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Abstract
Objective: To evaluate current concerns about transnasal endoscopic repair of bilateral congenital choanal
atresia, regarding technical difficulties, prognostic factors and important controversies.
Patients and methods: Ten infants with bilateral congenital choanal atresia, aged from 3 to 27 days
(mean, 11.2 days) were included. All cases underwent transnasal endoscopic repair and were clinically
and endoscopically monitored.
Results: Of the seven patients treated with stenting, five remained patent and two required minor
debridement (with complete patency thereafter). Of the three patients treated without stenting, one
remained patent and two required minor debridement (with patency thereafter).
Conclusions: Transnasal endoscopic repair of bilateral congenital choanal atresia is a safe and successful
technique. The use of powered instrumentation in neonatal patients requires experience and a correctly
sized drill. Stenting with an appropriate nasal tube for a suitable period is favoured, especially in
hospitalised patients.
Key words: Choanal Atresia; Endoscopy; Child; Otorhinolaryngologic Surgical Procedures
Introduction
Congenital choanal atresia is a rare malformation
which causes airway obstruction in neonates and
infants; it has an incidence of one in 7000 to 8000
births. It seems to occur more commonly in girls than
boys, and to be more frequently unilateral and rightsided than bilateral. The nature of the obstructing
atretic plate has been described as 90 per cent bony
and 10 per cent membranous. Modern imaging techniques have revealed that 30 per cent of such malformations consist of a purely bony obstruction, and 70
per cent of a mixed bony-membranous obstruction.1
Most cases of congenital choanal atresia involve
isolated malformations, but association with other
congenital deformities is not exceptional (as in the
CHARGE anomaly syndrome, which includes
coloboma, heart disease, congenital choanal atresia,
retarded development, genital hypoplasia and ear
anomalies).2
There are currently four hypotheses regarding
the embryological origin of congenital choanal
atresia, but none has been proved. These include
the persistence of the nasobuccal membrane or of
the foregut buccopharyngeal membrane, abnormal
mesodermal adhesions in the nasal choanae, and
a misdirection of mesodermal flow due to local
factors.3
Congenital choanal atresia is characterised by
hypertrophy of the posterior vomer, together with
From the ORL Department, Mansoura University Hospital, Mansoura University, Egypt.
Accepted for publication: 13 July 2009. First published online 25 November 2009.
387
388
H M ELADL
FIG. 1
Axial computed tomography scan showing bilateral congenital
choanal atresia.
TABLE I
PATIENT VARIABLES
Pt no
Age
(days)
Sex
Wt
(kg)
Stenosis type
1
2
3
4
5
6
7
8
9
10
Mean
4
15
7
9
5
3
22
13
27
7
11.2
F
M
F
F
M
M
F
M
F
F
2.9
3.2
3.0
3.2
2.9
2.5
3.0
3.2
3.5
3.0
3.04
Mixed
Bony
Bony
Bony
Mixed
Bony
Mixed
Mixed
Bony
Bony
Drilling?
N
Y
Y
N
N
Y
N
N
Y
N
N
Stenting?
(wks)
Y
Y
Y
N
N
Y
Y
Y
Y
N
(3)
(2)
(4)
(4)
(3)
(1)
(2)
2.7
Op time
(min)
Post-op stay
(days)
Follow up
(mths)
80
85
90
85
65
75
60
66
75
60
74.1
3
7
8
6
6
7
8
7
8
4
6.4
35
31
28
24
18
15
12
9
8
5
18.5
Post-op complications
L vestibular stenosis
Bleeding
Pt no patient number; wt weight; wks weeks; op time operation duration; post-op post-operative; mths months;
F female; M male; Y yes; N no; L left
389
FIG. 3
Customised soft nasal stent.
FIG. 2
(a) Endoscopic view of the septal window, showing two posterior choanae (arrows) and septum (star). (b) Endoscopic view of right
choana (arrow) after removal of atretic plate. (c) Endoscopic view of the septal window, showing two posterior choanae (arrows) and
posterior vomer bone (star).
390
FIG. 4
Endoscopic view taken during second look endoscopy,
showing nasal adhesions in the left posterior choana.
H M ELADL
391
resection of the atretic plate and formation of adequate neochoanae bilaterally. Flap preservation and
elevation were technically inapplicable in our
patient age group.
