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

Congenital choanal atresia where the atretic wall thickened while waiting for an elective surgery

INTRODUCTION AND IMPORTANCE

Although bilateral congenital choanal atresia (CCA) requires early intervention to open closure walls for safe breathing, it is desirable to be withheld until an infant acquires surgical and anesthetic tolerance. Here we introduce an infant of CCA whose closure wall had thickened during a waiting period for an elective surgery.

CASE PRESENTATION

The choana of the patient could not be identified by intranasal fiberscopy and the bilateral CCA was found by CT scan on day 17 after birth. Since he could breathe orally without distress, surgery was withheld until he acquires the tolerance. At nine weeks old, however, CT image detected thickening of the closure wall. At 10 weeks old, he underwent scheduled surgery in which the bilateral closure walls were removed together with attached posterior part of the nasal septum under endoscopic endonasal approach. The patient became able to breath nasally and the choana remained open without restenosis at 3 years after surgery.

CLINICAL DISCUSSION

This is the first CCA case reporting closure walls thickened during a waiting period for an elective surgery. Although waiting for surgery was systemically safer by growth, the surgery became more invasive to prevention from restenosis.

CONCLUSIONS

This case suggests that we must decide appropriate timing of surgery in an infant, considering dilemma between systemic safety ensuring and lesion aggravation by waiting for surgery.

Neonatal Nasal Obstruction: A Comprehensive Analysis of Our 20 Years' Experience

Neonates are obligatory nasal breathers hence nasal obstruction is a very important symptom to be evaluated. Although causes can be trivial most of the time, they can be life-threatening in some. Respiratory distress immediately after birth, feeding difficulties, paradoxical cyanosis, and failure to thrive are the most evident symptoms, and determination of unilateral or bilateral involvement guides the rationale for elective or emergency intervention. This study aimed to evaluate the causes, presentation, and management of neonates with nasal obstruction. We collected the data of all the neonates evaluated for nasal obstruction at our hospital over the past 20 years from June 2003 to May 2023 and assessed the strategy of approach for diagnosis and management of those cases. In our study, the commonest cause for neonatal nasal obstruction was found to be choanal atresia and the rarest was iatrogenic. A variety of other causes were also reported. As neonatal nasal obstruction has a multitude of rare causes each carries a unique assessment and treatment plan. History taking and clinical examination are the most important parts of evaluation including endoscopic evaluation in an office-based setup. Imaging studies add to the evaluation of cases of anatomical obstructions and associated anomalies (syndromes). Early diagnosis and swift intervention can be life-saving. The need for follow-up visits and second-stage corrections should be emphasized in getting the best long-term results.

Bilateral Choanal Atresia in a 42-year-old Patient: A Rare Condition Case Report

Choanal atresia is an uncommon condition with an incidence of 1:5,000-8,000 live births, affecting females more frequently and often associated with other malformations. This case report presents a 42-year-old female patient who was born with bilateral choanal atresia and intervened surgically for the first time at birth. However, the formed orifice was reobstructed a few months afterward, necessitating reoperation in adulthood. The purpose of this case report is to describe bilateral choanal atresia in detail, including its clinical presentation, epidemiology, diagnosis, pathogenesis, and therapeutic approach. It aims to enhance understanding of this rare but significant condition.

Pädiatrische Rhinologie

The following review article highlights key topics in pediatric rhinology that are currently the focus in research and at conferences as well as in the interdisciplinary discussion between otorhinolaryngologists and pediatricians. In particular, congenital malformations such as choanal atresia or nasal dermoid cysts are discussed, followed by statements on the current procedures for sinogenic orbital complications as well as on the diagnosis and therapy of chronic rhinosinusitis in children. Furthermore, updates on the role of the ENT specialist in the care for children with cystic fibrosis and primary ciliary dyskinesia are provided.

Can a second look improve the outcome of endoscopic choanal atresia repair?

PURPOSE

To evaluate the outcome of a routine postoperative endoscopic micro-debridement of granulation tissue after stentless transnasal endoscopic repair of choanal atresia (CA).

METHODS

This prospective case series included congenital CA patients who underwent stentless transnasal endoscopic repair, followed by an endoscopic second look and micro-debridement of granulation tissue at 1-2 weeks post-repair. Patients were followed every three months for assessment of nasal airway symptoms and objective evaluation by flexible nasolaryngoscopy.

RESULTS

Sixteen CA patients (8 bilateral and 8 unilateral) underwent surgical repair (12 primary and 4 revisions). The median  age was 13 days (range 1 day-6 months) in bilateral and 3 years  (range 7 months-15 years) in unilateral atresia. The mean follow-up was 1.5 years (range 1 year-3 years). In primary procedures, the obstruction was bony-membranous in 7 cases and bony in 5 cases. The mean interval time between the CA repair and re-examination was 10.75 days (range 6-18 days). Clinically significant neochoanal restenosis was not encountered.

CONCLUSIONS

Re-examination under general anesthesia with endoscopic micro-debridement of granulation tissue is a safe, potentially effective adjunct when done during the proliferative phase of neochoanal wound healing. This procedure might help in maintaining neochoanal patency by remodeling tissue healing process. Large-scale, long-term cohort studies are imperative.

Bilateral congenital choanal atresia in a preterm neonate - a rare neonatal emergency: A case report and review of literature

Congenital choanal atresia results from the developmental failure of the nasal cavity to connect posteriorly with the nasopharynx. Although congenital choanal atresia is a well-recognized developmental disorder, it is an uncommon condition with an overall incidence of approximately 1 per 10,000 live births. The authors aim to highlight that in very preterm neonates, early diagnosis of bilateral congenital choanal atresia needs a high index of suspicion to avoid life-threatening events. It is considered as one of the neonatal emergencies, and repair is recommended in the first few weeks of life. The authors report an uncommon presentation of a very preterm neonate born at 31 weeks of gestation, diagnosed to have bilateral congenital choanal atresia with repeated failure of a trial of extubation. A transnasal endoscopic repair was performed in the eighth week of life to relieve the life-threatening nasal obstruction.

[Clinical Management of Choanal Atresia]

Choanal atresia (CA) is a rare congenital anomaly of the nasal airway with an incidence of 1/5000 to 1/9000, which may occur unilateral (uCA) or bilateral (bCA). bCA manifests as an acute emergency immediately after birth by airway obstruction and paradoxical cyanosis, whereas uCA may present with a heterogeneous clinical picture in addition to unilateral nasal airway obstruction. Fiber endoscopic examination and cranial computed tomography are the gold standard in the diagnosis of CA. CA often occurs in association with congenital malformation syndromes, among which CHARGE syndrome stands out. Due to cardiopulmonary instability and difficult intubation conditions, syndromic CA patients should be considered as a separate risk group. After securing the airway, bCA must be treated surgically without delay, whereas correction of uCA should not be performed until after six months of age. Endoscopic techniques are the surgical standard in the treatment of CA. Different approaches can be distinguished: transnasal puncture of the atresia plate with subsequent extension medially and laterally, creation of a septal window with subsequent resection of the posterior vomer and atresia plate, and elevation of mucoperiosteal flaps with subsequent opening of the atresia plate. The transpalatal approach should only be employed in anatomically complex cases. The use of conventional choanal stents in the primary treatment of CA is increasingly rejected and should be reserved for high-risk constellations. Similarly, local application of mitomycin C should be avoided.

