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 non-specific and specific nature, ending in a scarring process with the formation of synechiae or total cicatricial membranes, completely excluding one or both halves of the nose from the respiratory process. According to their anatomical location, these pathological conditions are divided into anterior, related to the nostrils and the vestibule of the nose, median, located in the middle sections of the internal nose, and posterior, located at the level of the choanae.

Anterior atresia and stenosis of the nasal vestibule. Occlusion of the nostrils may be congenital or acquired. Congenital occlusion is rare and is manifested by the presence of a cutaneous membrane, less often - connective tissue and extremely rare - a cartilaginous or bone septum. The occurrence of this deformity is due to a violation of the resorption of epithelial tissue, which clogs the nostrils of the fetus, up to the 6th month of intrauterine life. Acquired occlusion is observed more often, caused by the scarring process that occurs in diseases such as syphilis, lupus, measles, diphtheria, scarlet fever, trauma, frequent repeated cauterization in the specified area. Usually, occlusion of the nostrils is unilateral and rarely bilateral. The obturating diaphragm can be of varying thickness and density, solid or perforated, marginal or contain one or two openings.

Treatment is surgical, lengthy and often unsuccessful due to the pronounced tendency to restore occlusion by proliferation of scar tissue and contraction of the tissues that form the nostrils. Repeated operations often lead to even greater deformations of the nasal vestibule, which often causes conflict between the patient and the doctor.

The main principle of treating atresia of the nasal entrance is excision of excess tissue and covering the wound surface with a thin skin flap on a pedicle taken from the nearest area of the face. The flap is fixed with hair sutures and tampons or an elastic rubber tube, which should not press on the flap, otherwise it will die, but only hold it in contact with the underlying wound surface.

Insufficiency ("weakness") of the nasal wings. This developmental anomaly is caused by bilateral atrophy of the muscles of the external nose: the muscle that raises the upper lip and the wing of the nose, and the nasal muscle itself, consisting of two bundles - transverse, narrowing the nasal openings, and alar, which pulls the wing of the nose downwards and widens the nostril. The function of these muscles is that with increased breathing on inhalation they widen the entrance to the nose, moving the wings of the nose apart, and on exhalation they bring them together. Atrophy of these muscles is also accompanied by cartilage atrophy. With atrophy of these muscles, the cartilages of the lateral wall of the nose are also subject to atrophy, due to which the wing of the nose becomes thin and loses its rigidity. These changes lead to the loss of the physiological function of the nostrils, the wings of the nose turn into passive valves that collapse on inhalation and widen on exhalation under the influence of the air stream.

According to V. Rakovyanu’s observations, insufficiency of the nasal wings develops over a long period of time (15-20 years) with chronic nasal breathing disorders (adenoidism, nasal polyposis, choanal atresia, etc.).

Treatment of this anomaly consists of making wedge-shaped incisions on the inner surface of the nasal wings and suturing their edges to give the nasal wings a certain rigidity or wearing tubular prostheses. Under appropriate anatomical conditions, it is possible to implant autocartilage plates taken from the nasal septum.

Median atresia and stenosis of the nasal passages. This type of obstruction of the nasal passages is caused by the formation of synechiae (fibrous strands) between the nasal septum and the nasal conchae, most often the lower one. The formation of synechiae can be caused by repeated surgical interventions in the nose, in which the integrity of the mucous membrane of the surfaces located opposite each other is violated. Granulations formed on both sides, growing and touching, are organized into scar tissue, tightening the lateral and medial surfaces of the nasal passages, narrowing them, up to complete obliteration. The cause of synechiae can also be injuries to the internal nose, in which timely specialized care was not provided, as well as various infectious banal and specific diseases.

Treatment is surgical, consisting of volumetric resection of adhesions and separation of wound surfaces using tampons or special insert plates, such as cleared X-ray film. In case of massive adhesions, to achieve a positive result, sometimes not only adhesions are excised, but also the concha or conchae are resected, and in case of deviation of the nasal septum towards the excised adhesions, cristotomy or submucosal resection of the nasal septum is performed.

Another form of median stenosis of the nasal passages may be dysgenesis of some morphological elements of the internal nose with changes in their shape, localization and volume. Basically, this type of anomaly includes hyperplasia of the nasal conchae, affecting both their soft tissues and bone skeleton. In this case, depending on the type of hyperplasia, a submucous resection of the nasal conchae or its lateral dislocation is performed by forcibly breaking it with the help of the branches of the nasal mirror of Killian. In the latter case, to hold the conchae in the given position, a tight tamponade of the nose is performed on the side of the operation, which is maintained for up to 5 days.

If it is impossible to displace the inferior nasal concha in the manner described, B.V. Shevrygin (1983) recommends the following manipulation: the nasal concha is grasped along its entire length with strong forceps and broken at the attachment point by lifting it upwards (lever mechanism). After this, it is easier to displace it toward the lateral wall of the nose.

