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PEDIATRICS Vol. 109 No. 5 May 2002, pp. 989-990

Absent Nasal Flaring in a Newborn With Bilateral Choanal Stenosis

To the Editor—

Nasal flaring is one of the manifestations of respiratory distress in neonates. ¹ Nasal flaring reduces nasal and total airway resistance, improving ventilation in neonates with respiratory distress. ^2,3

Bilateral choanal atresia/stenosis is a life-threatening cause of respiratory distress in neonates. The diagnosis is often delayed, resulting from lack of any specific clinical finding suggestive of the diagnosis.

CASE REPORT

Significant respiratory distress characterized by intense subcostal, intercostal, and suprasternal retractions was noticed in a newborn soon after birth. However, clinically evident nasal flaring was conspicuously absent, leading to the diagnosis of bilateral choanal atresia. The diagnosis was confirmed by failure of the passage of nasogastric tube. Congenital choanal atresia/stenosis occurs in 1/8000 live births with female preponderance. There is a failure of the perforation of mesenchymal plate, leading to complete or incomplete obliteration of posterior nasal apertures. ^4,5

Bilateral choanal atresia/stenosis is a life-threatening respiratory emergency in newborns. Significant respiratory distress with retractions, decreased ventilation over both lung fields, and episodic cyanosis relieved while crying suggest the diagnosis. ⁵ Because there is no specific clinical finding for this diagnosis, there is a potential for delay in making the diagnosis.

Phylogenetically, neonates are preferential nasal breathers like lower mammals. Because of the high placement of the epiglottis and larynx, the tongue is forced against the soft palate by negative pressure in the pharynx, leading to obstructive apnea in neonates with bilateral choanal atresia/stenosis. ⁶

Factors controlling the activation of upper airway muscles in a neonate with respiratory distress are varied and uncertain. Hypercapnea and hypoxia are considered systemic mechanisms, and inspiratory negative pressure or resistive loading is the local mechanism working by stimulating mechanoreceptors and other receptors in the nasal cavity and upper airway. ^7,8

An extensive literature search revealed no report of absent nasal flaring in neonates with respiratory distress attributable to bilateral choanal atresia/stenosis. It is proposed for the first time that absent nasal flaring in a neonate with bilateral choanal atresia/stenosis in the presence of significant respiratory distress characterized by intense diaphragmatic, external intercostal, suprasternal, and genioglossus activity is a specific clinical diagnostic sign. I further speculate this to be true with any pathology leading to complete nasal obstruction in neonatal life.

It is likely that hypoxia and hypercarbia are not significant controlling factors in neonates with bilateral choanal atresia/stenosis, and the sole stimulus for the nasal flaring in these neonates seems to be inspiratory negative pressure or resistive loading. With no inspiration and no airflow, there is no negative pressure and hence no nasal flaring (J. E. Hall, e-mail communication, June 2001). No comments can be made about electromyelogram activities in alae nasi. Normal architecture of the nose speaks against aplasia and lack of innervation of the alae nasi. ⁹

Amar Dave, MD, FAAP
Pediatrics Center
Ottawa, IL 61350, USA

REFERENCES

1. Silverman WA, Anderson DH. A controlled trial of mist on obstructive respiratory signs, death rate and necropsy findings among premature infants. Pediatrics.1956; 17 :1 –10[Abstract/Free Full Text]
2. Carlo WA, Marlin RJ, Bruce EN, Strohl KP, Fanaroff AA. Pediatric Alae nasi activation (nasal flaring) decreases nasal resistance in preterm infants. Pediatrics.1983; 72 :338 –343[Abstract/Free Full Text]
3. Strohl KP, O’Cain CF, Slutsky AS. Alae nasi activation and nasal resistance in healthy subjects. J Appl Physiol.1982; 52 :1432 –1437[Abstract/Free Full Text]
4. Sadek SA. Congenital bilateral choanal atresia. Int J Pediatr Otorhinolaryngol.1998; 42 :247 –256[CrossRef][Medline]
5. Bluestone CD, Stool SE, Kenna ME. Pediatric Otolaryngology. 3rd ed. Philadelphia, PA: WB Saunders,1995 :841 –842
6. Polgar B, Kong GP. The nasal resistance of newborn infants. J Pediatr.1965; 4 :558 –567
7. Mezzanotte WS, Tangel DJ, White DP. Mechanisms of control of alae nasi muscle activity. J Appl Physiol.1992; 72 :925 –933[Abstract/Free Full Text]
8. Tsubone H. Nasal "pressure" receptors. Jpn J Vet Sci.1990; 52 :225 –232
9. David GS, Clark B. Fronto-facio-nasal dysplasia [review]. Clin Dysmorphol.1997; 7 :245 –249

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PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Dave, A. Search for Related Content PubMed PubMed Citation Articles by Dave, A. Social Bookmarking                         What's this?