CHOANAL ATRESIADR JOEL G MATHEW, DLO

LOURDES HOSPITAL, KOCHI

• Absence of communication between the posterior nasal cavity and the nasopharynx.

• Incidence: 1 in 7000 live births.• 2/3 of cases are unilateral• More common on the right side.

Associated anomaliesCHARGE syndromePolydactylyNasal, auricular and palatal deformitiesCrouzon syndromeTreacher collins syndrome,Apert’s syndromeCraniosynostosisMicrocephalyHypoplasia of the orbit and midfaceCleft palateHypertelorism

Theories of Development• Persistence of the buccopharyngeal

membrane from the foregut,• Persistence of the nasobuccal

membrane of Hochstetter• Abnormal persistence of mesoderm-

forming adhesions in the choanal region,

• Misdirection of mesodermal fl ow secondary to local factors.

Prenatal US in coronal section shows a single ballooned nostril.

Clinical Features

Bilateral choanal atresia• Bilateral choanal atresia is a medical

emergency.• Child has the characteristic cyclic apnea,

cyanosis, and respiratory distress, which are temporarily relieved by crying.

• Bilateral choanal stenosis can present later in life with mouth breathing, recurrent sinusitis, chronic rhinorrhea, otitis media, failure to thrive, and defects of speech.

Unilateral choanal atresia

• Present with unilateral nasal discharge and nasal obstruction.

• On anterior rhinoscopy, the occluded nasal cavity is typically filled with thick, tenacious secretions.

Diagnosis• Typical clinical

features/Neonatal screening• Neonatal screening: Failure

to pass a 6F catheter through the nose into the nasopharynx (32mm)

• Endoscopy -occluded nasal cavity is typically filled with thick, tenacious secretions.

• Before CT, dionosil oil used to be instilled in the nasal cavity, and a lateral view X-ray taken.

• Failure of oil to enter the nasopharynx was taken as evidence of posterior choanal atresia

• Echocardiogram, Renal USS, Ophthalmologic and audiologic evaluation to rule out associated congenital defects

Medial bowing and thickening of the lateral wall of the nasal cavity, with impingement at the level of the anterior aspect of the pterygoid plates

• Differentiate bony from membranous atresia.

• Types:• Pure bony• Mixed bony-membranous• Pure membranous

CT scan is the investigation of choice

• Identifies other associated features:• diminished nasal airway secondary

to septal deflection toward the obstructed side

• widened vomer, • medial bowing of the lateral nasal

wall, • narrowing of the nasopharynx.

Acoustic rhinometry represents a new and valuable tool in the diagnosis of congenital choanal atresia.

TREATMENT• Early surgical approach to bilateral

atresia.• Unilateral atresia with significant

symptoms is operated soon after diagnosis.

• Preoperative planning – with CT scan:• Management of membranous is less complex• Identifies alterations in posterior septum,

configuration of lateral nasal wall and nasopharynx.

• Small Lempert curette or urethral sound is passed through nose to puncture the atretic plate

• Stent is inserted to prevent restenosis.

• Usually requires repeated revisions or dilatations.

• Complications include CSF leak and meningitis.

• Blind technique• Superceded by endoscopic

technique

Transnasal puncture technique

• Modified Trendelenberg position with shoulder extended.

• Mucoperiosteum of palatal bone elevated.

• Muscular aponeurosis and nasopharyngeal mucosa of soft palate is incised.

• Palate is retracted towards nasopharynx.

• Bony atresia plate and posterior third of vomer removed with rongeur or curette.

• Soft Silastic stents inserted and left in place for 2 months for healing and preventing restenosis.

• Palatal flap closed.

Transpalatal technique

• Helpful in neonates with unfavourable nasal anatomy or craniofacial anomalies.

• Sublabial incision into mucosa of floor of nose.

• Septum exposed.• Atretic plate exposed and

removed.

Sublabial Transseptal repair

• A cotton pledget soaked in oxymetazoline placed in nasal cavity to decongest.

• 2.5 to 4.4 mm scope placed in nasal cavity.

• Atretic plates and vomer is removed with powered instrumentation.

• A backbiting rongeur introduced nasally removes a part of vomer.

• Video

Transnasal endoscopic technique

Stents• Traditional part of the postoperative

management.• Stents are not always necessary after

endoscopic surgery. • No clear-cut evidence that stents prevent

stenosis after removal.• Avoid injury to the alar and septal cartilages .• Advisable in children with a higher risk of

failure including neonates and bilateral choanal stenosis.

• Some series show adverse effects of stenting in children with unilateral stenosis.

• Antibiotics• Suctioning and cleaning of stents to ensure patency.• Control crusting

Postoperative Management