Empirical overview of a delayed diagnosis of bilateral congenital choanal atresia in an adolescent male: management with 'coblation-assisted surgery'

Bilateral choanal atresia (CA) is a congenital anomaly consisting of an imperforated choana that leads to newborn fatalities but, if unilateral, may go unnoticed for many years. Bilateral CA occurring without significant symptoms and remaining undiagnosed for many years is rare. This case report identifies an adolescent male with bilateral CA who remained undiagnosed till adolescence. The patient presented with isolated complaints of chronic nasal obstruction and discharge and was diagnosed with bilateral CA by endoscopic and radiological evaluation. The patient underwent a coblation-assisted endoscopic CA repair, with a crossover mucoperiosteal flap technique, without stenting and with a successful outcome.

The utility of balloon dilation for piriform aperture stenosis - A first line surgical treatment

AIM

Describe the long-term outcomes of patients with piriform aperture stenosis managed with balloon dilation.

METHODS

Review of current literature. A retrospective case series of 6 patients with piriform aperture stenosis initially managed with balloon dilation at a tertiary paediatric hospital.

RESULTS

Six neonates diagnosed with piriform aperture were managed with balloon dilation under general anaesthesia after failing conservative treatment. Average age at first dilation was 28 days old (range 6-54). The piriform aperture was an average width of 5.15 mm, with a 4-6.5 mm range, as measured on axial CT scan. The average width at 25% of the nasal cavity, 50% and 75% was 7.7 mm, 9.3 mm and 9.98 mm respectively. Four neonates required only a single balloon dilation - two of these were stented post-operatively. The remaining two neonates required multiple balloon dilations with eventual drill-out through a sublabial approach. There was a trend of smaller piriform and nasal cavity diameters in those who required multiple procedures. The mean follow-up was 30 months.

CONCLUSION

Balloon dilation should be considered for primary operative management in neonates with piriform aperture stenosis who fail medical interventions. Balloon dilation can treat the narrowing at and beyond the piriform aperture. Patients who require more than one dilation are more likely to have a smaller piriform aperture and may need a drill-out procedure. The impact of nasal stents on outcomes is unclear.

Management of Choanal Atresia: National Recommendations with a Comprehensive Literature Review

Choanal atresia is the most common congenital anatomical abnormality of the nasal cavities, manifested with a clinical picture of neonatal respiratory distress. The treatment requires interdisciplinary management based mainly on tertiary referral centre experiences. However, there is a lack of high-quality evidence in the available literature. Recommendations were prepared based on a systematic review of the supporting literature: on a website survey addressed to the participating authors consisting of 28 questions and on five live meetings. The initial response to the recommendations was determined at their presentation at the sectional meeting of the section for otorhinolaryngology of the Slovenian Medical Association. Then, reactions from the professional public were accepted until the recommendations were presented at the Expert Council for Otorhinolaryngology of the Slovenian Medical Association. A systematic literature review identified eight systematic reviews or meta-analyses and four randomized controlled clinical trials. Thirty-four recommendations for diagnosis, treatment and postoperative management were consolidated. The paper presents the proposal and first Slovenian recommendations for treating patients with choanal atresia. They are based on foreign medical institutions' published literature and our clinical experience. They represent the basic requirements of diagnostics and may represent an essential guide in treatment.

Characteristics of Choanal Atresia in Patients With Congenital Anomalies: A Retrospective Study

Introduction

Choanal atresia (CA) is an uncommon congenital anomaly. There are various syndromes that are associated with CA. The purpose of this study is to determine the differences in CA's presentation and outcome when associated with other congenital anomalies and syndromes.

Method

This is a retrospective review study of all children (18 years and younger) who underwent CA repair in a tertiary referral healthcare center from January 2005 to April 2022. Demographics, comorbidities, radiological testing, operative reports, and outpatient reports were collected. Success was determined as a child with bilateral patent choana that is able to breathe from both nostrils comfortably.

Result

Twenty-four patients met the criteria for inclusion in this study. Bilateral CA was present in 15 (62.5%) patients. Mixed CA was the most common variant. There were various congenital anomalies in association with CA patients who are yet to be classified into a syndrome. The most common congenital anomaly was cleft lip and palate. Bony and mixed types were significantly associated with non-syndromic patients (p<0.05). Twenty patients (83%) were diagnosed with CA at age of less than one year, and four patients were diagnosed after one year of age. There were 36 surgeries performed on 24 patients, of which 27 were endoscopic and nine were using Hugher dilator. The overall success rate for CA repair was 50%. The median number of revisions per patient was 0.5.

Conclusion

CA is a challenging anomaly to repair. There are various factors that influence the outcome of children with CA. Otolaryngologists should counsel the patient and their families regarding possible need for revision especially in those with other craniofacial anomalies.

Treatment of choanal atresia in a cohort of 29 patients: Determinants for success or failure

BACKGROUND

Choanal Atresia is a congenital condition that presents as a blockage from the nasal cavity to the nasopharynx. According to the German statistical Institute (Statistisches Bundesamt), the incidence in Germany in 2018 reached 2.74 in 10,000 live births. It can present unilaterally or bilaterally. As newborns are obligate nasal breathers, management of bilateral atresia has to be performed early after birth. As for unilateral atresia, the optimal age for treatment was determined to be between 6 and 12 months in a recently published consensus.

OBJECTIVE

The main purpose of this study is to characterize the patients treated for choanal atresia in the Department of Otorhinolaryngology and Head and Neck Surgery at a tertiary hospital in the south of Germany and, based in the demographic characteristics as well as intra- and post-operative treatment, to identify factors for success or failure of the surgery. A secondary goal was to describe the complications in the use of stents and analyse its influence in the results.

MATERIAL AND METHODS

The cohort-based observational study included 29 patients, with a minimum follow up of one year, who underwent surgical endoscopic correction of both unilateral and bilateral choanal atresia from 2003 to 2020. Analysis of the demographics, intraoperative, and postoperative treatment, and their results, was performed. Multinomial logistic regression was applied for categorical values. Comparisons were performed using Fischer/chi-square test where applicable. A significance level of 0.05 was reached.

