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[New clinico-therapeutic directions in upper airway pathology]
1Centro di Fisiopatologia Respiratoria Infantile, Università di Parma, Italia.
Insights
Pediatric airway issues like rhinitis and obstructive sleep apnea are updated with new insights. Diagnosis and treatment strategies for persistent rhinitis and adenotonsillar hypertrophy are refined.
Area of Science:
- Pediatric Pulmonology
- Pediatric Immunology
- Otolaryngology
Context:
- Persistent rhinitis, recurrent pharyngeal/laryngeal diseases, and adenotonsillar hypertrophy are common in children.
- Recent advances in immunology, respiratory physiopathology, and diagnostic technology offer new perspectives.
Purpose:
- To re-examine and update the understanding of primary airway pathologies in children.
- To integrate new findings into diagnostic and therapeutic approaches for pediatric airway conditions.
Summary:
- Rhinitis is now viewed as multifactorial, including non-allergic forms with eosinophils, challenging traditional allergic classifications.
- Adenotonsillar hypertrophy presents diverse symptoms, from hypoventilation to sleep apnea; diagnosis relies on specific clinical observations, especially during sleep.
- Instrumental evaluation is crucial for young children to assess hypoventilation, guiding surgical decisions.
- Adenoidectomy benefits conditions beyond obstruction, including otitis media, sinusitis, and craniofacial anomalies.
- Radiology and endoscopy aid rapid diagnosis of epiglottic laryngitis, enabling prompt treatment and avoiding tracheostomy.
Impact:
- Refines diagnostic criteria for pediatric rhinitis, emphasizing multifactorial causes over solely allergic triggers.
- Improves management of obstructive sleep syndromes due to adenotonsillar hypertrophy through enhanced diagnostic accuracy.
- Highlights the expanded therapeutic role of adenoidectomy for various pediatric airway and related conditions.
- Facilitates timely and appropriate interventions for laryngitis, potentially preventing severe complications.
Abstract:
The main issues regarding the pathology of the primary airways in children, such as persistent rhinitis, recurrent disease of the pharynx and laryngitis, have been re-examined and updated on the basis of the latest findings regarding immunology and respiratory physiopathology as well as recent technological progress in the field of diagnosis. As far as rhinitis is concerned, recently demonstrations that nasal mucosa, like bronchial mucosa, responds to different kinds of stimuli with the same type of inflammation, have led to a new nosographic viewpoint: apart from classic allergic rhinitis, multifactorial forms are now recognised. They have been defined as nonallergic persistent rhinitis having a particular subgroup: nonallergic rhinitis with eosinophils. The fact that different factors contribute to bringing about the same inflammatory process is also confirmed by a personal study carried out on 132 asthmatic children with rhinitis: the results showed, in fact, that there are no differences regarding the nasal mucosa of allergic children (positive prick) and nonallergic children (negative prick). This observation therefore diminishes the importance of rhinoscopy in the etiologic diagnosis of rhinitis. As far as the obstructive syndrome caused by adenotonsillar hypertrophy is concerned, extremely polymorphic clinical pictures can be identified: from the slightest nocturnal hypoventilation to the apnea syndrome during sleep, even to the most severe forms with cardiocirculatory insufficiency. Personal data on 42 children helped to define both the anamnestic and objective findings necessary for making the diagnosis. It was therefore found that the most indicative and specific observations were those made either by the mothers (heavy breathing noises) or by the physician (inspiratory retractions) while the children were sleeping. Clinical data are therefore usually sufficient for making the diagnosis; however, in the first two years of life, a period in which surgical operations are usually delayed if possible, it is necessary to make an instrumental evaluation of the degree of hypoventilation. By means of radiological examination, pharyngoscopy and capnography, it is possible to record the degree of obstruction and therefore decide whether or not to delay surgery. Apart from the obstructive respiratory syndrome with hypoventilation, that requires surgery at all costs, other conditions were examined that can profit by adenoidectomy, such as affections of the middle ear, chronic sinusitis and craniofacial dysmorphisms. As far as laryngitis is concerned, the importance of radiology and endoscopy in rapidly diagnosing epiglottic laryngitis is reported. This in turn sometimes facilitates quick pharmacological treatment so as to avoid more invasive interventions, such as tracheostomy.