Endoscopic transnasal repair of choanal atresia

OBJECTIVES: To present our experience with a new endoscopic technique for transnasal repair of choanal atresia. METHODS: Seventeen patients aged 2 months to 13 years with choanal atresia, bilateral in 6 and unilateral in 11, underwent endoscopic repair using a mucoperichondrial flap developed from the nasal septum. The bony stenosis was opened with a surgical curette or drill, and the raw surface was covered by the flap. All patients in these case series with bilateral atresia had been treated with dilatation at birth and had restenosis. RESULTS: A total of 23 choanae were operated. Follow-up ranged from 10 to 60 months. There was one case of complete restenosis and one of partial restenosis, for a success rate of 91%. CONCLUSIONS: Endoscopic repair of choanal atresia is a safe and rapid procedure even in very young children, with no complications and a high rate of success.     

Transnasal endoscopic treatment of bilateral choanal atresia in newborns using balloon dilatation: Own results and review of literature

Objectives

Congenital choanal atresia is a complete obliteration of the posterior nasal aperture leading to life-threatening airway emergencies. Several surgical options including sublabial, transpalatal, transseptal or external approaches have been developed for the repair of choanal atresia. So far, no gold standard has been established, but transnasal endoscopic approaches have been favored by many surgeons in recent years.

Methods

Since 2008 a standard procedure for bilateral choanal atresia repair in neonates using an endoscopic transnasal approach supported by balloon dilatation has been established at the Department of Otorhinolaryngology at Ulm University Medical Center. During the last five years, six cases of bilateral choanal atresia were diagnosed and treated, including two male and four female patients aged between three days and two months, at the date of surgery. All interventions were performed in transnasal endoscopic technique. In all patients the abnormally thick posterior vomer and the atretic bony plate were resected and the mucosa was perforated. A balloon dilator was used to dilate the neochoanae and prevent restenosis. All six patients were intraoperatively stented for at least six weeks.

Results

All six neonates with bilateral choanal atresia, who were operated in endoscopic transnasal technique had patent neo-choanae on both sides. No severe postoperative complications were found. The number of revisions depends on the age at primary surgery.

Conclusions

Endonasal endoscopic approach and balloon dilatation is a safe, reproducible technique for surgical repair of choanal atresia. We recommend the use of bilateral stents, especially in very young patients, as a prerequisite to prevent early restenosis.     

Congenital nasal pyriform aperture stenosis

Congenital nasal pyriform aperture stenosis is an unusual and previously undescribed cause of nasal airway obstruction in the newborn. The nasal pyriform aperture is narrowed due to bony overgrowth of the nasal process of the maxilla. This anomaly may produce signs and symptoms of nasal airway obstruction in newborns and infants similar to those seen in bilateral posterior choanal atresia. Computed tomography confirms the diagnosis and delineates the anomaly. A series of six patients with nasal pyriform aperture stenosis is presented. Four patients were treated with surgical enlargement of the nasal pyriform aperture via a sublabial approach. One patient was repaired via a transnasal approach, and one patient did not undergo surgical intervention. Follow-up reveals normal nasal airway and facial growth in all patients. Mildly symptomatic patients with congenital nasal pyriform aperture stenosis may be treated expectantly, while severely symptomatic patients benefit from repair via the sublabial approach.     

Surgical technique in endoscopic posterior septoplasty for an adult patient with choanal stenosis

The technique in endoscopic posterior septoplasty for the case of a female aged 49 with bilateral choanal stenosis is presented. This female had undergone endoscopic nasal surgery for stenosis twice before the posterior septoplasty. However, restenosis of the choanae had arisen within 2 weeks after each surgery. This patient underwent the endoscopic posterior septoplasty under general anesthesia. After removal of the cartilage and bony structures of the nasal septum, the posterior one-third of bilateral septal membranes was excised. This technique is to enlarge the choanal opening obliquely. Excellent visualization for the septoplasty using the endoscope was obtained. Sufficient patency of the choanae was achieved using this technique. There still is no restenosis of the choanae observed and the rhinomanometry shows extreme decrease of nasal airway resistance 1 year after this surgery. It is considered that endoscopic posterior septoplasty for choanal stenosis is an effective procedure with low morbidity and long-term patency.     