RESULTS

The population was comprised of 34.5% male and 65.5% female patients. The age varied from 2 days to 20 years old, with a mean of 4.98 years and Standard Deviation (SD) 6.88. The weight of the patients varied between 1.4 kg and 85.0 kg, with a mean of 19.36 and SD 22.58. Unilateral choanal atresia was present in 58.6%, and bilateral in 41.4%. Out of this population, 48.3% presented with associated malformations. The number of procedures per patient performed in general anesthesia varied from 1 to 9, with a mean of 2.52 and SD of 2.23: statistically higher for patients presenting with bilateral atresia with a p value of 0.001*. 20 patients had a tube (Vygon, France) placed at first surgery. In 5 patients, a drug-eluting stent (Propel mini ^(R); Intersect ENT, USA) was applied intraoperatively, without complications. In unilateral choanal atresia, surgical and functional success was attained in 88.2% of the cases. In bilateral cases, it reached 75%. We observed a strong linear relationship between the weight of the patient and the size of the choana perioperatively: R quadrat 0.596, which may be a determinant factor in the wound healing. Weight, age, and concomitant pathology achieved statistical significance in the logistic regression model (p respectively 0.001*, 0.001* and 0.010*), which shows its influence in the result of the surgery. In particular, weight inferior to 3 kg (p 0.001*, chi-square test) at the time of the first surgery is a determinant demographic factor for need of revision in order to achieve patency. There were no major complications associated with the use of a stent, besides its dislodgement. We could not infer an implication of its use on the success of the surgery in the present cohort.

LIMITATIONS

for this study were the small size of the cohort and non-standardized records for some variables.

CONCLUSIONS

Younger patients presenting with low weight and concomitant pathology have worse results after surgical endoscopic treatment of choanal atresia, revealing these characteristics to be determinant for success. The size of the neochoana is related to the weight of the patient, which is a limiting factor. In particular, patients under 3 kg had to undergo more procedures in order to achieve patency. The implication of the use of locally applied medication needs to be further studied.

Nasal Obstruction in the Infant

Neonatal nasal obstruction is common in both the hospital and clinic settings. Causes can range from rhinitis to congenital masses, with a wide variety of congenital nasal masses described. A complete history and physical examination are necessary for correct diagnosis and management. Arhinia and bilateral choanal atresia will present with complete obstruction leading to forced mouth breathing. Partial obstruction will require assessment of nasal patency with possible nasal endoscopy and imaging. Medical and surgical options for treatment are discussed.

Congenital bilateral choanal atresia: an endoscopic approach with multi-flaps supported by neuronavigated CT

We present a case of a 2-month-old patient with CHARGE syndrome, cerebral haemorrhage and bilateral congenital choanal atresia (CCA). He was admitted to our otorhinolaryngology unit to solve his congenital bilateral choanal atresia proposing a transnasal endoscopic surgery. A study of CT of the skull showed that the air column was interrupted on both sides of nasal cavities; a nasal endoscopy with neonatology flexible optics showed the presence of a membrane and bony structure obstructing the passage into the nasopharynx. Preoperative brain magnetic resonance (MRN) has been made. We decided to carry out a transnasal endoscopic neuronavigation approach with multi-flaps without stenting apposition to solve the CCA, using a 0° 2.7-millimetre rigid endoscopic and Skeeter-type drill with a 2.3-millimetre microblade cutter. Postoperative nasal care was essential to avoid recurrences. Endoscopic follow-up was performed; a large uni-neochoane was residual at 3 months, all raw surfaces were covered by multiple mucosal flaps welded with fibrin.

A Case Report of Late Diagnosis of Bilateral Choanal Atresia

Choanal atresia (CA) is a congenital closure of the posterior nasal choanae. The closure can be unilateral or bilateral. Since the first report of CA, there have been controversies regarding its pathogenesis and the effectiveness of surgical approaches. The few cases reported in the literature were not diagnosed immediately after birth. We present a case of delayed presentation of CA. The patient was born pre-term (35 weeks) by cesarean section. He was diagnosed with bilateral CA by history, physical examination, endoscopic and radiologicalimages at five months of age.

Congenital bilateral CA is rarely discovered in neonatal patients after one week of age, therefore few such cases have been reported in the literature. Nasal endoscopy and computed tomography help diagnose CA before planning surgery. Several surgical approaches for repairing congenital CA have been reported, including the transnasal and transpalatal routes. Endoscopic transnasal choanoplasty is currently the preferred approach.

Though CA is a rare congenital malformation, there are cases with a delayed diagnoses reported in the literature. These findings raise the question of whether all newborns are obligate nasal breathers. Although rare, bilateral CA should be suspected in infants who exhibit difficulty with feeding and bilateral nasal obstruction, as in such cases it is impossible to feed and breathe simultaneously.

Features and Strategies in the Management of Choanal Atresia: A 6-Year Retrospective Analysis

INTRODUCTION

Choanal atresia although rare, is the most common inborn nasal deformity and an important cause of newborn airway obstruction. This study aims to describe a single-center experience in the management of choanal atresia and emphasize the ambiguous issues regarding its surgical repair.

PATIENTS AND METHODS

The authors retrospectively analyzed the treatment strategy of 18 patients with choanal atresia and their outcomes during the follow-up period.

RESULTS

Bilateral choanal atresia was diagnosed in 9 patients, 6 of those had mixed bony-membranous type (67% versus 33% who had pure bony type). Almost half of the 18 patients had a mixed bony-membranous type of atresia (56%). Interestingly, 89% of patients with bilateral atresia underwent transnasal endoscopic repair with stenting, compared to 44% of those with unilateral atresia (P = 0.04). A trend to preference of stent procedure in patients with bony type was also observed, in comparison with mixed bony-membranous type (89% versus 50%, P = 0.09). No significant difference in the need for revision treatment was noticed among the two treatment groups.

CONCLUSIONS

Both in our data and literature there is no clear supremacy of stenting. Considering the high incidence of re-stenosis, all patients should be under close follow up for a long-term period. Inevitably, further investigation is necessary to establish an ideal surgical procedure.

Synergistic role of retinoic acid signaling and Gata3 during primitive choanae formation

Developmental defects of primitive choanae, an anatomical path to connect the embryonic nasal and oral cavity, result in disorders called choanal atresia, which are associated with many congenital diseases and require immediate clinical intervention after birth. Previous studies revealed that reduced retinoid signaling underlies the etiology of choanal atresia. In the present study, by using multiple mouse models which conditionally deleted Rdh10 and Gata3 during embryogenesis, we showed that Gata3 expression is regulated by retinoid signaling during embryonic craniofacial development and plays crucial roles for development of the primitive choanae. Interestingly, Gata3 loss of function is known to cause hypoparathyroidism, sensorineural deafness and renal disease (HDR) syndrome, which exhibits choanal atresia as one of the phenotypes in humans. Our model partially phenocopies HDR syndrome with choanal atresia, and is thus a useful tool for investigating the molecular and cellular mechanisms of HDR syndrome. We further uncovered critical synergy of Gata3 and retinoid signaling during embryonic development, which will shed light on novel molecular and cellular etiology of congenital defects in primitive choanae formation.

