CHOANAL ATRESIA

DEFINITION
Choanal Atresia is a congenital anomaly of the anterior skull base characterized by closure of one or both posterior nasal cavities (the back of the nasal passage called choana is blocked by abnormal bony or soft tissue formed during fetal development).

INCIDENCE
The condition is the most common nasal abnormality in newborn infants, affecting about 1 in 7,000 live births. Females get this condition about twice as often as males. More than half of affected infants also have other congenital problems.

CAUSES
The cause of choanal atresia is unknown. It is thought to occur when the thin tissue separating the nose and mouth area during fetal development remains after birth. Embryogenesis
The nasal cavities extend posteriorly during development under the influence of theposteriorly directed fusion of the palatal processes. Thinning of the membrane occurs, which separates the nasal cavities from the oral cavity. By the 38th day of development, the 2-layer membrane consisting of nasal and oral epithelia ruptures and forms the choanae (posterior nares). Failure of this rupture results in choanal atresia.

PRESENTATION
It can be unilateral or bilateral. i.e. Choanal atresia may affect one or both sides of the nasal airway
y

Unilateral Choanal Atresia: More than half of infants have a blockage on only one side, which causes less severe problems and is not detected until much later in life because the baby manages to get along with only one nostril available for breathing. Bilateral Choanal Atresia is a very serious life-threatening condition because the baby will then be unable to breathe directly after birth as babies are obligate nasal breathers (they must use their noses to breathe)

ASSOCIATED CONDITIONS

Sometimes babies born with choanal atresia also have other abnormalities:
y y y y y

coloboma heart defects mental retardation growth impairment others e.g CHARGE syndrome

Also any condition that causes significant depression of the nasal bridge or midface retraction can be associated with choanal atresia. Examples include the craniosynostosis syndromes such as Crouzon syndrome, Pfeiffer syndrome, and Antley-Bixler syndrome.

SIGNS AND SYMPTOMS

Symptoms Babies with choanal atresia have difficulty breathing unless they are crying. Choanal atresia blocking both sides (bilateral) of the nose causes acute breathing problems with cyanosis and breathing failure. Bilateral Choanal Atresia may present as cyanosis while the baby is feeding, because the oral air passages
are blocked by the tongue, further restricting the airway. The cyanosis may improve when the baby cries, as the oral airway is used at this time.

Symptoms include:
y y y y

Chest retracts unless the child is breathing through mouth or crying Difficulty breathing following birth, which may result in cyanosis (bluish discoloration), unless infant is crying. Inability to pass a catheter through each side of the nose into the throat Persistent one-sided nasal blockage or discharge

Signs
Choanal atresia can be presented as
y

impossible to insert a nasal catheter. if there is a continuous stream of mucous draining from one or both nostrils

DIAGNOSIS
y

Signs and symptoms

Diagnosis is confirmed by radiological imaging, usually CT scan.

Tests include:
y y y

CT scan Endoscopy of the nose Sinus x-ray

TREATMENT
Emergency intervention is necessary at birth to ensure the infant's survival. Surgery within the first month is frequently necessary to perforate the blocked nasal passages. After these interventions, the infant requires continued care within the home.

EMERGENCY INTERVENTION : Infants with bilateral choanal atresia may need resuscitation at delivery. The immediate concern is to resuscitate the baby if necessary.
Temporary alleviation can be achieved by inserting an ORAL AIRWAY into the mouth. In some cases,

intubation or tracheostomy may be needed. SURGERY ( is the only definitive treatment) to remove the obstruction cures the problem. Surgery may be delayed if the infant can tolerate mouth breathing. The surgery may be done through the nose (transnasal) or through the mouth (transpalatal). Surgery corrects the defect by perforating the atresia to create a nasopharyngeal airway.If a membranous obstruction is present , it can be pierced by the use of nasoscope. If the blockage is caused by bone, this is drilled through and stent inserted. A stent may be inserted to keep the newly formed airway patent or repeated dilatation may be performed.

NURSING MANAGEMENT
Keep the nostrils clean Prevent upper rewspiratory infections Gavage feeding for infants with bilateral choanal atresia until defect is corrected. Follow precautions and techniques of feeding for unilateral atresia as there arises trouble with breathing and sucking at the same time and from the danger of aspiration: feed the infant slowly with frequent pauses to permit breathing.  Watch for any problems with difficulty in swallowing after sucking, if so remove the nipple at once.  Ensure the the size of the nipple hole should be carefully chosen to provide the rate of flow that the infant finds easier to handle  Keep the infants in an upright position when they are fed and that the bottle is supported in proper angle.    

PROGNOSIS
Full recovery is expected.

COMPLICATIONS
Possible complications include:
y y y y

Aspiration while feeding and attempting to breathe through the mouth Respiratory arrest Re narrowing of the area after surgery
Brain damage and death due to hypoxia.

PREVENTION
There is no known prevention.

