More than a common cold: causes of nasal obstruction in children

Many children will have nasal blockage and chronic cough and have tried medication but have never seen an ENT surgeon or similar who can examine their nose and determine the problem.

Leading London ENT surgeon Mr Annakan Navaratnam is one of the few surgeons nationally with a dedicated tertiary paediatric rhinology practice, running a specialist clinic at Great Ormond Street Hospital dedicated to seeing children with problems related to their nose.

Nasal obstruction in children is usually caused by one of three things, with a fourth cause becoming more prevalent.

1 Allergies

Allergies are very common, whether to dust, pets, or pollen. Allergic rhinitis can cause nasal blockage, chronic cough, and stomach issues because mucus from the nose drips down. A child will often be seen by a paediatrician, and the problem may be put down to an issue with their throat or even the stomach. So, first of all, we can do allergy tests, whether skin or blood and then we may advise using nasal steroids.

Often, patients and their parents are concerned about using nasal steroids, but they have a low systematic absorption rate – about 0.1% compared to inhaler steroids, which is about 20 to 30%. So, they are very safe to use long-term and show a significant benefit in improving symptoms. Once you treat the nose, you often find that in children with asthma, their chest gets better.

2 Adenoids

In children, adenoids are a continuation of the tonsils and sit at the back of the nose and another cause of nasal obstruction in children. Most adenoids will reduce in size as the child gets older, but also, as their face and nose enlarge, the relative size of the adenoids will decrease.

However, that only happens at about seven or eight and onwards, and the child may well struggle significantly as a young child with nasal blockage, difficulty with sleeping at nighttime, and even sleep apnoea.

You can do X-rays to diagnose this, but I use a very thin nasal endoscope to examine the back of the nose in a controlled setting. I can do this successfully for most age groups; if the child is very distressed, we stop, but in most cases, you can get the diagnosis then and there.

We can then counsel the parents about the treatment options. Firstly, the child will often grow out of it eventually – only children from certain ethnic groups, such as African and Afro-Caribbean, have persistent adenoids – and we can try nasal washes, which we use to treat allergies to improve the symptoms. The other option is adenoidectomy surgery, which is a straightforward, relatively safe operation that can significantly improve symptoms. It is often worth intervening, even if only necessary for a relatively limited amount of time.

3 Deviated septum

The timing of deviated septum surgery in children is a critical factor. Mid-facial growth in children finishes at about 15 or 16. So, if you intervene before then, certain growth plates on the septum can be disrupted, and you alter growth patterns.

It is also true that a minor nasal injury in a child can lead to the nose growing misaligned, requiring more extensive correction as an adult if you don’t intervene surgically earlier on.

My approach to septal surgery is also different in children than in adults. I preserve as many structures as possible and counsel patients that they may need revision surgery at some point in the future.

4 Sinusitis

This next group of paediatric patients often get overlooked, as sinusitis is rare in children.

Typically, sinusitis is caused by a change in the immune system. This means that you overreact to things in the air, and bacteria can then colonise or sit in your sinuses. This usually happens after prolonged exposure and multiple viral infections; we tend to see that in patients in their 30s.

Patients who have asthma or allergic rhinitis can suffer from a type of sinusitis known as central compartment atopic disease (CCAD), which is an exacerbation of their allergies, and we can see that in a younger age group.

However, because allergies have become more common over the last ten or twenty years, we see more significant disease presentations in teenagers and even younger. These patients may have been prescribed antihistamines, steroids, or even things like house dust mite desensitisation, a type of immunotherapy, but no one’s ever looked inside their nose or done a CT scan of the sinuses.

When I’ve examined these patients, though, I’ve seen evidence of significant sinus disease that could benefit from sinus surgery. The idea of paediatric sinus surgery sounds scary, but in my experience, children heal very well because their tissues have plasticity, and they usually have excellent healing properties as they grow. So, the outcomes are excellent in children.

I am comfortable performing sinus surgery on younger children, as my emergency work informs and supports my elective work. Another small subset of paediatric patients is those who experience infections around the eye or just in front of the brain as a complication of sinusitis. I regularly operate on those as emergency cases.

Treating nasal obstruction in children

It’s always a careful, shared decision between the parents, the child and myself about how and when we intervene: whether a more limited intervention now is appropriate with a more significant operation performed when mid-facial growth is completed. If the child is older, I always try and involve them in the decision as well.

For more advice on treating nasal obstruction in children, call +44 (0)203 627 2918 to arrange a consultation.