Bilateral Choanal Atresia and Endoscopic Surgery: A Chance for CHARGE Patients

Bilateral choanal atresia (CA) is a rare congenital malformation frequently associated with other anomalies. CHARGE association is closely linked to bilateral CA. The aim of this study was to describe the outcomes of the endoscopic repair in bilateral CA, and to assess the role of postoperative nasal stenting in two cohorts of CHARGE-associated and non-syndromic CA. Thirty-nine children were retrospectively analyzed (16 patients had CHARGE-associated CA). The rate of postoperative neochoanal restenosis was 31.3% in the CHARGE population, and 47.8% in the non-syndromic CA cohort. Data on postoperative synechiae and granulation tissue formation, need for endonasal toilette and dilation procedures, and number of procedures per patient were presented. Stent positioning led to a higher number of postoperative dilation procedures per patient in the non-syndromic cohort (p = 0.018), and to a higher rate of restenosis both in the CHARGE-associated, and non-syndromic CA populations. Children with CHARGE-associated and non-syndromic bilateral CA benefitted from endonasal endoscopic CA correction. The postoperative application of an endonasal stent should be carefully evaluated.

Radiological Parameters Review for Choanal Atresia

(1) Background: The study aims to identify which imaging parameters are necessary for a new correct surgical approach in the study of choanal atresia, and which anatomical findings are essential for correct planning of endoscopic treatment in choanal atresia. (2) Methods: In this retrospective study, 19 patients with choanal atresia had high-resolution multiplanar imaging (14 cases aged ≤1 year and 5 cases aged 1 to 3 years) and 35 patients in the control group similarly distributed by age. Fourteen variables, the most relevant from a surgical point of view, were selected and measured. A comparison was made between the averages of the study group and the different control groups, either directly observed or selected from the literature, using Pearson's correlation. (3) Results: In 14 out of 26 cases, the differences were statistically significant. There was a correlation between the structures assessed, such as choanal height, rostrum height, and age. (4) Conclusions: Thanks to volumetric reformatting, this work identified and provided the clinician with useful information that helped choose the correct surgical approach. Furthermore, it focused on which imaging parameters are necessary to improve the planning of the surgical correction of choanal atresia.

Neonatal nasal obstruction

PURPOSE

Congenital nasal obstruction can be a significant cause of respiratory distress in the newborn, given that they are considered to be obligate nasal breathers. Several different causes have been described, which can be broadly classified as anatomical/malformative, non-tumoral masses and cysts, benign and malignant neoplasia, inflammatory/infectious, traumatic/iatrogenic, and miscellaneous. The purpose of this review is to provide updated and useful clinical information for teams involved in neonatal care, especially in a hospital setting.

METHODS

A review of the available literature was performed. Studies were sourced from PubMed with searching of relevant headings and sub-headings and cross-referencing.

RESULTS

The most common etiology is inflammatory, which can have different precipitating factors or be idiopathic, a condition known as neonatal rhinitis. On the other hand, some less frequent but nonetheless relevant conditions causing severe nasal obstruction include choanal atresia, midnasal stenosis, and pyriform aperture stenosis. Some cystic lesions, such as dacryocystoceles with intranasal mucocele, can also produce significant obstruction. Diagnosis usually requires a nasal endoscopy and in some cases imaging such as computed tomography. Management includes different medical and surgical strategies and will greatly depend on the etiology and the severity of symptoms.

CONCLUSION

Congenital nasal obstruction can be a significant cause of respiratory distress in the newborn. The wide spectrum of differential diagnoses requires a thorough knowledge of nasal anatomy, physiology, and pathology; as well as different management strategies.

Choanal atresia surgery: outcomes in 42 patients over 20 years and a review of the literature

BACKGROUND

Choanal Atresia (CA) is potentially life-threatening and its repair has a variable revision rate.

OBJECTIVES

A case series study from 1997 to 2017 to evaluate the results of repair of CA and review factors affecting outcome.

METHODS

Forty-two patients aged one day to 16 years were included. The outcome measures were the number of revision operations and the length of time over which surgery was required. A focused review of the recent literature (2000-2018) was done.

RESULTS

Bilateral cases (17) had a mean of 5.24 operations compared to 2.2 operations in unilateral cases (25). Nine patients had bony CA and required 3.56 operations, twenty-four patients had mixed CA and required 3.58 operations. Twelve patients with comorbidities required more operations. Patients with reflux disease required a mean of 4.67 operations.

CONCLUSION

An increased rate of restenosis was found in patients with bilateral CA, GERD and those with comorbidities. Parents should be counselled regarding the likelihood of revision surgery. Use of stents or Mitomycin C did not impact the revision rate in this series.

Pediatric unilateral isolated choanal atresia is not associated with mandibular condyle hypoplasia

PURPOSE

We hypothesized that the ontogeny of unilateral isolated choanal atresia involves a field defect manifesting as ipsilateral mandibular condylar hypoplasia. The topic is important because the mechanism of the unilateral isolated choanal atresia is unknown.

MATERIALS AND METHODS

Retrospective self-controlled case series. We included 20 patients (2 males and 18 females, ages 2 weeks to 13 years) with unilateral isolated non-syndromic choanal atresia. We studied their high-resolution computed tomographic scans. Two otolaryngologists measured the largest cross-sectional area of the mandibular condyle in the axial plane perpendicular to the posterior border of each mandibular ramus independently. Statistical significance and inter-rater agreement were calculated with paired Wilcoxon rank sum test and Spearman's non-parametric correlation coefficient respectively.

RESULTS

Cross-sectional areas of the condyles ipsilateral to the choanal atresia were not statistically different than those of the contralateral condyle (P = 0.27). Inter-observer agreement of condyle areas was excellent: Spearman's r = 0.85 on the right and r = 0.94 on the left.

CONCLUSIONS

In this cohort of children with the rarity of isolated non-syndromic unilateral congenital choanal atresia, no associated mandibular condyle hypoplasia was found. The data suggest that the underlying ontogeny was unlikely attributable to a field defect.

Diagnostics and therapy of bilateral choanal atresia in association with CHARGE syndrome

BACKGROUND

Bilateral choanal atresia in patients with CHARGE syndrome becomes symptomatic immediately after birth. A prompt diagnosis, the implementation of sufficient preliminary measures, and the delivery of surgical therapy are crucial. This article is intended to assist in terms of diagnostics and a therapy recommendation.

METHODS

We performed a retrospective study using the medical records of all newborns in the University Hospital in Bonn, diagnosed with bilateral choanal atresia and CHARGE syndrome and underwent surgery at the Department of Otorhinolaryngology, Head and Neck Surgery.

RESULTS

A total of 21 patients have been treated with a unilateral or bilateral choanal atresia. 14 patients were primarily treated with transnasal endoscopy or underwent transnasal endoscopic surgery as a follow-up intervention (73.68%). Nine patients had a syndromal appearance, which was considered a definite diagnosis in six patients (five with CHARGE syndrome). All five patients with CHARGE syndrome received transnasal endoscopic treatment and a stent was inserted.