BIBLIOGRAPHY
      Marlow D R, Redding B.A.Textbook of paediatric nursing,6th edition: Noida,2008 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002608/ http://en.wikipedia.org/wiki/Choanal_atresia http://emedicine.medscape.com/article/872409-overview#showall http://www.atresia.info/choanal-atresia.htm http://ministryhealth.adam.com/content.aspx?productId=117&pid=1&gid=001642

EPISTAXIS
DEFINITION
Epistaxis is bleeding from the nose

CAUSES
 LOCAL 1. Congenital

y Osler-Weber-Rendu Disease (Hereditary Hemorrhagic Telangiectasia) 2. Traumatic a) Breach in mucosal continuity y Fractures of nose y Operations e.g. submucosal resection (SMR), polypectomy etc y Nose picking b) Baro trauma y Nose blowing y High altitude 3. Inflammatory a) Acute y Non specific rhinitis e.g coryza y Specific rhinitis e.g diphtheria, adenoiditis, sinusitis etc. b) Chronic y Non specific rhinitis e.g atrophic rhinitis y Specific rhinitis e.g scleroma, rhinosporidiosis, chronic sinusitisa etc. y Midline nasal granuloma 4. Neoplastic a) Benign y Angiomatous polyp y Papilloma y Nasopharyngeal angiofibroma b) Malignant y Carcinoma y Sarcoma of the sinuses/ naso pharynx 5. Miscellaneous a) Foreign body b) Rhinolith c) Nasal parasites

 SYSTEMIC 1. Cardiovascular system y Rheumatic heart disease y Pulmonary hypertension y Infective endocarditis

2. Blood disorders y Christmas disease y Haemophilia y Purpura y Aplastic anemia 3. Drugs y

Salicylates

Quinine

4. Renal failure 5. Hepatic failure 6. Septicemia

INVESTIGATIONS
1. 2. 3. 4. 5. Vital parameters- for evaluation of shock Haemoglobin- anemia Coagulation tests- bleeding disorders Radiology-sinusitis, fractures, tumors Biopsy- malignancy

MANAGEMENT
1. IMMEDIATE a) Pressure By compression of the nose between the thumb and first two fingers. b) Ice cold packs Applied on the bridge of the nose, which may stop the bleeding by reflex vaso constriction c) Trotter s method The patient is made to sit upright and incline forwards with mouth open and pinched (self) nostrils, then asked to breathe out quietly spitting out all the blood from pharynx Assessment of blood loss and checking vital parameters Treatment of shock and hypovolemia Measures to control bleeding: a) Cautery y Chemical y Electrical b) Cryo surgery c) Packing y Anterior nasal packing y Posterior nasal packing d) Foley s cather e) Surgery- ligation of y Anterior ethmoidal artery y Maxillary artery y External carotid artery General measures a) Sedation: this reduces restlessness of the patient and allays anxiety. b) Hematinics and multivitamins to improve the haemoglobin. c) Antibiotics are required along with packing to prevent infections.

2. 3. 4.

5.

NURSING MANAGEMENT
 Reassure the child and family members- make them calm. Reassure that the loss of blood is not serious and that the bleeding usually stops within 10-15 minutes.  Inspect both nares for bleeding, though bleeding may occur just from one nostrils  Ask the child to relate to those activities that occurred before the episode, also question on frequency of epistaxis  Continuous monitoring of vital signs, bleeding , hypoxia, respiratory difficulty and nasal packing.  Detailed family history and history of illness, intake of medications  Perform necessary investigations  Teach parents and family members about measures to stop epistaxis. -first aid measures: digital pressure for 10-15 minutes by pinching the nose to stop bleeding; bending forward in comfortable positions, loosing clothes. -splashing cold water and cold compress over the nose bridge .  Instruct the child and care givers to avoid nose pricking, forceful blowing and sneezing.  The cause for epistaxis, the management needed should be informed and emphasized. Inform the parents on the need for evaluation for the possibility of a bleeding disorder in cases of repeated bleeding episodes lasting longer than 30 minutes

BIBLIOGRAPHY
        

Hockenberry .M.J. Wongs Essentials Of Paediatric Nursing,7th edition:Noida,2007 Marlow D R, Redding B.A.Textbook of Paediatric Nursing,6th edition: Noida,2008 Parthasarathy A.IAP Text Book Of Paediatrics,4th Edition: New Delhi , 2010 Data P. Pediatric Nursing , 2nd edition: New Delhi , 2009 http://en.wikipedia.org/wiki/Epistaxis http://emedicine.medscape.com/article/994459-overview http://www.ncbi.nlm.nih.gov/pubmed/2676467 http://www.emedicinehealth.com/nosebleeds/article_em.htm http://www.uptodate.com/contents/management-of-epistaxis-in-children

ASPIRATION
Foreign bodies may be found in the larynx, trachea, bronchi or lungs. They include non- organic ( buttons, metallic objects) or organic foreign bodies ( eatables, pea nuts etc)

DEFINITION
The passage of a foreign body into the respiratory tract.

