Discussion

Neonatal nasal obstruction presents with respiratory distress, feeding difficulties and sleep apnoea, and is associated with a failure to thrive^{Reference Kwok, Leong and Koltai1} as neonates are obligate nasal breathers for the first six months of life. Fifty per cent of neonates with nasal obstruction experience oxygen desaturation that may lead to respiratory distress, poor feeding and failure to thrive.^{Reference Miller, Martin, Carlo, Fouke, Strohl and Fanaroff3} The most common cause of congenital nasal obstruction is choanal atresia.

Congenital inferior turbinate hypertrophy as the cause of nasal obstruction in children has been scarcely reported.^{Reference Kwok, Leong and Koltai1} Interestingly, the clinical presentation of congenital inferior turbinate hypertrophy is similar to that for other congenital nasal anomalies, ranging from harmless nasal rhinorrhoea, stertorous breathing and feeding difficulties to more severe cyanosis and apnoea symptoms. In light of the similar clinical presentation and close anatomical relation with other congenital nasal anomalies, initial misdiagnosis may occur,^{Reference Wan Mansor, Ahmad and Kulasegarah4} and congenital inferior turbinate hypertrophy may be overlooked and under-reported. It is also salutary to note that, as in adults, inferior turbinate hypertrophy in children can be either mucosal or bony, or even both.^{Reference Adil, Huntley, Choudhary and Carr5}

In neonates, congenital inferior turbinate hypertrophy is attributed to mucosal irritation associated with meconium rhinitis or gastroesophageal reflux.^{Reference Kwok, Leong and Koltai1} Hence, evaluation in neonates should include a complete history, including familial genetic disorders and antenatal history, and birth history of any prematurity, length of labour, presentation, meconium aspiration or trauma during delivery, which might indicate a potential cause of obstruction.^{Reference Patel and Carr6}

A thorough physical examination should be conducted to rule out other congenital nasal anomalies. Signs of tachypnoea, nasal flaring, cyclical cyanosis, sternal retraction and episodic apnoea are consistent with nasal obstruction.^{Reference Patel and Carr6} Failure to pass a soft transnasal catheter size 6 Fr is traditionally considered diagnostic for congenital choanal atresia.^{Reference Abdullah, Hassan and Salim7} Obstruction caused by congenital inferior turbinate hypertrophy or nasal mass may also exert the same findings;^{Reference Abdullah, Hassan and Salim7} however, in the former, the catheter cannot be passed beyond the nostril. Other simple bedside examinations, such as the absence of misting on a metal spatula or of cotton wool movement in front of the nostril, could indicate the presence or absence of nasal airflow,^{Reference Abdullah, Hassan and Salim7} and these tests should be conducted to support the diagnosis. The current investigation of choice is a combination of fibre-optic nasal endoscopy and CT,^{Reference Abdullah, Hassan and Salim7} which were carried out on both of our patients.

Computed tomography enables optimal mucosal and bony delineation,^{Reference Patel and Carr6} it demonstrates site and thickness of obstruction, and it excludes other differential diagnoses of congenital nasal anomalies,^{Reference Abdullah, Hassan and Salim7} which make it the ideal investigation of congenital nasal anomalies. In the same vein, the plane of CT also plays a role; we found that the coronal view of CT showed a more definite view of inferior turbinate hypertrophy as compared to the axial view (Figure 5).

Fig. 5. Coronal computed tomography scan showing inferior turbinate hypertrophy causing narrowing of the nasal cavity bilaterally.

Congenital inferior turbinate hypertrophy, if not obstructing the entire nasal passage, can be managed conservatively (i.e. suctioning, humidification) and using medical therapies (i.e. intranasal steroids with the addition of decongestants in older children). If extra-oesophageal reflux is the suspected culprit of congenital inferior turbinate hypertrophy, anti-reflux medications can be prescribed.^{Reference Kwok, Leong and Koltai1} The presence of cough, frequent spitting and back-arching are tell-tale signs of reflux in children.

Surgical intervention is usually reserved for when conservative treatment fails, or if the child presents with respiratory distress, as in our patients. The main aim of surgical therapy is to maximise nasal airflow while preserving physiological mucociliary clearance.^{Reference Kwok, Leong and Koltai1} Myriad surgical techniques have been proposed, including radiofrequency ablation and microdebrider use,^{Reference Arganbright, Jensen, Mattingly, Gao and Chan8} although no consensus has been established regarding the ideal method.

Complete resection of the inferior turbinate (turbinectomy) is rarely advocated, as it is reported to be associated with a high incidence of atrophic rhinitis, causing crusting, nasal dryness and malodorous secretions,^{Reference Hol and Huizing9} which could be devastating in the long-term. Chen et al. concluded that the microdebrider technique was superior to radiofrequency ablation, as it is shown to preserve mucosa while increasing nasal flow.^{Reference Chen, Liu and Huang10} However, Arganbright et al. reported no differences between the two surgical techniques in terms of patient satisfaction, improvement of nasal patency and recurrence.^{Reference Arganbright, Jensen, Mattingly, Gao and Chan8}

In our cases, one child underwent microdebrider-assisted turbinoplasty, followed by nasal dilatation and stenting, while the other child only had nasal dilatation and stenting. As for the two other published articles, one paper reported performing an endoscopic microdebrider-assisted turbinoplasty, while another article recommended nasal dilatation and stent insertion along with posterior septoplasty (Table 1). We recommend that the surgical approach should be decided based on the examination performed under general anaesthesia. The initial assessment should be carried out without topical anaesthesia, intranasal packing or pledget placement into the nasal cavity, followed by packing with nasal decongestant (adrenaline). If the nasal cavity appears to be roomy after decongestants, mucosal predominance is suggested, while the absence of changes suggests bony predominance and indicates that a relatively ‘aggressive’ procedure such as microdebrider-assisted turbinoplasty ought to be performed.

Table 1. Summary of surgical techniques for congenital inferior turbinate hypertrophy

Our experience treating congenital inferior turbinate hypertrophy with partial endoscopic inferior turbinoplasty with a microdebrider, coupled with nasal stenting, has shown promising results. Controversy regarding the optimal type of surgery for paediatric congenital inferior turbinate hypertrophy persists, with few publications and studies pertaining to congenital inferior turbinate hypertrophy. Hence, further prospective evidence-based studies need to be conducted to support current practices.