Choanal atresia. Clinical considerations for management

Unilateral choanal atresia in identical twins: case report and literature review

Choanal atresia is postulated to be secondary to an abnormality of the rupture of the buccopharyngeal membrane during the embryological period. This condition usually occurs sporadically, but has been described in siblings and successive generations. The genetics remain unclear. We present monozygotic twins with identical findings of unilateral choanal atresia and no other associated anomalies. To our knowledge, this is the first report of such an occurrence.

Cogenital bony nasal cavity deformities

Although the most common form of nasal obstruction in neonates is soft tissue edema, congenital bony nasal deformities are being recognized as an important cause of newborn airway obstruction. In addition to the well described choanal atresia, CT imaging of the newborn in respiratory distress reveals two other forms of bony nasal cavity deformities: nasal pyriform aperture stenosis and nasal cavity stenosis. All of the three types of bony nasal cavity deformities have characteristic anatomical features, are associated with distinctive congenital anomalies, and are postulated to have differing embryological causes. Five patients with congenital bony nasal cavity deformities are presented. These cases illustrate the clinical and radiological presentation of varied types of congenital nasal cavity obstruction as well as the criteria used to guide clinical management.

Choanal atresia: a new anatomic classification and clinical management applications

The anatomic classification of choanal atresia is commonly quoted as 90% bony and 10% membranous. This incidence is from a review by Fraser in 1910 of 115 cases, "many of which were insufficiently described." We have reviewed 47 computed tomography scans of choanal atresia from the literature and 16 from our clinical experience, and classified the anatomy as bony, mixed bony-membranous, or pure membranous. Our results reveal a combined incidence of 18 (29%) pure bony, 45 (71%) mixed bony-membranous, and no pure membranous atresia. We propose a new classification of choanal atresia to include bony, mixed, and membranous to accurately reflect the anatomic abnormalities. Our series of 11 patients undergoing transnasal microsurgical repair, a critical review of the literature, and the implications of the anatomic classification on the choice of surgical procedure are presented.

Choanal atresia and congenital pharyngeal stenosis

From 1980 to 1992, 8 patients with choanal atresia were treated in our facility. The female to male ratio was 5:3. One patient, a girl, had unilateral osseous obstruction with membranous closure of the opposite naris while the other 7 had bilateral osseous obstruction. Seven of the 8 had other congenital anomalies, CHARGE association (2 cases), Apert's syndrome (1 case), meningocele and banded fingers (1 case), omphalocele (1 case), subdural hematoma (1 case), and nasal fistula (1 case). Of the 7 patients who underwent endonasal surgical repair, 3 (40%) experienced reclosure. The remaining one patient, whose obstruction was of the bilateral osseous type, was successfully operated on via a transpalatal approach. Surgical correction is particularly difficult in those with craniofacial abnormalities, e.g. Apert's syndrome and maxillary hypoplasia. We treated 5 congenital pharyneal stenosis cases (CPS). Our CPS cases were divided into Types 1, 2 and 3, the latter being a new type not previously reported on. We consider Type 3 to be the result of fetal tissue remnants. We performed uvula splitting surgery in 4 cases and obtained good results in 3.

Choanal atresia: How useful is computed tomography

Computed tomography (CT) has recently been hailed as the most useful tool in the diagnosis and management of congenital posterior choanal atreasia. Our study of 11 patients with posterior choanal atresia by CT does not seem to confirm this claim. CT, which demonstrates very clearly all the anatomical details of the region, does not appear to play any major role in the diagnosis of the condition; nor in the planning of the management of patients in whom posterior choanal atreasia is the only major craniofacial abnormality.

Anatomic findings and management of choanal atresia and the CHARGE association

The CHARGE association is a collection of multisystem congenital anomalies including choanal atresia. A review of the literature failed to identify any specific findings that suggested the need to alter the management of choanal atresia in these patients. Our review of 24 patients with choanal atresia managed between 1974 and 1986 identified nine patients with the CHARGE criteria. These nine patients demonstrated a higher prevalence of surgical failures than the patients without the CHARGE association. The reasons are discussed, and computed tomographic scans demonstrate the anatomic findings of a more contracted nasopharynx and narrowed posterior choanal region. Thus, successful repairs require a more radical resection of the posterior nasal septum and lateral bony walls that can be achieved only with a transpalatal approach. The preoperative airways of CHARGE association patients are also at increased risk of obstruction and may require intubation or tracheotomy during the early life of the patient.

Congenital nasal stenosis in neonates

Sixteen newborn infants with respiratory problems due to bony nasal obstruction were studied. In 14 patients no surgery was needed. In two patients surgery became necessary after a few months. Congenital narrowing of the nasal passage was unknown until recently. The origin of the disorder is discussed.

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.

Choanal atresia: early management and an association with marble bone disease

A series of five cases of choanal obstruction is presented and a simple scheme of early management is described. A case of Albers-Schönberg Syndrome presenting with choanal atresia is also described.

Surgery of choanal atresia in infants and children: historical notes and updated review

This review of the surgical treatment of congenital choanal atresia starts with the first descriptions of the disease and its successful operations in the 19th century. Then, data concerning the facial development of the untreated and surgically corrected disease are presented. After that, advantages and drawbacks of the transnasal, transpalatal and transseptal approaches are discussed.