CAUSES
  Inhalation of a foreign body Altered level of consciousness y Sedation y Anesthesia

RISK FACTORS

 

y Seizure disorders y Stroke Trachea esophageal fistula Central nervous system (CNS) abnormalities

PATHOPHYSIOLOGY
 Occurs in children with an impaired swallowing mechanism and cough reflex  Common in infants and toddlers because they have narrow airways and high levels of curiosity  Dried bean aspiration poses the greatest danger because beans absorb respiratory moisture and form an obstruction; peanuts cause an immediate emphysema reaction  Most small objects end up in the right bronchus because it is straighter and wider than the left

TYPES AND MANIFESTATIONS

LARYNGEAL FOREIGN BODIES
y Croupy or hoarse cough, y Aphonia, y Haemoptysis, y Dyspnea, y Wheezing and y Cyanosis y Fatal aspiration may occur due to the foreign body or its inflammatory reaction

TRACHEAL FOREIGN BODIES

y Cough y Hoarseness y Dyspnea and cyanosis y Wheeze with audible slab and palpable thud produced due to momentary impaction at the subglottic level are characteristic.

BRONCHIAL FOREIGN BODIES

y Cough, wheeze , blood streaked sputum may occur y With slight obstruction, passage of air in both directions produces only wheezing [bypass valve] y If the obstruction allows air entry without exit, over inflation results y With complete obstruction atelectasis occurs due to absorption of air distal to obstruction y History of choking, gagging paroxysmal coughing, history of eating substances like ground nuts etc is vital in the diagnosis y There may be a latent period of months prior to presentation y On examination tracheal shift, decreased breath sounds on side of the Foreign Body aspiration occurs.

COMPLICATIONS
   Respiratory insufficiency Pneumonitis Death

ASSESSMENT FINDINGS
    Coughing Stridor Wheezing Foreign object in the mouth or throat

DIAGNOSTIC TEST FINDINGS

  Bronchoscopy allows visualisation of the foreign object Neck or chest x ray reveals the location of the object

MEDICAL MANAGEMENT
    Tracheostomy or intubation, if necessary Bronchoscopy to identify and remove the foreign object Abdominal thrust to dislodge the object if its obstructing the airway for a child > 1 yr, while back blows and chest thrusts are required in infants. Antibiotics for any secondary infections

NURSING MANAGEMENT
 Examine the mouth and nose to locate the foreign body  Be aware that the object may be expelled spontaneously  Perform the abdominal thrust if the childs airway is occluded: for infants, back blows and chest thrusts are used to relieve obstruction and to prevent injury to abdominal organs  Ensure * that chest physiotherapy and broncho dialators are not gives as these may lead to disimpaction and movement of the foreign body with obstruction of a more distal airway.  After the removal of the foreign body , the infant or child is placed in an atmosphere of high humidity  Assess for evidence of inability to vocalise cry or speak, cyanosis and collapse: manifestation of airway obstruction /indicate choking  Teach parents and baby sitters how to detect airway obstruction.[ inability to vocalise cry or speak, cyanosis and collapse: manifestation of airway obstruction /indicate choking]  Teach parents emergency management for aspiration: HEIMLICHS TECHNIQUE- This maneuver increases the intra thoracic pressure and is used only for children older than one year of age. Procedure Stand behind the standing child and encircle his torso by putting both arms directly under his axillae. Place the thumb side of one fist against the childs abdomen in midline slightly above the navel and well placed below the xiphoid, with the other hand , grasp this fist and exert quick upward thrusts taking care not to touch the xiphoid process or lower rib margins. Each thrust should be forceful enough and intended to relieve the obstruction BACK SLAP AND CHEST THRUSTS - this method is to expel out the foreign bodies from the airway of an infant. Procedure

Hold the infant face down on your forearm, which are resting on your thighs. Support the head of the child by firmly holding the jaw. Position the infants head lower than the trunk. Deliver upto five blows with the heel of your hand between the shoulder blades of the infant. Then the child is turned around as a unit to a supine position while firmly supporting the head and the neck. Administer upto 5 quick chest thrusts as used for chest compression. The whole process is repated till the foreign body is expelled out.

PREVENTION
 Prevention is of utmost importance with small objects being placed beyond the reach of young children.  Nuts, small toys with lose parts, coins, should never be given to young children

BIBLIOGRAPHY
      

Hockenberry .M.J. Wongs Essentials Of Paediatric Nursing,7th edition:Noida,2007 Marlow D R, Redding B.A.Textbook of Paediatric Nursing,6th edition: Noida,2008 Parthasarathy A.IAP Text Book Of Paediatrics,4th Edition: New Delhi , 2010 Data P. Pediatric Nursing , 2nd edition: New Delhi , 2009 Gupta P. Essential Pediatric Nursing, 1st edition: New Delhi , 2004 http://www.ncbi.nlm.nih.gov/pubmed/16354221 http://www.jpedsurg.org/article/S0022-3468%2803%2900263-X/abstract

CHILD HEALTH NURSING

PRESENTATION ON CHOANAL ATRESIA, ASPIRATION & EPISTAXIS

SUBMITTED TO
Ms. G. LAVIGA Lecturer NUINS

SUBMITTED ON
08 -06-2011

SUBMITTED BY
SUBIN MARIYA JACOB 2
nd

yr MSc(N)

NUINS