Acquired posterior choanal stenosis and atresia: management of this unusual complication after radiotherapy for nasopharyngeal carcinoma

PURPOSE: To report on acquired posterior choanal stenosis and atresia after radiotherapy for nasopharyngeal carcinoma. MATERIALS AND METHODS: Four patients with acquired bilateral choanal atresia and 2 with severe unilateral choanal stenosis in the posterior choanae were identified after treatment of nasopharyngeal carcinoma with radiotherapy. The mean age was 42 years (range, 29 to 48 years). Two patients had stage II, and 4 had stage III disease, according to Ho's classification. They all received a 66 Gy dose of external irradiation delivered to the nasopharynx, and a mean dose of 62.6 Gy to the neck. Five patients had an additional 20 Gy delivered to the parapharyngeal region, and 1 patient had intracavitatory brachytherapy of 18 Gy delivered to the nasopharynx. The mean onset of symptoms was 10.5 months (range, 2 to 40 months) postirradiation. All patients were treated by transnasal endoscopic resection. Merocel epsitaxis packing (Medtronic Xomed, Jacksonville, FL) was used to stent the nasal airway for 2 weeks postoperatively. RESULTS: The mean follow-up was 16.2 months (range, 14 to 18 months) after surgery. Four patients (67%) were symptom-free. Two patients (33%) had unilateral restenosis in the postnasal space that required revision surgery and further nasal stenting for 2 weeks, and both were subsequently free from further restenosis. No adverse postoperative complication occurred. CONCLUSION: Acquired posterior choanal stenosis and atresia is an unusual long-term complication after radiotherapy that can be successfully treated with transnasal endoscopic resection. A 2-week Merocel nasal stent is recommended to prevent restenosis in the posterior choanae.     

Transnasal repair of unilateral choanal atresia

OBJECTIVES: To evaluate the outcomes of the surgical correction of unilateral choanal atresia using a transnasal approach. PATIENTS AND METHOD: Over a 36-months period (from 1999 to 2001), seven children underwent endoscopic endonasal repair of an unilateral choanal atresia using the microdebrider (powered instrumentation). At the end of the procedure, topical application of Mitomycin-C was performed. No postoperative nasal stenting was inserted. Clinical characteristics of these patients, CT scan examination, complications of the procedure and outcomes were analysed and compared to historical cases treated in the same institution from 1990 to 1998. RESULTS: Seven patients (2 M/5F) (age 6 to 46 months) presented with primary unilateral choanal atresia and were operated during the period from 1999 to 2001. All the patients were symptomatic before surgical correction. No patients showed other facial anomaly. Of the 7 patients procedures, 6 (85.7%) remained patent (follow-up range 12 to 36 months). Mean surgical repair per patient before obtaining patent choana was 1.14. One patient required surgical transnasal revision nine months after the initial procedure with a patent choanal after this second procedure (follow-up 9 months). Minor turbinoseptal synechiae diagnosed 6 months after the surgical correction occurred in one patient and was the only postoperative complication. When compared to historical cases of unilateral choanal atresia (19 patients from 1990 to 1998) repaired without endoscopic control and without Mitomycin-C, it was shown that this current method provided better results; mean surgical repair per patient; 1.14 vs 1.89 and 85.7% of patent choanae at twelve months vs 47.3%. CONCLUSION: An endoscopic endonasal approach without postoperative stenting, using the microdebrider seems to us the treatment of choice for unilateral choanal atresia. The exact role of the topical application of Mitomycin-C needs to be further investigated.     

Congenital choanal atresia and nasal stenosis

The most common form of nasal obstruction in neonates is soft tissue edema, but congenital bony nasal anomalies are recognized as an important cause of newborn airway obstruction. We reviewed 20 cases of congenital bony nasal abnormalties such as choanal atresia and nasal stenosis referred to National Children's Hospital between 1996 and 2001. Of the 20, 8 involved choanal atresia (6 bilateral and 2 unilateral) and 12 nasal stenosis (5 nasal cavity stenosis, 2 pyriform aperture stenosis and 5 unknown). Six cases of bilateral choanal atresia and 5 of 12 cases of the nasal stenosis presented severe airway distress. Most cases in respiratory distress required immediate surgical enlargement of nasal cavity and stenting with an endotracheal tube for 4 to 8 weeks. Of 12 with nasal stenosis, 5 with mild nasal obstruction were treated with nasal drops and 3 with mild airway distress required no treatment. Five of 7 (71%) with choanal atresia and 1 of 4 with nasal stenosis (25%) required restenosis of the nasal cavity after stent removal. Restenosis occurred more often in choanal atresia than in nasal atresia. Two of 5 with nasal restenosis required stenting for 1 to 2 months again and 1 of those was followed by stenting for more 4 months. Longer stenting did not prevent choanal from restenosis, however, no standard stenting protocol exists for neonates, highlighting the need for further study.     

