Atresia and narrowing of the nasal passages: causes, symptoms, diagnosis, treatment

Atresia and narrowing of the nasal passages can be congenital or acquired. In the latter case, they can be caused by inflammatory-purulent diseases of a nonspecific and specific nature, culminating in a scarring process with the formation of synechia or total scar membranes completely excluding one or both halves of the nose from the respiratory process. These pathological states are divided into anterior anatomical location, related to the nostrils and vestibule of the nose, middle, located in the middle sections of the inner nose, and the rear ones, which are on the level of the khohan.

Anterior atresia and constrictions of the vestibule of the nose. Occlusion of the nostrils can be congenital or acquired. Congenital occlusion is rare and is manifested by the presence of a skin membrane, rarely - connective tissue and extremely rarely - cartilaginous or bone septum. The appearance of this deformity is due to a violation of the resorption of the epithelial tissue, which clogs the nostrils of the fetus, until the sixth month of intrauterine life. Acquired occlusion is observed more often, due to the process of scarring, arising from diseases such as syphilis, lupus, measles, diphtheria, scarlet fever, trauma, frequent repeated cauterizations in this area. Usually, the occlusion of the nostrils is one-sided and rarely bilateral. The obturating diaphragm can be of different thickness and density, solid or perforated, marginal or contain one or two holes.

Treatment is surgical, prolonged and often unsuccessful due to a pronounced tendency to restore occlusion by the growth of scar tissue and contraction of tissues that form nostrils. Often repeated operations lead to even greater deformations of the vestibule of the nose, which often causes conflict between the patient and the doctor.

The main principle of treating atresia of the entrance to the nose is excision of excess tissues and covering the wound surface with a thin skin flap on the feeding stem taken from the nearest area of the face. Fixation of the flap is carried out by hair seams and tampons or an elastic rubber tube, which should not press on the flap, otherwise it will become dead, but only to keep it in contact with the underlying wound surface.

Insufficiency ("weakness") of the wings of the nose. This developmental anomaly is caused by the bilateral atrophy of the muscles of the external nose: the muscle that lifts the upper lip and the wing of the nose, and the nasal muscle itself, consisting of two bundles-the transverse, narrowing nasal apertures, and the wing that pulls the wing of the nose down and expands the nostril. The function of these muscles is that, with increased breathing on inhalation, they widen the entrance to the nose, pushing the wings of the nose apart, while exhaling - they bring them closer. Atrophy of these muscles is also accompanied by cartilage atrophy. With the atrophy of these muscles, atrophy and cartilage of the lateral wall of the nose are exposed, which causes the nose wing to become thin, loses rigidity. These changes lead to a loss of the physiological function of the nostrils, the wings of the nose are converted into passive valves, which are released by inhalation and expand upon exhalation under the influence of an air jet.

According to observations of V. Rakovyan, insufficiency of the wings of the nose develops for a long time (15-20 years) with chronic disturbance of nasal breathing (adenoidism, polyposis of nose, atresia of the khohans, etc.).

Treatment of this anomaly is the application of wedge-shaped incisions on the inner surface of the wings of the nose and the stitching of their edges to give the wings of the nose a certain stiffness or the wearing of tubular prostheses. With appropriate anatomical conditions, implantation of autochondrial plates taken from the nasal septum is possible.

Median atresia and narrowing of the nasal passages. This type of violation of the patency of nasal passages is due to the formation of synechiae (fibrous cords) between the septum of the nose and nasal conchas, more often the lower one. The reason for the formation of synechia can be repeated surgical interventions in the nose, in which the integrity of the mucosa of mutually opposing surfaces is disturbed. Formed on both sides of the granulation, growing and in contact, organized into scar tissue, tightening the lateral and medial surfaces of the nasal passages, narrowing them, until complete obliteration. The cause of synechia can also be injuries of the internal nose, in which timely specialized care was not provided, as well as various infectious common and specific diseases.

Surgical treatment consists of volume resection of synechia and separation of wound surfaces using tampons or special insert plates, for example, a purified X-ray film. With massive adhesions, to achieve a positive result, sometimes not only the synechia is excised, but the shell or shells are also resected, and with the deviation of the septum of the nose toward the excised synechia, cryostotomy or submucosal resection of the septum is performed.

Another form of median narrowing of the nasal passages may be the dysgenesis of certain morphological elements of the internal nose with a change in their shape, localization and volume. Basically, this type of anomaly includes hyperplasia of the nasal concha, affecting both their soft tissues and the bone skeleton. In this case, depending on the type of hyperplasia, a submucosal resection of the nasal concha or its lateral dislocation is produced by violent fracture with the help of a cut nose mirror of Killian. In the latter case, to hold the shell in its given position, a tight tamponade of the nose is made on the side of the operation, which is maintained for up to 5 days.

If it is impossible to displace the lower nasal shell in this way, BV Shevrygin (1983) recommends the following manipulation: with strong forceps grab the nasal cone along the entire length, and break it at the attachment site by lifting it upward (the mechanism of the lever). After that, it is easier to shift to the lateral wall of the nose.

