Unusual cause for unilateral nasal obstruction in a child☆☆☆

Article Outline

• Summary
• 1. Introduction
• 2. Examination
  • 2.1. C.T. PNS
• 3. Management
• 4. Discussion
• References
• Copyright

Summary 

An unusual presentation of a common anatomical variation presenting as unilateral nasal obstruction in a child of 14 years. Choncha bullosa is a common anatomic variant seen in 34–53%; it can be the cause of the osteomeatal obstruction predisposing to sinusitis and their complications due to mucosal contact points and impairing the mucociliary clearance or causing mechanical obstruction at the osteomeatal complex. Here we are presenting a case of unusually large concha bullosa, which was causing unilateral nasal obstruction, deviated septum and bilateral anterior sinusitis and recurrent chest infection in a 14-year-old girl. The concha bullosa was filled with thick pus making it a pyocele. The culture did not grow any organisms. The CT scan done was not conclusive the origin of the lesion but could be diagnosed only during the surgery.

Keywords: Choncha bullosa, Middle turbinates, Sinusitis, Pyocele, Presentation

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1. Introduction 

Fourteen-year-girl presented with history of progressive nasal obstruction since 3 years on left side gradually both sides. Left side nasal discharge, usually white mucoid occasional yellowish mucoid, which was associated with headache and cough. These acute exacerbations subside with antibiotic treatment by general practitioner (Fig. 1) [1], [2].

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• Fig. 1. 

  Endoscopic picture of the lesion at the level of the anterior end of the inferior turbinate.

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2. Examination 

A single, pink, smooth mass seen in the anterior naries on left side, which was sensitive to touch. Probing could be done after anaesthetizing and decongesting the nasal mucosa, which revealed that the mass was arising from the lateral wall of the nose, does not bleed to touch. Mass had a feel of eggshell crackling feel. Endoscope could not be passed.

Posterior rhinoscopy showed a smooth pink mass filling the left choana and pushing the septum to the opposite.

2.1. C.T. PNS 

A bone lined mass with non-homogenous (density similar to soft tissue) opacities in the cavity. Mass extending from the anterior nasal cavity till the posterior choana. The lesion is pushing the septum to the right. There is associated bilateral maxillary and ethmoidal sinusitis (Fig. 2) [3], [4].

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• Fig. 2. 

  CT scan in coronal and axial views, showing non-homogenous opacity covered in a bony shell.

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3. Management 

Child was operated under general anesthesia using endoscope. On incising the mass purulent material came out of the mass and on exploring into the mass, there was think insipitated pus filling the cavity of the choncha. The medial and lateral lamella of the choncha was removed and the attachment of the middle turbinate was not disturbed.

Uncinectomy, anterior ethmoidectomy was done. The maxillary ostium was normal and no interference was done with septum or the maxillary ostium.

Postoperative the child had uneventful recovery. Endoscopic clearance was done on the follow-up days. After 1 month, there were no sings of infection in the nose and there was nasal mucosa lining the remnant middle turbinate, and the child was asymptomatic.

Follow-up after 1 year, the child did not have any symptoms and the encoscopy revealed healthy nasal mucosa, septal deviation had reverted back (Fig. 3).

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• Fig. 3. 

  Excised bony shell of the concha bullosa.

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4. Discussion 

Concha bullosa is a common anatomical variation, it is asymptomatic in many and becomes symptomatic in few due to mucosal contacts and produces the signs of nasal infection and can predispose to sinusitis and nasal obstruction [5]. This can also lead to infection of the lining mucosa in the concha bullosa as a part of ethmoid sinusitis.

There are various studies to show the relation between the concha bullosa, sinusitis and deviation of septum and also leading to complication of the orbit, cranial cavity, frontal and ethmoid sinuses [1], [2], [3], [4], [5].

This was an unique case presented with unilateral nasal obstruction in a child, undiagnosed for more than 3 years and the size of the concha bullosa was gigantic occupying entire left nasal cavity, producing bilateral anterior sinusitis, deviated septum and could not be clinically conclusive nor radiologically as the attachment was not clearly seen. The pus was thick and impacted to progressively increase the size of the lesion to occlude the entire nasal cavity. Recurrant infection of the pyocele, sinuses produced respiratory tract infection. The sterile pus proved it to be an expanding pyocele of the concha bullosa.

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References 

1. Uygur K, Tuz M, Dogru H. The correlation between septal deviation and concha bullosa, Otolaryngol.. Head Neck Surg. 2003;129(1):33–36
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2. Aktas D, Kalciogly MT, Kutlu R, Ozturan O, Oncel S. The relationship between the concha bullosa, nasal deviation and sinusitis. Rhinology. 2003;41(2):103–106
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   • MEDLINE
3. Marianowski R, Farragi M, Zerah M, Brunella F, Manach Y. Subdural empyema complicating a concha bullosa pyocele. Int. J. Peadiatr. Otorhinolaryngol. 2002;65(3):249
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4. Riera Sala C, Agud Fuster M, Valladares Molina J, Ramos Marti F. Mucocele from concha bullosa with invasion of the orbit. Acta Otorrinolaringol. Esp. 2002;53(1):46–49
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   • MEDLINE
5. Dawlatly EE, Telmesani LM. Conchal bullosa Pyocele—undiagnosed for three years. Rhonology. 1999;37:90–92
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