Computed tomography in the evaluation of choanal atresia

Nine patients with choanal atresia or stenosis, ranging in age from two days to 6 years were evaluated by computer tomography (CT). The clinical, conventional radiographic and surgical findings were correlated with CT findings. In all patients, the complete anatomic abnormality and the thickness of the obstruction were better defined with CT than with a choanogram. Findings on CT included: thickening of the vomer, bowing of the lateral wall of the nasal cavity and fusion of bony elements in the choanal region. This information is essential in planning surgical correction.     

Congenital nasal pyriform aperture stenosis: a case report

Congenital nasal pyriform aperture stenosis is a rare and poorly understood pathology. It's etiology is unknown. In cases with severe nasal airway obstruction, this anomaly may produce newborn respiratory destress similar to those seen in bilateral posterior choanal atresia. It can occur as an isolated anomaly or it can be associated with a dental anomaly, craniofacial, ophthalmological or central nervous system malformation. The diagnosis is made by physical examination. Computed tomography confirms the diagnosis. Magnetic resonance imaging of the brain and pituitary endocrine axis must be performed. In patients with severe obstruction, surgical correction is necessary. We describe the case of a 1-month-old child who needed surgical treatment with a sublabial approach for a congenital nasal pyriform aperture stenosis associated with a solitary maxillary central incisor. The follow-up (4 years) reveals normal nasal airway and facial growth.     

Endoscopic repair of bilateral congenital choanal atresia

OBJECTIVE: The literature about endoscopic repair of bilateral choanal atresia is scarce. The advantages and difficulties encountered with this technique are discussed. STUDY DESIGN: Prospective case series in a tertiary care center. METHODS: Nine infants with bilateral choanal atresia underwent transnasal endoscopic repair. On computed tomography scans, six had mixed atresia and three had bony atresia. Extra-long burrs, ear curettes, and dissectors all have been used with 4- and 2-mm, 0 degrees telescopes. The neochoana has been stented for 5 to 8 weeks. All cases were examined with the endoscope on removal of the stent; any granulation or polyps were removed at that time. RESULTS: Five cases remained patent after removal of stenting. Two patients required revision surgery because of repeat stenosis; one case remained patent and the other had repeat stenosis on one side. One infant died because of unrelated medical problems that occurred later. In one case the atretic tissue was thick, and the procedure was stopped because of bleeding; the infant died in the postoperative period after resuscitation. CONCLUSION: Careful review of the computed tomography scan and experience with endoscopic nasal surgery makes the transnasal endoscopic treatment a safe and effective approach for managing bilateral choanal atresia.     

Endoscopic bilateral congenital choanal atresia repair of 112 cases,evolving concept and technical experience

ObjectiveThis study aims to present 18 years’ experience with endoscopic treatment of bilateral congenital choanal atresia as regard to management concept, surgical technique, results, pitfalls, and complications.Patients and methodsA retrospective study including 112 cases of bilateral congenital choanal atresia, treated at Mansoura University Hospital endoscopically in the period from January 1998 to March 2015. As far as we know, this is the largest study group on transnasal endoscopic choanal atresia repair in literature.ResultsOne hundred and twelve infants (87 females, 25 males) were included in the study. Age at operation ranged between 1 day and 28 days (8.75 days in average), and body weight average was 2.76 kg. All patients were diagnosed at birth except 3 infants. In this study, 85 cases were mixed atresia, 25 cases were bony atresia, and only two cases were membranous. In all cases, obliterated choana bone and vomer bone was removed, lateral wall drilling was used in 33 cases. Follow up ranged between 6 months and 18 years (95.6 months in average). The most common complication was restenosis, occurred in 42% (47 cases). Second-look procedure was done in 68 cases. The need for second-look evaluation with stent group was 74.5% (62 out of 83 infants), whereas in non-stent group was 20.6% (6 out of 29 infants).ConclusionEndoscopic repair of bilateral choanal atresia is a safe, effective technique with minimal complication. Usage of 30 degree sinuscope permits better visualization and higher accessibility for the surgical instruments. Surgically formed wide single neochoana with removal of all intervening tissue surroundings, and good follow up permit higher success rate without stenting. Advanced learning curve permits tailoring the perfect surgery with minimal tissue injury and better outcome. Post-operative choanal dilatation using esophageal dilators under endoscopic examination decrease the need for stenting and second-look evaluation.     

