Endoscopic Management Of

Choanal Atresia

Nassim Talaat M.D.Faculty of Medicine, Cairo University

Definition & Incidence

-Choanal atresia(CA) is characterised by narrowing of the posterior opening of the nasal cavity into the nasopharynx.

-The condition occurs in 1:5000 to 1:8000 live births.

-Females are affected twice as often as males.

-Unilateral CA account for 65 to 75 % of cases.

DevelopmentAt 4-week embryo, facial area includes paired lateral nasal placodes (ectodermal), and the midline frontonasal process(mesodermal)

.

The nasal placodes eventuallywill develop into nasal cavitiesand lining. during the nextweeks , the nasal placodesinvaginate to form the nasalpits, these extend back to theoral cavity, but remainseparated from it by thebucconasal membrane. Later indevelopment this membraneundergoes resorption to for the

posterior choanae.Failure of this membrane toperforate results in choanal

atresia

CHARGE syndromeBilateral CA is frequently associated with other anomalies: the most common is CHARGE syndrome:

Coloboma & cranial nerve palsies

Heart disease.

Atresia of the choanae

Retardation of growth and development

Genitourinary anomalies

Ear malformation and hearing loss

Predisposition

In utero exposure to the antithyroid drug methimazole has been associated with increased incidence of CA

Anatomic deformity

4 parts:

-A narrow nasal cavity.

-Medialized lateral pterygoid plate.

-Diamond shaped wide vomer.

-Thinning of the atresia plate inferomedially.

Bony Vs Membraous !!

-30% are pure bony

-70% are mixed

-pure membranous is very rare !

Presentation

Bilateral: respiratory distress at birth and cyclic cyanosis that is relieved by crying and exacerbated with feeding.

Unilateral: unilateral rhinorrhea and nasal obstruction. Usually later in life.

Findings on exam.

-Inability to pass a small catheter into NPX

-Nasal endoscopy.

CT

For diagnosis and classification.

Posterior choanalorifice measures less than 0.34 cm unilaterally, or if posterior vomermeasures greater than 0.55 cm.

Management-Unilateral: elective, usually after first year.

-Bilateral: training of mouth breathing: McGovern nipple, oral airway, in emergency, stimulation to cry or intubation.

-sometimes, feeding via a very narrow orogastric tube till definitive management.

-In bilateral CA, multisystem evaluation is mandatory.

Approaches

-Surgery for CA can be approached via: transnasal, transseptal, or transpalatal routes.

-The key to a successful repair is creating an adequate 3 dimensional opening, by removing the widened posterior vomer, and thinning of the lateral pterygoid plate, with preservation of mucosal flap wherever possible.

Steps

-Decongest.

-Decongest.

-Decongest.

-NPX packing.

StepsPerforate

Steps

Resect the posterior vomer

Steps

-Thinning of lateral wall

Steps

-Remove all bony specules, and projections.

-Remove adenoid, if present.

-Stenting !!!

Results

-Functional nasal airway in 50-80 % of children.

-Post surgical medications as local mitomycin C, and steroid injection to the borders of the neo-choanae seem to decrease incidence of restenosis.

-Wound care at 1 & 3 weeks under GA, is important.

-Short term stenting is preferred.

The technique of endoscopic management of choanal atresia is not difficult, but more important is the proper judgment and patient handling

-Patient age.

-Associated stigmata.

-post-operative.

-Recurrence.

THANK YOU