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Differential diagnosis
Differential diagnosis is rarely an issue.
- In the event of rhinorrhea, simple rhinitis can lead to confusion. Rhinorrhea is usually associated with rhinopharyngitis and is treated using a similar therapeutic approach.
- In the event of nasal obstruction :
- Bilateral choanal imperforation manifests itself as a total neonatal nasal obstruction, with dramatic symptoms in newborns who cannot breathe through their mouth: asphyxia and feeding problems with false passages. Diagnosis is easy and can be made simply using a mirror placed in front of the nostrils (lack of condensation when breathing out) and a catheter introduced into both nasal cavities, which comes to a halt after a few centimeters, without passing into the pharynx. The immediate gesture is to install a Mayo tube. Alimentation is supplied by a feeding tube; surgical treatment should be performed as early as possible, consisting of perforation of the mucosal or osseous diaphragms blocking the posterior apertures of the nose;
- Unilateral choanal imperforation does not cause any significant problems. Detection of the condition is often late, when confronted with nasal obstruction and long-term unilateral mucosal rhinorrhea. Surgical treatment can be postponed;
- benign tumor: nasopharyngeal fibroma or male puberty bleeding fibroma. This rare, histologically benign tumor, is a highly vascularized fibromyxoma that develops at the level of the external wall of the choanal orifice. In a pubescent teenager, its gradual expansion into the nasal cavity and nasopharynx leads to progressive nasal obstruction, with rhinorrhea and recurrent epistaxis, which is more and more abundant and sometimes dramatic;
- malignant tumors: nasopharynx cancer. Not exceptional in children.
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Hypertrophy of adenoid vegetations causing recurrent rhinopharyngitis
The hypertrophy of the pharyngeal tonsil is considered a normal reaction during immune maturation. In case of significant enlargement, this hypertrophy may have clinical consequences. Given this scenario, there are the telltale signs of upper respiratory obstruction (nasopharyngeal):
- general appearance of the child, often pale, hypotrophic or sometimes overweight and listless;
- permanent nasal obstruction;
- breathing through the mouth;
- snoring at night with restless sleep;
- nasal voice (closed rhinolalia);
- particular facies, known as "adenoid", which is common to any chronic nasopharyngeal obstruction: mouth open with incisor open bite, dazed look, long and narrow face, and high arched palate;
- pectus carinatum (pigeon breast).
Clinical examination reveals :
- rarely an anterior bulging of the soft palate on examination of the buccal cavity, or rather the appearance of the lower part of large vegetations, especially during a gag reflex;
- cervical bilateral polyadenopathy on palpation of the neck: the lymph nodes are small (<1.5 cm), firm, and painless.
Further investigations may include :
- posterior rhinoscopy with a mirror or optical fibers for ENT investigations, which is often difficult or impractical in the young;
- nasal fibroscopy by an ENT specialist;
- lateral x-ray of nasopharynx.
Disease evolution is often beset with outbreaks of rhinopharyngitis along with possible complications.
Adenoid vegetations, which reach maximum development between 4 and 7 years, generally involute spontaneously around the age of puberty. Residual traces of adenoid vegetations may persist and cause rhinopharyngitis in adults.
Specific surgical treatment is at times necessary when :
- volume of these adenoid vegetations results in significant and permanent mechanical difficulties in breathing;
- infectious outbreaks accompanied by ear infections (with hearing loss), laryngitis, or tracheobronchitis are common.
Removal of the adenoid vegetations or adenoidectomy is a benign operation that is possible from the age of 1 year onwards, sometimes even earlier. This intervention, however, never involves total eradication of nasopharyngeal lymphoid tissue, which may recur quickly, especially in young children (recommendations of the AFSSAPS [French Health Products Safety Agency]).
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Other factors favoring nasopharyngeal infections
Recurrent uncomplicated rhinopharyngitis is characterized by its subacute or chronic evolution that extends for weeks and months. These children, usually with adenoid vegetations, have a "perpetual cold", which is barely relieved during the summer months and hence, a difficult therapeutic problem. The contributing factors are :
- hypertrophy of adenoid vegetations,
- climate-related factors: spring and fall,
- epidemic factors: flu, etc.,
- lifestyle: crèche, school, "infecting" family environment, and passive smoking,
- eruptive fevers in childhood: measles, chicken pox, and scarlet fever, etc.,
- environment, family history of "mucosal fragility", allergic or otherwise.
The treatment of each factor enables recurrent rhinopharyngitis to be controlled :
- stopping of passive smoking, removal of the child from group activities if possible, and showing the child how to blow its nose and keep the nose clean are always appropriate measures,
- vitamins, trace elements, sulfur (Rhinathiol, Solacy, and Oligosols, etc.) have been sufficiently discussed, but their safe prescription has a positive psychological effect on the family,
- iron deficiency (very common)correction,
- removal of the vegetations remains the most effective treatment,
- gastro-esophageal reflux may require specific treatment.
The condition heals spontaneously around the age of 6 to 7 years without any significant consequences, at least in uncomplicated forms.
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