Unilateral choanal atresia: surgical technique and long-term results

Although transnasal techniques to treat choanal atresia have become the standard, risks remain of restenosis of the opened choana requiring dilatations. In addition, a new technique without stenting and requiring less invasive post-operative care would be an improvement. With this in mind, in a non-randomized trial, a modification of the transnasal surgical repair was used in eight patients with unilateral choanal atresia by which no stents were used. While the standard procedure consists of partial resection of the bony septum and the atretic plate, we additionally removed lower parts of the anterior wall and the floor of the sphenoid sinus, creating a new airway canal from the nasal cavity to the sphenoid into the epipharynx. Post-operative care by the patient and the surgeon was noted. The success of choanal patency was followed by nasal endoscopy and rhinomanometry with a mean post-operative follow-up time of 1.9 years. In all patients, both choanae remained patent confirmed by nasal endoscopy and rhinomanometry showing almost symmetric resistance. Post-operative care comprised antibiotic prophylaxis and nasal douching with saline solution by the patient; no further treatment by the surgeon was necessary. According to these long-term results we would recommend this type of surgery for two reasons: the use of stents no longer necessary and post-operative care by the surgeon can be minimized.     

Nasal septal cross-over flap technique: a choanal atresia micro-endoscopic surgical repair

Choanal atresia is a congenital malformation of the posterior portion of the nasal cavity, which is usually unilateral. The incidence is estimated to be 1 in 5,000 to 8,000 live births. Several surgical approaches have been described to correct choanal atresia since Emmert's initial trocar perforation in 1853, including transnasal, transpalatal, transseptal, sublabial transseptal, transantral, and external rhinoplasty. Although the micro-endoscopic transnasal access is a more conservative technique, it allows greater surgical precision, and is currently recommended by many authors; choanal atresia repair is still considered a challenge, with risks of intraoperative and postoperative complications and re-stenosis. This paper reports the results of a series of 33 patients operated via the transnasal micro-endoscopic surgical approach, and describes a new endoscopic technique that the authors call "nasal septal crossover flap technique."     

Topical mitomycin as an adjunct to choanal atresia repair

OBJECTIVE: To evaluate the use of topical mitomycin in choanal atresia repair to reduce the development of granulation tissue and cicatrix. DESIGN AND SETTING: Retrospective case series in 2 tertiary care centers. PATIENTS: Twenty patients with either unilateral or bilateral congenital choanal atresia underwent repair using the transnasal endoscopic approach, the transpalatal approach, or both. INTERVENTIONS: The surgeons favor the use of the endoscopic transnasal drillout technique for all unilateral cases of choanal atresia and for selected bilateral cases. We describe our experience and treatment paradigm for these 20 patients (15 with unilateral atresia, 5 with bilateral atresia). Topical application of mitomycin was used, and in some cases postoperative stenting, for a period of 1 to 2 weeks. In 8 cases, a second application of mitomycin was used. Follow-up ranged from 3 months to 2 years (mean, 9 months). OUTCOME MEASURE: The patency of the choanae without respiratory distress or nasal drainage, as assessed by endoscopic evaluation, determined a successful repair. RESULTS: Of the 20 patients, 17 retained patent airways. Three patients experienced improvement from a total atresia to a narrowed, stenotic choana. CONCLUSIONS: The use of mitomycin as an adjunct to the surgical repair of choanal atresia may offer improved patency with a decreased need for stenting, dilatations, and revision surgery. Newer endoscopic techniques with powered instrumentation further enhance the safety and efficacy in the repair of choanal atresia.     

Choanal atresia: an unusual serious complication of complementary and alternative medical treatment

The use of complementary and alternative medicine (CAM) is common among patients with chronic, long-standing nasal disease. Complications resulting from inappropriate CAM practices are sometimes reported, but serious complications such as choanal atresia and stenosis are rare. We report a case of choanal atresia and stenosis due to herbal drug (ie, chemical) cauterization of the nasal cavity in a 39-year-old man. We reviewed the literature on why patients previously given conventional treatment seek alternative therapies. The patient underwent surgical intervention to relieve choanal atresia and stenosis. The postoperative course was unremarkable, and follow-up for 1 year revealed no evidence of restenosis. Choanal atresia and stenosis resulting from CAM treatment are rare. Otolaryngologists should be aware of possible complications occurring in patients receiving such treatments.     