DISCUSSION

Bilateral choanal atresia can be a life-threatening situation requiring acute measures. The therapeutic trend goes towards transnasal endoscopic resection. Primary intervention should be: minimally invasive, one-stage surgery, functional, and associated with low complication rates. Patency can be increased by saline irrigations, topical corticosteroids, endoscopic controls, and regular dilatation. The insertion of stents is controversially discussed but can be useful in syndromal patients. However, adjuvant therapy with a stent and mitomycin C is increasingly being abandoned. A significantly higher recurrence rate must be expected in association with CHARGE syndrome. Stenting should be considered on an individual basis. Continuous training and support of the parents are obligatory.

Nasal cavity shape in unilateral choanal atresia and the role of fetal ventilation in facial growth

OBJECTIVE

The respiratory movements of fetal amniotic fluid areconsidered by certains cleft surgery teams to contribute to the growth of the nasal cavities (NC). To assess this functional hypothesis, we considered a group of patients with unilateral choanal atresia (CA) as a model of unilateral absence of amniotic fluid flux in the NC, and compared their NCs shape to age-matched controls.

MATERIAL AND METHODS

Three-dimensional reconstructions of NC were performed using Avizo 9.7 (Thermo Fisher Scientific, MA, USA), based on CT-scans of 32 patients with unilateral CA and 96 age- and gender-matched controls. Landmarks were placed on anatomical structures of NC. Procrustes superimpositions and principal component analysis were performed. Anatomically relevant Euclidean distances were computed using the coordinates of selected landmarks - maxillary length, piriform orifice width, choanal width - and tested using multivariate analysis. Growth rates between patients and controls for these distances were screened for correlations.

RESULTS

The atretic NC was significantly deformed when compared to the control cases: Procrustes distance was 0.28 (P<0.0001). The maxillary length and width of the atretic choana were significantly decreased compared to controls (-2.95mm and -1.35mm respectively, P<0.001). There were no differences in growth rates between CA and controls, except for the choanal width on the atretic side.

CONCLUSION

NCs in CA were significantly different from controls. More precisely, the maxillary length was significantly reduced in the CA group. There was no other major shape difference between the NC in CA and controls. NC seems to develop despite abnormal fetal ventilation.

Surgical Management of Choanal Atresia With Intranasal Hegar's Dilator and Transnasal Endoscopic Excision: A 20-year Retrospective Comparative Study

Background

Although choanal atresia (CA) was first described 250 years ago, its description and understanding remain incomplete, as is the distinction between unilateral and bilateral CA. Among the surgical techniques introduced to manage this condition are intranasal Hegar’s dilator (IHD) and transnasal endoscopic excision (TNEE).

Objectives

This study retrospectively evaluated the outcomes and effectiveness of IHD and TNEE in the treatment of patients with CA, including differences in the incidence of re-stenosis with these techniques.

Methods

Patients diagnosed with CA who underwent surgical interventions in the Otolaryngology Department of Al-Noor Specialist Hospital, Makkah, Saudi Arabia, between 1997 and 2017 were analyzed. Postoperative outcomes including re-stenosis rates were compared in patients who underwent IHD and TNEE. Factors associated with patient outcomes were analyzed, including ages at diagnosis and surgery, nationality, gender, type of atresia (unilateral/bilateral and bony/membranous/mixed), surgical intervention (IHD or TNEE), and re-stenosis and need for revision surgery after IHD and TNEE.

Results

A total of 30 patients were diagnosed with CA, including 21 (70%) girls and 9 (30%) boys. Of them, 18 (60%) patients were diagnosed at younger than one month of age, 28 (93%) were Saudi nationals, and 20 (67.70%) were aged younger than three months at the time of surgery. Of these 30 patients, 17 (56.70%, all Saudi nationals) underwent IHD, and 13 (43.30%), including 15 Saudi nationals, underwent TNEE. The 17 patients who underwent IHD included 13 (76.50%) girls and 4 (23.50%) boys, whereas the 13 patients who underwent TNEE included 8 (61.50%) girls and 5 (38.50%) boys. Fifteen patients (50%) had mixed-type CA, nine (30%) had bony-type CA, and six (20%) had membranous-type CA. Twenty-six (86.67%) patients underwent primary surgery, whereas four (13.33%) underwent revision surgery; of the latter, three (75%) had undergone primary IHD, and one had undergone primary TNEE. Only one (3.33%) patient experienced re-stenosis after revision surgery, which consisted of IHD. Twelve patients (40%) underwent stenting, with one developing re-stenosis. The relationships between surgical approach and re-stenosis after primary and secondary surgery were not statistically significant.

Conclusion

The outcomes in patients with CA treated with IHD and TNEE are comparable. Rates of re-stenosis and need for revision surgery do not differ significantly in patients treated with these surgical approaches.

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Diagnosis, pre-operative, operative and post-operative pediatric choanal atresia care

OBJECTIVE

To provide recommendations to otolaryngologists and allied physicians for the comprehensive management of young infants who present with signs or symptoms of choanal atresia.

METHODS

A two-iterative delphi method questionnaire was used to establish expert recommendations by the members of the International Otolaryngology Group (IPOG), on the diagnostic, intra-operative, post-operative and revision surgery considerations.

RESULTS

Twenty-eight members completed the survey, in 22 tertiary-care center departments representing 8 countries. The main consensual recommendations were: nasal endoscopy or fiberscopy and CT imaging are recommended for diagnosis; unilateral choanal atresia repair should be delayed after at least age 6 months whenever possible; transnasal endoscopic repair is the preferred technique; long term follow-up is recommended (minimum one year) using nasal nasofiberscopy or rigid endoscopy, without systematic imaging.

CONCLUSION

Choanal atresia care consensus recommendations are aimed at improving patient-centered care in neonates, infants and children with choanal atresia.

Anesthesia management in patients with choanal atresia

In this retrospective study, we reviewed the anesthesia management of patients with choanal atresia (CA). Fourteen patients undergoing surgery for CA between June 2007 and September 2018 were evaluated for age, gender, CA side, complications, American Society of Anesthesiologists score, duration of anesthesia, and presence of any additional anomalies. Six patients (42%) had bilateral atresia, and 8 (58%) had unilateral atresia. Various congenital anomalies were present in 50% of patients with bilateral atresia. Three patients were intubated with a C-MAC D pediatric blade because their Cormack-Lehane grade was 3 or 4. Though sevoflurane was used for all patients, total intravenous anesthesia was used for two patients with unilateral atresia. All patients were followed postoperatively while intubated except one patient with bilateral atresia. There was no need for postoperative intubation of any patients with unilateral atresia. In conclusion, clinicians should be aware of perioperative and postoperative complications in patients with CA, bilateral atresia, and accompanying congenital anomalies in the neonatal period. Total intravenous anesthesia can be chosen instead of inhalation anesthesia in appropriate cases, but sevoflurane can be used safely in the induction of anesthesia.

Short-Term Risk Factor Profile of Pediatric Choanal Atresia Repair Using ACS-NSQIP National Database

OBJECTIVES

The goal of this study is to describe the 30-day postoperative sequelae of pediatric choanal atresia repair and identify predictive factors for adverse events.

