
can be dened as bleeding between the mucoperichondrium, which vascularly supplies the septum cartilage, and the septal cartilage, and the separation of the mucoperichondrium from the septum. This condition blocks blood ow to the nasal
septum and causes avascular cartilage necrosis. The collected blood and necrotic
tissue become an excellent focus for infection of the nasal mucosa, and an abscess
forms. Septal hematoma clinic manifests itself with nasal obstruction, and if not
intervened, septal necrosis occurs, resulting in septal perforation and irreversible
nasal deformities (Fig.22.5). Therefore, septal hematoma is a critical ENT emergency requiring early childhood diagnosis and treatment [64].
Examination of children after nasal trauma is more complex than for adults.
Nasal palpation, deformity, and crepitation are problematic in pediatric patients.
Endoscopic nasal examination is the gold standard. As an imaging modality, CT is
the gold standard for imaging craniofacial and nasal fractures. Plain radiographs do
not help diagnose nasal fractures in children. Signs and symptoms of septal hematoma after nasal trauma may develop within 24–72h after the injury.
Fig. 22.5 (a) Septal hematoma anterior rhinoscopy nasal examination image, black star septal
hematoma. (b) White arrow, septal hematoma image on paranasal coronal CT
306
M. Gümüşsoy and İ. Çukurova
For this reason, if nasal congestion occurs after nasal trauma, it should be shared
with the children’s families that it may be caused by septal hematoma. Septal hematoma and abscess treatment is performed under general anesthesia with incision,
drainage, and tampons placed in the nose. Antibiotics and nasal care should be recommended to patients. The nasal tampon is usually left on for 2–3days. It may be
difcult for children to tolerate tampons [65].
22.10.2 Septum Deviation
While some authors mention that birth trauma is an essential factor in forming septum deviation in children, it has been reported that it can occur without birth trauma.
As a result, septal deviation can cause nasal congestion in children and adults,
whether congenital or acquired. The diagnosis of septum deviation can be easily
made by endoscopic nasal examination. Its treatment is surgery, and its clinical
indications must be based on solid foundations. These relate to the severity of the
child’s nasal congestion, such as sleeping with an open mouth, sleep-disordered
breathing, and craniofacial anomalies. Septoplasty is possible at any age but rarely
performed before age seven. The reason is that septoplasty may negatively affect the
development of the nose and face. This view stems from the fact that, anatomically,
the story of the septal cartilage continues until the age of ve to six, and the vomer
and perpendicular lamina continue until adolescence. On the other hand, waiting
instead of surgically correcting a septum deviation that causes nasal congestion in a
pediatric patient may be more harmful, considering the complications that may
occur. Radiologically, paranasal CT is necessary for planning surgery [66, 67].
Surgically, to avoid disrupting the development of the nose and face, rearranging
the septum with minimal resection of the cartilage part blocking the passage is a
correct approach. In children, active growth foci should not be touched, and the
bony septum should not be removed to avoid changes in facial development [68].
22.10.3 Nasal Foreign Bodies
Nasal foreign bodies are frequently encountered in children under the age of ve.
The most important reason is that children in this age group put objects in their
hands into their noses while crawling or playing on the ground. We can divide foreign objects into two parts: living and non-living. Inanimate objects such as grains,
beads, or buttons are more commonly seen in children. They often fall on the kitchen
oor during cooking or are found by children at home [69].
When organic foreign bodies (chickpeas, beans, peas, etc.) come into contact
with the nasal mucosa, they swell and become difcult to remove as they remain in
the nose. Organic foreign bodies tend to swell and are generally more symptomatic
than inorganic ones. For this reason, one should not wait for the removal of such
foreign bodies and should be removed as soon as possible. Button batteries are
attractive to children because of their small size and bright appearance; they are
22 Nasal Congestion inChildren
307
often inserted into the nose, ear, or mouth. Early diagnosis and urgent removal are
essential. Any delay may lead to necrosis of the nasal mucosa and septal perforation [70].
The most critical complaints of patients with foreign bodies in the nose are nasal
congestion and foul-smelling nasal discharge. It may also cause symptoms such as
nosebleeds, facial pain, nasal regurgitation, facial swelling, nasal crusting, and
cough. Objects can be located in any nasal cavity region, inferior to the inferior
turbinate or anterior to the middle turbinate. Sometimes, the foreign body is not visible on nasal examination. When in doubt, the ideal method is rigid or exible nasal
endoscopy (Fig.22.6). Edema, inammation, or bleeding around the foreign body
may prevent the foreign body from being seen. Foreign body and unilateral choanal
atresia, nasal tumor, nasal polyp, septal abscess, and septal hematoma should be
considered in the differential diagnosis in pediatric patients presenting with unilateral nasal obstruction or foul-smelling, purulent nasal discharge. In diagnosing
nasal and paranasal sinus foreign bodies, the most important diagnostic methods
besides examination are plain radiographs, CT, and MRI [71].