Surgical management of choanal atresia: improved outcome using mitomycin.

OBJECTIVE: To evaluate the intraoperative use of mitomycin to improve the surgical outcome and reduce the rate of soft tissue restenosis in children undergoing choanal atresia repair. DESIGN: Retrospective chart review of all patients surgically treated for congenital choanal atresia by the senior author (W.F.M). SETTING: Tertiary children's hospital. PATIENTS: Eight consecutive patients with bony choanal atresia (6 unilateral and 2 bilateral) were compared with 15 historical controls (6 unilateral and 9 bilateral). All study and historical control patients were treated with soft plastic postoperative stenting. INTERVENTION: At the completion of the surgical repair of the choanal atresia, 0.4 mg/mL of topical mitomycin was applied to the posterior choanae for 3 minutes. MAIN OUTCOME MEASURE: The success rate of the repair of the choanal atresia as determined by the postoperative need for dilation or revision surgical procedures was compared with that of the historical controls. RESULTS: All 8 children with intraoperative use of mitomycin were treated with a mean +/- SEM of 0.375 +/- 0.183 dilations per patient. The 15 children in the control group received a mean +/- SEM of 3.667 +/- 0.583 postoperative dilations for soft tissue restenosis. The difference in the number of postoperative dilations between the study and control group was statistically significant (P =.006) using a t test. CONCLUSIONS: Mitomycin is an effective and reliable treatment for improving the surgical outcome for choanal atresia repair. This may obviate the need for postoperative dilations and may potentially eliminate the need for surgical stenting.     

Experiencia de 20 años en el tratamiento microquirúrgico de la atresia de coanas

Introduction and objectivesChoanal atresia is the most common congenital nasal anomaly. Diagnosis is confirmed by endoscopic examination and computed tomography. The definitive treatment is surgical, and different surgical techniques and approaches are used. We describe our experience in transnasal microsurgical treatment of congenital choanal atresia.MethodsWe retrospectively evaluated 49 patients with congenital choanal atresia operated in the Department of Respiratory Endoscopy over a period of 20 years. The clinical variables analysed were type of atretic plate, age at diagnosis and surgery, associated malformations, maternal history of hyperthyroidism treated with methimazole during pregnancy, mode of airway stabilisation before surgery, surgical technique, complications, and outcome.ResultsMixed bilateral choanal atresia was the most frequent (29 cases). Its incidence was higher in females (61.2%). Almost 51% of patients showed associated malformations, and 7 had a history of maternal hyperthyroidism treated with methimazole during pregnancy. The surgical procedure consisted of a transnasal microscopic approach and placement of a silicone endonasal stent for one to 12 weeks. Thirty-five patients required revision after surgery. Nine patients had complications. Suitable nasal ventilation was achieved in 46 patients (93.9%). One patient died of causes unrelated to the surgery. Two patients with permeable choanae remain with tracheotomy.ConclusionThe transnasal microsurgical repair with endonasal stent proved to be a safe and effective procedure.     

Choanal atresia: embryologic analysis and evolution of treatment, a 30-year experience

OBJECTIVES: Choanal atresia (CA) is a congenital obstruction of the posterior nasal apertures. Multiple surgical techniques have been proposed to repair the atresia. The purpose of this study is to review the basic science and embryology of CA with emphasis on the senior author's extensive experience, and refinement of the treatment of CA. In addition, we will review the outcomes after surgical correction of pediatric patients with CA. PATIENTS AND METHOD:: Retrospective review of 73 pediatric patients. Demographic information was recorded, including type of CA, concomitant medical problems, surgical method, and date of last follow-up by the surgeon. RESULTS: Our series show a 1.6:1 ratio of unilateral atresia to bilateral atresia. The incidence in males and females is statistically equal. High-arched palate and cross-bite deformities are particularly present if the patients undergo the transpalatal approach in the first year of life. The senior author has evolved to favoring the endoscopic approach, having a minimal long-term complication rate, and low stenosis rate (12%). CONCLUSIONS: The first repair of choanal atresia is the one most likely to succeed. The nasal endoscopic technique is the favored technique. It has the advantages of a low restenosis rate, does not violate the palate, and does not cause the cross-bite and palate arch deformities seen in the transpalatal technique.     

Endoscopic sublabial transnasal approach for correction of congenital choanal atresia

This report highlights the use of the nasal endoscope and drill following a sublabial transnasal approach in achieving effective patency in a case of unilateral posterior choanal atresia (PCA).