STUDY DESIGN

The American College of Surgeons' National Surgery Quality Improvement Program-Pediatric (NSQIP-P) database was searched between January 2012 and December 2015 to identify pediatric patients status post choanal atresia repair. Postoperative outcomes included surgical site complications, readmissions, and total length of stay.

RESULTS

A total of 178 children underwent choanal atresia repair. The overall complication rate was 6.2%, while the 30-day readmission rate was 15%. Patients with CHARGE had a longer mean duration of hospitalization (26.91 days vs 8.05 days, P = .013). Additionally, patients ≤10 days of age had longer duration of hospitalization (17.84 days vs 9.24 days, P ≤ .001) and higher readmission rates (33.30% vs 10.1%, P = .001). Among the nonsyndromic cohort, ventilator dependence was a predictor of postoperative complications (odds ratio [OR] = 16.08, P < .001), higher readmission rates (OR = 5.46, P = .002), and a longer hospital stay (OR = 18.69, P < .001).

CONCLUSION

Analysis of the 2012-2015 NSQIP-P data set reveals that patients with a diagnosis of CHARGE and those ≤10 days of age have a longer duration of hospitalization. Increased risk of postoperative complications and longer duration of hospitalization were both influenced by chronic steroid use and ventilator dependence.

Skull base anatomy and surgical safety in isolated and CHARGE-associated bilateral choanal atresia

INTRODUCTION

Bilateral choanal atresia (BCA) is associated with a high incidence of congenital abnormalities that include skull base anomalies and defects. Surgical repair of BCA is necessary in the early neonatal period and any altered anatomy of the adjacent skull base will heighten the risk of intracranial injury. This risk may be further increased in patients with CHARGE syndrome.

OBJECTIVES

To measure surgically relevant nasal and skull base dimensions in neonates with BCA in order to determine whether any difference exists between isolated and CHARGE syndrome associated subgroups, thereby optimizing the safety of surgical repair.

METHODS

A retrospective review of medical charts and computed tomography was undertaken at a tertiary pediatric hospital of all neonates diagnosed with BCA between 2004 and 2016. Isolated and CHARGE syndrome subgroups of BCA were identified from clinical records and CT data was analyzed and compared between the two. The skull base parameters measured were choanal width, choanal height, mid-nasal skull base height and skull base slope.

RESULTS

Of the 13 patients included, 3 had CHARGE syndrome and 10 had isolated BCA. Whilst the difference in mid-nasal height approached significance for the two groups, numbers were too small for a statistical difference to be identified. The mean value for choanal width in the isolated BCA group was significantly less the largest series of normative data available in the literature for comparison (p < 0.001). No skull base anomalies were noted in either group.

CONCLUSION

While this is a small study with limited numbers, it is the first that has attempted to identify and measure the posterior nasal and skull base anatomy most pertinent to avoiding skull base injury in the surgical management of BCA.

Familial congenital choanal atresia with GATA3 associated hypoparathyroidism-deafness-renal dysplasia syndrome unidentified on auditory brainstem response

Hypoparathyroidism-deafness-renal dysplasia (HDR) syndrome is a rare autosomal dominant disorder primarily caused by GATA3 haploinsufficiency and is challenging to diagnose in early childhood. We report a Japanese family with HDR syndrome and congenital choanal atresia. The 6-year-old female proband was diagnosed with epilepsy at the age of three. Under carbamazepine monotherapy, the patient presented hypoparathyroidism accompanied by severe hypocalcemia. Subsequently, renal ultrasound analysis revealed bilateral multicystic dysplastic kidneys. Because she had difficulty hearing, we sequenced GATA3 and determined that she had a c.708_709insC (p.Ser237Glnfs*66) allelic variant in exon 3. As a result, we found a family of this disease. Each family member, including her grandfather, mother, and two siblings, had HDR syndrome of varying clinical penetrance. We found a craniofacial anomaly, congenital choanal atresia, which was inherited as an autosomal dominant trait. Hypocalcemia coupled with vitamin D deficiency, triggered by carbamazepine treatment, ultimately revealed the proband's childhood- onset HDR syndrome. Pure-tone audiometry revealed different severities of deafness as well as the progression of sensory hearing loss. However, auditory brainstem response for hearing screening is probably insufficient for ascertaining HDR syndrome in the early stages of life. We presented new clinical clues to diagnose the HDR syndrome.

Choanal atresia and stenosis: Development and diseases of the nasal cavity

Proper craniofacial development in vertebrates depends on growth and fusion of the facial processes during embryogenesis. Failure of any step in this process could lead to craniofacial anomalies such as facial clefting, which has been well studied with regard to its molecular etiology and cellular pathogenesis. Nasal cavity invagination is also a critical event in proper craniofacial development, and is required for the formation of a functional nasal cavity and airway. The nasal cavity must connect the nasopharynx with the primitive choanae to complete an airway from the nostril to the nasopharynx. In contrast to orofacial clefts, defects in nasal cavity and airway formation, such as choanal atresia (CA), in which the connection between the nasal airway and nasopharynx is physically blocked, have largely been understudied. This is also true for a narrowed connection between the nasal cavity and the nasopharynx, which is known as choanal stenosis (CS). CA occurs in approximately 1 in 5,000 live births, and can present in isolation but typically arises as part of a syndrome. Despite the fact that CA and CS usually require immediate intervention, and substantially affect the quality of life of affected individuals, the etiology and pathogenesis of CA and CS have remained elusive. In this review I focus on the process of nasal cavity development with respect to forming a functional airway and discuss the cellular behavior and molecular networks governing this process. Additionally, the etiology of human CA is discussed using examples of disorders which involve CA or CS. This article is categorized under: Signaling Pathways > Cell Fate Signaling Comparative Development and Evolution > Model Systems Birth Defects > Craniofacial and Nervous System Anomalies.

Early Transient Prenatal Ultrasound Features of Choanal Atresia

We present a case series of early second-trimester prenatal ultrasound (US) features in 4 fetuses with a confirmed diagnosis of choanal atresia. The clinical characteristics and outcomes evaluated included prenatal US findings, genetic analyses, postmortem autopsies (2 cases), and computed tomographic findings. A transient large nasal cavity was detected by US in all 4 fetuses. This finding disappeared a few weeks later. Three cases were unilateral choanal atresia, and 1 was bilateral. Transient enlargement of the nasal cavity in early pregnancy appears to be a US sign of choanal atresia.

Congenital Choanal Atresia Repair: An Analysis of Adverse Perioperative Events

Objectives

To identify risk factors and determine the perioperative morbidity of infants undergoing congenital choanal atresia (CCA) repair.

Study Design

Retrospective analysis of the ACS-NSQIP-P database (American College of Surgeons National Surgical Quality Improvement–Pediatric).

Setting

Tertiary medical center.

Subjects and Methods

Patients who underwent CCA repair at age ≤365 days at the time of surgery were queried via the ACS-NSQIP-P database (2013-2016) via Current Procedural Terminology code 30540. Analyzed outcomes include age, length of stay, medical comorbidities, operative time, readmission, reoperation, and postoperative complications.