When mediaposition of the middle nasal cavity, covering the olfactory gap and preventing not only the nasal breathing, but also the olfactory function, the lateral position of this shell is produced by the method of BV Shevrygin and MK Manyuk (1981). The essence of this method is as follows: after anesthesia, the Shrikeken scissors cut the nasal conch in the transverse direction at the point of greatest curvature. Then, with the help of Bransham, Killian's mirrors move the curved segment laterally and insert a tightly rolled gauze roll between it and the septum. In the curvature of the anterior part of the shell, the authors recommend that the operation be supplemented with an incision at the attachment site, which will ensure greater mobility.

The causes of the midline disruption of the nasal passages can also be attributed to the dystopia of the individual anatomical formations of the nasal cavity, characterized by the fact that ordinary formations develop in an unusual place in their development. These anomalies include the bullous mid nasal concha (concha bullosa), the dystopia of the septum of the nose and its parts, and others.

The most common anomaly in the development of eidonal structures is the bulla of the middle nasal cavity - one of the cells of the latticed bone. The origin of bulla may be due to the constitutional feature of development of the latticed bone, which can be combined with other anomalies in the development of the facial skeleton, possibly due to chronic long-term etmoiditis leading to an increase in the volume of cells, including cells of the central nasal concha, its excision with the final konkhotom, however, this often leads to the formation of synechia, so a number of authors recommend that this type of dysplasia be performed, or a cutaneous resection of pneumonia and enshrined of the bulls (for small and medium size it), or the so-called bone-plastic operation with large bulls.

The first method consists of a vertical section of the mucosa over the bull, its detachment from the bone part, resection of the bone bladder, laying of the formed mucosal flap on the lateral wall of the nose and fixing it with a tampon.

The second method differs in that it removes not the entire bone marrow, but only the part that is attached to the septum of the nose. The rest is mobilized and used to form a normal middle nasal concha. A flap of the mucous membrane is used to cover the formed shell, otherwise the exposed bone can become covered with a granulation tissue, followed by its scarring and the formation of synechia.

Posterior atresia.

Pathological anatomy. This type of pathological condition is characterized mainly by atresia of the khohan. Which can be complete or partial, bilateral or unilateral, with the presence of several openings in the occlusal tissue, the latter may be fibrous, cartilaginous or bone, and also in combinations of the three types of tissues. The thickness of the diaphragm separating the nasal cavity from the nasopharynx varies from 2 to 12 mm. One-sided occlusion of the choana is more common. The origin of this species is most often congenital and less frequent - the result of any radical surgical interventions in this area with the patient's tendency to excessive formation of scar tissue.

The pathogenesis of congenital atresia of the khohans is still a debatable issue: a number of authors believe that their cause is congenital syphilis, others believe that the atresia of the khohans are embryonic developmental anomalies in which there is no resorption of the buccal nasal membrane from which the soft palate is formed.

Symptoms manifest mainly in violation of nasal breathing, depending on the degree of patency of the khohan. With unilateral atresia, the most frequent, there is obstruction of one half of the nose, with bilateral - complete absence of nasal breathing. A newborn with total atresia, the khoan can not breathe normally, suck and in former times die in the first days after birth. With partial atresia, the child's feeding can be possible, but with great difficulty (choking, coughing, difficulty breathing, stridor, cyanosis). Survival of the child with complete atresia is possible only if it is timely, on the first day after birth, the appropriate surgical intervention to ensure nasal breathing. At partial atresia, the viability of the child depends on the degree of its adaptation to oral breathing. In children and adults, mostly partial overlapping of the khohans is observed to some degree, providing at least a minimal possibility of nasal breathing.

Other symptoms include impaired sense of smell, taste sensitivity, headaches, poor sleep, irritability, fatigue, physical retardation (body weight and height) and intellectual development, craniofacial dysmorphia, etc.

With anterior rhinoscopy, as a rule, the curvature of the septum of the nose on the side of atresia is revealed, the nasal concha atrophic, the cyanotic on the same side, the lumen of the common nasal passage is narrowed towards the choana. In the back of a rhinoscope, there is a lack of lumen of one or both of the khoans because of their smooth fibrous tissue covering.

Diagnosis is established on the basis of subjective and objective data. Additional studies are carried out by probing through the nose with a probe probe, as well as radiography, which allows differentiating fibrous and cartilaginous atresia from bone atresia.

Differential diagnosis is performed with adenoids and nasopharyngeal tumors.

Treatment. In newborns, the recovery of nasal breathing is performed in the order of emergency care immediately after birth. Signs of having atresia of the khoans is the absence of nasal breathing when closing the mouth, cyanosis of the lips and face, severe anxiety, lack of normal postpartum inspiration and screaming. Such a newborn is made a hole in the diaphragm that closes the khans from the side of the nasopharynx, using a probe, trocar or any metal instrument such as a cannula to probe the auditory tube with immediate expansion of the hole made with a curette.

In children, adolescents and adults, surgical intervention is performed routinely, it consists in excision of the fibrous or cartilaginous diaphragm and in preserving the lumen of the choana by placing a probe of the corresponding diameter in it. In bone atresia, surgical intervention is greatly complicated, since before the main stage of the operation, it is necessary to gain access to the bone septum to be resected. For this, a number of preliminary steps are carried out, consisting of removal of the inferior nasal cavity, partial or complete resection of the septum of the nose or its mobilization, and only after that the bone barrier is removed by beating it with a chisel and widening the hole with the aid of bone forceps. Surgeons-rhinologists have developed various approaches to the object of action - endonasal, transseptal, supra-maxillary and extra-ordinary. The completed hole is retained by means of special drains.

[1], [2], [3], [4]