In immobile patients with full cooperation, foreign bodies can usually be
removed using appropriate tools without leaking into the nasopharynx, esophagus,
or trachea. Organic foreign objects that do not have corners are round (balls, beads,
etc.) or may break apart when held. They should be removed by going behind the
thing and pulling it forward with a curved tool such as an Itard probe or an angled
hook. No attempt should be made to grasp or remove round foreign objects from the
front with a bayonet or forceps. Meanwhile, the foreign body may return to the
a b
a
b
Fig. 22.6 (a) The foreign body is in front of the middle turbinate during an endoscopic examina-
tion of the left side of the nose. (b) The foreign body (plastic toy part) was removed from the nose
308
M. Gümüşsoy and İ. Çukurova
nasopharynx, trachea, or esophagus. Suppose the foreign body is angular and prominent. In that case, it can be removed by grasping it with special tools such as bayonet Hartman forceps, and if it is angular and small, alligator forceps. In cases where
the nasal foreign body cannot be seen or retained, a balloon catheter can be applied
[69–71].
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22 Nasal Congestion inChildren
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311
Nasal Itching andSneezing inChildren
23
NurullahTüre andFatihOğhan
23.1 Introduction
Nasal itching and sneezing occur after neural activation stimulation by environmental irritants and biological agents released during the local inammation process. In
particular, sneezing protects the body by playing an essential role in protecting and
clearing the airway from irritating substances. A runny nose, nasal itching, and
nasal congestion often accompany sneezing. This condition is generally observed
due to rhinitis seen in allergies and viral upper respiratory tract infections.
Rhinitis is inammation of the nasal mucosa. In rhinitis, nasal itching, sneezing,
runny nose, and nasal congestion are observed. Along with rhinitis symptoms,
accompanying complaints in the eyes, ears, and throat may be observed. Rhinitis is
generally classied as allergic and non-allergic rhinitis [1, 2].
Regarding complaints, there is no signicant difference between allergic and
non-allergic rhinitis. For this reason, most pediatric patients presenting with rhinitis
complaints are diagnosed with allergic rhinitis. Treatment management is carried
out according to this diagnosis. Sometimes, differential diagnosis can be difcult in
pediatric patients due to overlapping conditions. It is difcult to determine its incidence epidemiologically due to the need for more data on the prevalence of nasal
itching and sneezing in allergic and non-allergic rhinitis in pediatric patients.
This chapter explains the pathophysiology and etiology of nasal itching and
sneezing in children, the differential diagnosis of co-occurring diseases, and appropriate treatment options.
N. Türe · F. Oğhan (*)
Kütahya Health Sciences University, Evliya Çelebi Training and Research Hospital,
Izmir, Turkey
e-mail: fatih.oghan@ksbu.edu.tr
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
H. Yüksel et al. (eds.), Pediatric Airway Diseases, Comprehensive ENT,
https://doi.org/10.1007/978-3-031-74853-0_23
313
314
N. Türe and F. Oğhan
23.2 Pathophysiology
Itching is a nociceptive primitive defense mechanism that stimulates avoidance of
inhaling harmful substances involving innate and adaptive immune mechanisms
[3]. On the other hand, sneezing is caused by neural activation triggered by external
environmental stimuli (irritants) or biological products formed in a local inammatory process. Sneezing is a central reex whose afferent arm begins in the nasal
mucosa and whose efferent arm includes the nerves innervating the diaphragm,
accessory respiratory muscles, and larynx. Sensory nerves in the nasal mucosa originate from the ophthalmic and maxillary branches of the trigeminal nerve [4].
Terminal sensory nerve endings are mostly unmyelinated nociceptor C bers.
Sometimes Aδ bers (Aβ bers) are also included [5, 6]. Nociceptor nerves respond
to noxious external and internal stimuli through a series of receptors, such as transient receptor potential vanilloid type 1 (TRPV1) and transient receptor potential
ankyrin type 1 (TRPA1) [7].
Nasal nerve endings contain receptors for chemicals such as the Histamine 1
(H1) receptor or the cysteinyl leukotriene 1 receptor (CysLTR1) [8, 9].
While H1 receptors in nasal sensory nerve endings explain the sneezing that
occurs during exposure to allergens, transient receptor channels explain the
sneezing and itching that occur when exposed to non-antigenic irritating substances [10].
Many pruritogens and receptors mediate itching, which occurs due to allergic
rhinitis. After stimulation of nerve bers in the nasal mucosa and activation of mast
cells, histamine is released, which causes nasal itching [11]. Histamine increased in
the nasal lavage uid of allergic patients, but no increase was observed in nonallergic patients [12]. Neuropeptides such as substance P, CGRP, and vasoactive
intestinal polypeptide (VIP) have been reported to be increased in the nasal lavage
wash of patients with allergic rhinitis, which are thought to play a role in nasal itching. Furthermore, nerve growth factor (NGF) is expressed in the nasal epithelium
and peripheral nerves in the nasal mucosa, and the expression of this neuropeptide
is signicantly increased after nasal allergen challenge in patients with allergic rhinitis compared to controls [13, 14]. House dust mites are affected by proteaseactivated receptor 2 (PAR2).
It has been shown to induce the release of inammatory cytokines and ultimately
cause nasal itching [15]. Additionally, it has been reported that nasal itching
increases when a TRPV1 activator such as capsaicin is administered to patients with
allergic rhinitis during seasonal allergen exposure [16]. Nerve expression of TRPV1
is also increased in patients with non-allergic rhinitis [17]. This phenomenon suggests inammatory cytokines such as histamine and bradykinin cause nasal itching
through TRPV1 receptors [18].
Physicians should know its close relationship with other allergic diseases, such
as allergic conjunctivitis and asthma. Interestingly, pruritus has been reported as a
preliminary symptom in patients with asthma [19]. Additionally, in a study investigating non-respiratory symptoms of acute asthma, nasal itching was observed
before the asthma attack [20].