Results

A total of 168 patients were identified, 70 of which were within the neonatal period. Preoperatively, gastrointestinal disease ( P < .0001), mechanical ventilation ( P < .0001), and oxygen supplementation ( P = .0040) were significantly greater in frequency among neonates. For all children preoperatively, ASA class ( P < .0001), chronic lung disease ( P = .0019), oxygen supplementation ( P < .0001), and prematurity ( P = .0016) had a significant impact on prolonged length of stay. Neonates had a persistent requirement for postoperative mechanical ventilation ( P < .0001) and a prolonged length of stay ( P < .00001).

Conclusion

Neonates undergoing CCA repair are more likely to have a persistent requirement for postoperative mechanical ventilation and a prolonged length of stay. Recognition of key clinical factors may aid in optimizing perioperative risk assessment, patient counseling, and procedural planning.

Maxillary Hypoplasia: Differential Diagnosis of Nasal Obstruction in Infants

Maxillary hypoplasia (MH) is a rare cause of respiratory dysfunction in infants and may occur in association with genetic abnormalities or as an isolated condition. It is included in the differential diagnosis of congenital nasal obstruction. This paper seeks to report a case series of infants with MH, discuss methods for its diagnosis, and compare computed tomography (CT) measurements of nasal cavities of infants with MH and without craniomaxillofacial abnormalities. The therapeutic approach in each patient is also described. All infants with MH admitted to a tertiary hospital between 2012 and 2015 were included. Baseline nasal endoscopy was performed at bedside. The width of the infants' nasal cavities was measured by a radiologist with experience in CT scanning of facial bones. Control patients were infants of matched sex and similar age who underwent head CT scanning for various reasons. Overall, 8 infants with MH and 8 controls were assessed. All nasal cavity dimensions of infants with MH were significantly smaller than those of control subjects. The authors conclude that the diagnosis of MH should be considered in infants with nasal obstruction and nasal cavity narrowing at nasal endoscopy.

[Diagnostics and management of choanal atresia]

Choanal atresia is a rare malformation that represents a special challenge. While bilateral choanal atresia usually needs to be surgically treated within a few days of birth, the intervention for one-sided choanal atresia can be postponed for years. Treatment planning requires adequate imaging (CT or MRI), which also serves to exclude other skull base malformities. Surgical treatment currently focuses on transnasal endoscopic techniques. Simultaneous resection of the parts of the vomer involved in the atresia seems to be important surgical success. Postoperative stenting is still controversially discussed. Postoperative application of corticosteroid nasal sprays and saline nasal rinsing for several weeks is of great importance. Due to the rarity of the diagnosis, the absence of prospective randomized controlled trials does not allow definitive statements regarding the optimal surgical technique or stenting.

Choanal Atresia and Craniosynostosis: Development and Disease

A number of textbooks, review articles, and case reports highlight the potential comorbidity of choanal atresia in craniosynostosis patients. However, the lack of a precise definition of choanal atresia within the current craniosynostosis literature and widely varying methods of detection and diagnosis have produced uncertainty regarding the true coincidence of these conditions. The authors review the anatomy and embryologic basis of the human choanae, provide an overview of choanal atresia, and analyze the available literature that links choanal atresia and craniosynostosis. Review of over 50 case reports that describe patients diagnosed with both conditions reveals inconsistent descriptions of choanal atresia and limited use of definitive diagnostic methodologies. The authors further present preliminary analysis of three-dimensional medical head computed tomographic scans of children diagnosed with craniosynostosis syndromes (e.g., Apert, Pfeiffer, Muenke, and Crouzon) and typically developing children and, although finding no evidence of choanal atresia, report the potentially reduced nasal airway volumes in children diagnosed with Apert and Pfeiffer syndromes. A recent study of the Fgfr2c Crouzon/Pfeiffer syndrome mouse model similarly found a significant reduction in nasal airway volumes in littermates carrying this FGFR2 mutation relative to unaffected littermates, without detection of choanal atresia. The significant correlation between specific craniosynostosis syndromes and reduced nasal airway volume in mouse models for craniosynostosis and human pediatric patients indicates comorbidity of choanal and nasopharyngeal dysmorphologies and craniosynostosis conditions. Genetic, developmental, and epidemiologic sources of these interactions are areas particularly worthy of further research.

Comprehensive management of congenital choanal atresia

OBJECTIVES

To present results of a one-stage minimally invasive surgical procedure for congenital choanal atresia (CCA). Seven outcome measures were applied.

MATERIALS AND METHODS

Retrospective study conducted between 1999 and 2015. The same endonasal endoscopic approach with multiflaps and no stenting was used on 36 children. The flaps were attached with fibrine glue. There were 50% unilateral and 50% bilateral cases, 70% primary and 30% secondary surgery. The mean age at primary surgery for bilateral atresia was 10 days and for unilateral atresia 4 years. Associated loco-regional disorders were: hypoplasia of the inferior turbinate, rhinopharyngeal stenosis and rhinopharyngeal web.

RESULTS

The average follow-up time was 6 years, ranging from 1 to 14 years. There was a functionally patent choanae in 94% of children, and 6% showed severe restenosis with a diameter less than 4 mm, which needed one revision surgery each. Charge patients were not associated with worse outcome. There was no external nasal valve stenosis and no permanent Eustachian tube dysfunction. Synechiae occurred in 3 patients with hyperplastic inferior turbinate. No patients showed any disharmonious nasal growth. In neonates with isolated bilateral CCA, breast-suction could be started within 1 day (range 1-2 days), and pain-killers were needed on average for 1.5 days (range 1-4 days). The hospital stay for unilateral isolated CCA was on average 1.5 days (range 1-2 days) and for bilateral isolated CCA, 8 days (range 3-20 days). Postoperative procedures under a short general anesthesia were necessary in 12 cases, 10 of them were infants under 6 months of age.

CONCLUSION

Surgery could be performed safely in the newborn in the early stage of life, even for unilateral atresia. Tendency for restenosis can be minimized by: 1. the construction of an as large as possible uni-neochoanae by removing the posterior part of the vomer and by drilling away the medial pterygoid; 2. in case of rhinopharyngeal stenosis, part of the endochondral clivus bone should be resected; 3. all raw surfaces should be covered by multiple mucosal flaps secured with fibrin glue; 4. no stenting; 5. appropriate postoperative care.