In the case of the medial position of the middle nasal concha, which covers the olfactory cleft and prevents not only nasal breathing but also the olfactory function, the lateral position of this concha is performed according to the method of B.V. Shevrygin and M.K. Manyuk (1981). The essence of this method is as follows: after anesthesia, the nasal concha is cut transversely with Struycken scissors at the site of greatest curvature. Then, the curved segment is moved laterally with the branches of the Killian mirror and a tightly rolled gauze roller is inserted between it and the nasal septum. In the case of curvature of the anterior section of the concha, the authors recommend supplementing the operation with an incision at the site of its attachment, which will ensure its greater mobility.

The causes of median obstruction of the nasal passages may also include dystopias of individual anatomical structures of the nasal cavity, characterized by the fact that normal structures in their development end up in an unusual place. Such anomalies include bullous middle nasal concha (concha bullosa), dystopias of the nasal septum and its parts, etc.

The most common anomaly of the development of endonasal structures is the bulla of the middle nasal concha - one of the cells of the ethmoid bone. The origin of the bulla may be due to a constitutional feature of the development of the ethmoid bone, which can be combined with other anomalies of the development of the facial skeleton, but it can also be due to chronic long-term ethmoiditis, leading to an increase in the volume of the cells, including the cell of the middle nasal concha, most often carried out by excision with a fenestrated conchotome, but this often leads to the formation of synechia, therefore a number of authors recommend performing for this type of dysplasia either sub-lysate resection of the pneumatized part of the bulla (for small and medium sizes), or the so-called bone-plastic surgery for large bullae.

The first method involves a vertical incision of the mucous membrane above the bulla, its separation from the bone part, resection of the bone bleb, placement of the resulting flap of mucous membrane on the lateral wall of the nose and fixation with a tampon.

The second method differs in that it does not remove the entire bone sac, but only the part that is adjacent to the nasal septum. The remaining part is mobilized and used to form a normal middle nasal concha. A flap of mucous membrane is used to cover the formed concha, otherwise the exposed bone may become covered with granulation tissue, followed by scarring and the formation of adhesions.

Posterior atresia.

Pathological anatomy. This type of pathological conditions is characterized mainly by choanal atresia, which can be complete or partial, bilateral or unilateral, with the presence of several openings in the occluding tissue, the latter being fibrous, cartilaginous or bony, as well as combinations of the three types of tissue. The thickness of the diaphragm separating the nasal cavity from the nasopharynx varies from 2 to 12 mm. Unilateral choanal occlusion is most often observed. The origin of this type is most often congenital and less often the result of some radical surgical interventions in this area with the patient's tendency to excessive formation of scar tissue.

The pathogenesis of congenital choanal atresia remains a controversial issue to this day: a number of authors believe that their cause is congenital syphilis, while others believe that choanal atresia is an embryonic developmental anomaly in which there is no resorption of the buccal-nasal membrane, from which the soft palate is formed.

Symptoms are mainly manifested by impaired nasal breathing depending on the degree of patency of the choanae. With unilateral atresia, which is the most common, there is obstruction of one half of the nose, with bilateral - complete absence of nasal breathing. A newborn with total choanal atresia cannot breathe or suck normally and in the past died in the first days after birth. With partial choanal atresia, the child can feed, but with great difficulty (choking, coughing, difficulty breathing, stridor, cyanosis). The survival of a child with complete atresia is possible only if appropriate surgical intervention to ensure nasal breathing is performed in a timely manner, on the first day after birth. With partial atresia, the viability of the child depends on the degree of its adaptation to oral breathing. In children and adults, partial choanal obstruction is mainly observed to varying degrees, ensuring at least a minimal possibility of nasal breathing.

Other symptoms include olfactory and taste disturbances, headaches, poor sleep, irritability, increased fatigue, delays in physical (weight and height) and intellectual development, craniofacial dysmorphia, etc.

Anterior rhinoscopy usually reveals a deviated nasal septum on the side of atresia, the nasal turbinates are atrophic, cyanotic on the same side, and the lumen of the common nasal passage is narrowed toward the choanae. Posterior rhinoscopy reveals the absence of lumen in one or both choanae due to their covering with smooth fibrous tissue.

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

Differential diagnosis is carried out with adenoids and tumors of the nasopharynx.

Treatment. In newborns, nasal breathing is restored as an emergency measure immediately after birth. Signs of choanal atresia include the absence of nasal breathing when the mouth is closed, cyanosis of the lips and face, severe anxiety, and the absence of normal postnatal inhalation and crying. In such newborns, an opening is made in the diaphragm that closes the choanae from the nasopharynx using a probe, trocar, or any metal instrument such as a cannula for probing the auditory tube with immediate widening of the opening using a curette.

In children, adolescents and adults, surgical intervention is performed on a planned basis, it consists of excision of the fibrous or cartilaginous diaphragm and preservation of the choana lumen by placing a probe of the appropriate diameter in it. In case of bone atresia, surgical intervention is significantly complicated, since before performing the main stage of the operation, it is necessary to achieve access to the bone septum to be resected. For this, a number of preliminary stages are carried out, consisting of removal of the inferior nasal turbinates, partial or complete resection of the nasal septum or its mobilization, and only after this is the bone obstruction removed by knocking it down with a chisel and widening the opening with bone forceps. Rhinological surgeons have developed various approaches to the object of action - endonasal, transseptal, transmaxillary and transpalatine. The opening made is preserved with the help of special drains.

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