Unilateral Choanal Atresia: Indications of Long-Term Olfactory Deficits and Volumetric Brain Changes Postsurgically

[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.

Endoscopic Endonasal Repair of Congenital Choanal Atresia: Predictive Factors of Surgical Stability and Healing Outcomes

Background: To assess the long-term outcomes and independent predictors of surgical success of a one-stage minimally invasive surgical procedure for congenital choanal atresia (C.C.A.). Methods: a retrospective multicentric study was conducted between 2010 and 2022. An endonasal endoscopic approach was performed in 38 unilateral or bilateral C.C.A. children. All the patients were clinically and radiologically assessed and followed for at least 2 years. Seven outcome measures were applied. Consequently, surgical success was correlated with all the independent variables reported. Results: 18/38 (47.36%) patients presented normal postoperative healing, 8/38 (21.05) had moderate restenosis (<50%), while 12/38 (31.57%) cases were severe (>50%), requiring a surgical revision. No statistical significance was found for average hospital stay between stenosis >50% and <50% patients (p = 0.802) and postoperative pain (p = 0.075); instead, the severe restenosis group demonstrated a higher delay of breast suction (p < 0.001). Among the independent variables predictors of surgical success, the presence of Charge syndrome and rhinopharyngeal stenosis demonstrated higher risks for surgical revision (OR: 4.00, 95% CI: 0.57−28.01, and OR: 2.75, 95% CI: 0.55−13.69, respectively). On the contrary, the hypoplastic inferior turbinate and bilateral C.C.A. showed a lower risk for severe restenosis by a higher endoscopic surgical space and creating a single larger opening (OR: 0.88, 95% CI: 0.22−3.52, and OR: 0.45, 95% CI: 0.10−2.08). Conclusion: Several independent variables could influence the surgical success after C.C.A. endoscopic repair; however, more high-quality evidence is needed to generate an effective predictive model.