Rdh10 loss-of-function and perturbed retinoid signaling underlies the etiology of choanal atresia

Craniofacial development is a complex process that involves sequential growth and fusion of the facial prominences. When these processes fail, congenital craniofacial anomalies can occur. For example, choanal atresia (CA) is a congenital craniofacial anomaly in which the connection between the nasal airway and nasopharynx is completely blocked. CA occurs in approximately 1/5000 live births and is a frequent component of congenital disorders such as CHARGE, Treacher Collins, Crouzon and Pfeiffer syndromes. However, the detailed cellular and molecular mechanisms underpinning the etiology and pathogenesis of CA remain elusive. In this study, we discovered that mice with mutations in retinol dehydrogenase 10 (Rdh10), which perturbs Vitamin A metabolism and retinoid signaling, exhibit fully penetrant CA. Interestingly, we demonstrate Rdh10 is specifically required in non-neural crest cells prior to E10.5 for proper choanae formation, and that in the absence of Rdh10, Fgf8 is ectopically expressed in the nasal fin. Furthermore, we found that defects in choanae development are associated with decreased cell proliferation and increased cell death in the epithelium of the developing nasal cavity, which retards invagination of the nasal cavity, and thus appears to contribute to the pathogenesis of CA. Taken together, our findings demonstrate that RDH10 is essential during the early stages of facial morphogenesis for the formation of a functional nasal airway, and furthermore establish Rdh10 mutant mice as an important model system to study CA.

An Italian multicentre experience in endoscopic endonasal treatment of congenital choanal atresia: Proposal for a novel classification system of surgical outcomes

OBJECTIVE

The purposes of this study were to report our experience with endoscopic treatment of choanal atresia (CA), to illustrate our surgical technique and analyse the different factors that may affect outcomes.

MATERIAL AND METHODS

A retrospective review was performed of patients affected by congenital CA and treated between June 1996 and November 2013 at three referral centres which follow a uniform policy.

RESULTS

Eighty-four patients with CA (55 unilateral and 29 bilateral), aged between one day and 76 years (mean, 13 years) were included. Associated malformations were present in 28 patients. The overall success rate was 93%, with 96.3% and 86.2% success rates for unilateral and bilateral CA respectively. Six patients (7%) required revision surgery for early symptomatic restenosis. Statistical analysis revealed that outcomes were not influenced by sex, previous surgeries, unilateral versus bilateral atresia or associated anomalies. However, age seemed to be a prognostic risk factor for patients under one year-old.

CONCLUSION

The endoscopic endonasal approach is safe and effective, with a very high success rate and low morbidity. The removal of the vomer and the use of mucoperiosteal flaps are the main keys to avoiding postoperative stenosis. The use of stents or Mitomycin C is therefore not mandatory.

Endoscopic repair of bilateral choanal atresia, starting with vomer resection: Evaluation study

BACKGROUND

Choanal atresia is the most common inborn nasal anomaly, and its definitive treatment is surgical to achieve proper bilateral nasal patency. Four main surgical approaches were used for repair: transantral, transpalatal, transseptal, and transnasal. The transnasal endoscopic approach is the most widely accepted nowadays. In this study, we aimed to evaluate the long-term results of a transnasal endoscopic repair of congenital choanal atresia started with resection of the posterior portion of the vomer and was completed without the use of stents in a large series of patients.

METHODS

Twenty-five patients (age range, 3-15 days) with bilateral congenital choanal atresia had surgery by using stentless endoscopic transnasal repair by starting with resection of the vomer bone. Postoperative control included office fiberoptic nasal endoscopy.

RESULTS

During the follow-up period of 15-66 months (mean [standard deviation], 35.76 ± 16.8 months), 18 patients (72%) had a wide choana with adequate nasal breathing; Six patients (24%) had narrowing of the choana (<50%), still with adequate and satisfactory airway without feeding difficulties, and one patient (4%) developed restenosis (>50%) after 7 months, which necessitated repeated surgery. One patient (the fourth case) developed a palatal defect, which healed conservatively. No other complications were detected.

CONCLUSION

The described technique proved to be effective and easier, with good long-term satisfactory results in a large series of patients. This technique allows early use of both nasal passages for simultaneous endoscope and instrument insertion to excise both atretic plates without the use of stents or flaps.

Disorders of the neonatal nasal cavity: Fundamentals for practice

Neonatal nasal obstruction is a well-known clinical entity. Fortunately, it is rarely life-threatening and usually resolves with conservative management. As with most conditions, a systematic history and thorough physical examination are crucial for correct diagnosis and management. The initial diagnosis may be elusive and require either serial or more in-depth evaluations. Occasionally, examination may reveal structural abnormalities necessitating surgical intervention. Fortunately most of these abnormalities are amenable to surgery; however, a select few are notoriously difficult to treat.

[Nasal breath recovery and rhinoplasty in cleft lip and palate patient with unilateral choanal atresia]

The paper presents the analysis of clinical case of endoscopic nasal breath restoration and elimination of the secondary cleft lip nasal deformity in 27 years old patient with unilateral choanal atresia and secondary nasal deformity after rhinocheiloplasty. Preoperative examination revealed the absence of nasal breathing on collateral side due to complete bone choanal atresia. Surgical treatment included endoscopic choanal repair, elimination of the secondary nasal deformity, septoplasty, conchotomy and lateroposition of the inferior conchae. The treatment resulted in nasal breath restoration and elimination of nasal deformity. Long-term follow-up at 1 and 12 months post-operatively proved stable positive aesthetic and functional results.

Assessment and causes of stridor

Stridor is a variably pitched respiratory sound, caused by abnormal air passage during breathing and often is the most prominent sign of upper airway obstruction. It is usually heard on inspiration (typically resulting from supraglottic or glottic obstruction) but also can occur on expiration (originating from obstruction at or below glottic level and/or severe upper airway obstruction). Stridor due to congenital anomalies may exist from birth or may develop within days, weeks or months. Various congenital and acquired disorders prevail in neonates, infants, children, and adolescents, and have to be distinguished. History, age of the child and physical examination together often allow a presumptive diagnosis. Further investigations may be necessary to establish a definite diagnosis, and flexible airway endoscopy is the diagnostic procedure of choice in most circumstances ("stridor is visible").

The endoscopic transseptal approach for choanal atresia repair

BACKGROUND

There are many standard repair options for choanal atresia including puncture, dilatation and drilling of the atretic plate. Most of these techniques involve postoperative stenting, which may promote granulation and scarring, with possible progression to restenosis. This article describes a novel approach for choanal atresia repair without postoperative stenting.

METHODS

This article describes our experience with this choanal atresia repair technique utilized in 16 pediatric patients and 1 adult patient across multiple tertiary pediatric and rhinology centers during 2008 through 2015. Seven cases were bilateral and 10 were unilateral. Surgery was performed using an endoscopic transseptal approach with preservation of the mucosa and creation of flaps. No stents or packing was used. The main outcome measures were: response to treatment based on endoscopic examination, need for further revision and incidence of complications.

RESULTS

All patients underwent routine postoperative endoscopic inspection of their nasal cavity, postnasal space, and assessment of neochoanal patency. The neochoanae of all patients remained patent to a minimum follow-up duration of 9 months with most patients follow up for 2 years or more. Two neonatal patients required transfusion postoperation from intraoperative bleeding. Two pediatric patients developed postoperative respiratory complications. One patient required revision surgery for nasal vestibule scarring from incision made on the nasal alar to facilitate the initial endoscopic approach.

CONCLUSION

This novel endoscopic transseptal repair technique is effective in the management of choanal atresia. Careful fashioning of mucosal flaps and the omission of stenting has resulted in lasting patency of the neochoanae.