Stenting is preferred in the neonatal age group,
especially in cases with extensive mucosal lacerations
and/or drilling, and in hospitalised patients, to avoid
restenosis and reoperation. In this study of seven
patients with stenting, five remained patent, while
two required minor debridement of granulation
tissue, with a patent result thereafter. Of three
patients without stenting, two remained patent,
while one required minor debridement of granulation
tissue, with a patent result thereafter. However,
prolonged stenting should be avoided, in order to
prevent adhesions, vestibular stenosis and infection.
An adequate post-operative follow-up period and
second look endoscopy are crucial to the success of
this type of surgery. Despite the controversies and
debates regarding transnasal endoscopic repair of
bilateral congenital choanal atresia, this technique
is still target-specific, easily applicable and widely
accepted.
References
1 Brown OE, Smith T, Armstrong E, Grundfast K. The
evaluation of choanal atresia by computed tomography.
Int J Pediatr Otorhinolaryngol 1986;12:85 98
2 Van Den Abbeele T, Francois M, Narcy P. Transnasal endoscopic treatment of choanal atresia without prolonged stenting. Arch Otolaryngol Head Neck Surg 2002;128:93640
3 Hengerer AS, Marshall S. Choanal atresia: a new embryologic theory and its influence on surgical management.
Laryngoscope 1982;92:913 21
4 Wiatrak BJ. Unilateral choanal atresia: initial presentation
and endoscopic repair. Int J Pediatr Otorhinolaryngol 1998;
15:27 35
5 Pardo Romero G, Mogollon Cano-Cortes T, Pando Pinto
JM, Trinidad Ruiz G, Gonzalez Palomino A, Pantoja Hernandez C et al. Endoscopic treatment for choanal atresia
[in Spanish]. Acta Otorrinolaringol Esp 2007;58:34 6
6 Richardson MA, Osguthorpe JD. Surgical management of
choanal atresia. Laryngoscope 1988;98:915 18
7 Kamel R. Transnasal endoscopic approach in congenital
choanal atresia. Laryngoscope 1994;104:642 6
8 Pasquini E, Sciarretta V, Saggese D, Cantaroni C, Macr` G,
Farneti G. Endoscopic treatment of congenital choanal
atresia. Int J Pediatr Otorhinolaryngol 2003;67:271 6
9 Anderhuber W, Stammberger H. Endoscopic surgery of
uni- and bilateral choanal atresia. Auris Nasus Larynx
1997;24:13 19
10 Lazar RH, Younis RT. Transnasal repair of choanal atresia
using telescopes. Arch Otolaryngol Head Neck Surg 1995;
121:517 20
11 Elloy MD, Cochrane LA, Albert DM. Refractory choanal
atresia: what makes a child susceptible? The Great
Ormond Street Hospital experience. J Otolaryngol Head
Neck Surg 2008;37:813 20
12 Stankiewicz JA. The endoscopic repair of choanal atresia.
Otolaryngol Head Neck Surg 1990;103:931 7
13 Andrieu J, Guitrancourt P, Stipon M. Surgery of choanal
atresia [in French]. In: Surgical Techniques-Head and
neck. EMC, Editions Techniques, Paris 1994;[46 230]:
1 10
14 Friedman NR, Mitchell RB, Bailey CM, Albert DM,
Leighton SE. Management and outcome of choanal atresia
correction. Int J Pediatr Otorhinolaryngol 2000;52:4551
15 Samadi DS, Shah UK, Handler SD. Choanal atresia: a
twenty-year review of medical comorbidities and surgical
outcomes. Laryngoscope 2003;113:254 8
16 Cedin AC, Peixoto Rocha JF Jr, Deppermann MB, Moraes
Manzano PA, Murao M, Shimuta AS. Transnasal
392
17
18
19
20
21
22
23
H M ELADL
24 Saetti R, Santoro R, Silvestrini M. Choanal atresia: endoscopic trans-nasal approach. International Congress Series
2003;1254:443 5
25 Westendorff C, Dammann F, Reinert S, Hoffmann J.
Computer-aided surgical treatment of bilateral choanal
atresia. J Craniofac Surg 2007;18:654 60
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