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4 5 6 TH E JO U RN A L O F PRO STH ETI C D EN TI STRY V O LU M E 8 3 N U M BER 4

Choanal atresia is a life-threatening congenial

anatomic malformation tissue blockage across the pos-

terior nasal choanae (Fig. 1). Embryologic explanation

for choanal atresia is uncertain, but it is thought that

insufficient excavation of the nasal pits by the time the

fusion is complete could account for the failure of the

back of the nasal cavity to open into the primitive phar-

ynx.1 This results in a tissue blockage of the nasal air

passage.

The natural instinct in the neonate is to breathe

through the nose, but for anatomic and physical rea-

sons oral respiration, when the nasal passages are

obstructed, is difficult.2 The infant presents within afew hours of birth with cyclical cyanosis. As the normal

neonate breathing mechanism is pernasal, the infant

becomes progressively cyanotic until it cries. Crying

bypasses the blocked nasal passage, the infant then

becomes pink again until the cycle recommences.3

Feeding is also difficult because of the additional

obstruction of the o ral airway when sucking a bott le or

breast. The majority of the bilateral cases present as

neonatal respiratory emergencies.

Initial diagnosis of choanal atresia or stenosis is

made by observing the absence of nasal air flow with a

mirror or cotton wisk.1,4 Computerized tomography

(CT scanning) has been u seful for improving d iagnosesand evaluating the extent of the nasal obstruction. The

incidence of choanal atresia as reported in the literature

varies, but appears to be approximately 1 in 8000

births.1,2,5 Choanal atresia can be an isolated congeni-

tal defect, or it can be associated with a wide variety of

congenital anomalies such as midline cranial facial dis-

orders, Cro uzons syndrome, marble bone d isease, and

others. Several congenital malformations can coexist

with choanal atresia: coloboma of the eye (C), heart

disease (H ), atresia of the cho anae (A), retarded

growth development and/ or CN A anomalies (R), gen-

ital hypoplasia (G), and ear anomalies and/ or deafness

(E).1,3 The acronym C H ARGE symbolizes the collec-

tion of these malformations.

The definitive treatment for choanal atresia is

surgery with a goal of obtaining an improved opening

through the atresic plate to allow air passage and, hope-

fully, not have a recurrence of stenosis. There are vari-ous surgical approaches, including transnasal, transep-

tal, and transantral procedures.1-3,6,7 Surgical interven-

tion for patients with bilateral choanal atresia is per-

formed as soon as possible after diagnosis, usually

within 24 hours or within the first few weeks of life,

because the condition is potentially fatal. As soon as the

infant is deemed healthy for surgery, it is performed.4,8

Correcting unilateral atresia often is delayed until the

child is more fully developed.6,9

Oral airways have been used to maintain the airway

until surgery can be performed if birth complications

such as low birth weight, heart problems, or other

medical difficulties develop. Traditional pediatric,

infant, and adult standard airways do not work well on

a long-term basis because they fit poorly, are uncom-

fortable, may cause irritation, and do not maintain an

adequate stable airway. It would be ideal if a stent could

be fabricated that would comfortably and consistently

maintain the oral airway until the infant is medically

stable enough to have the necessary surgery.

This clinical report describes the treatment of a

patient and a procedure to support this type of patient

unt il surgical correction can be performed.

Prosthetic alternative treatment for choanal atresia: A clinical report

Alan J. H ickey, D M D ,a and Thomas J. Vergo, D D Sb

M aine M edica l Center , Por t l and, M e. ; and Tuf t s U n iversi t y Scho o l o f D enta l M edic in e, Boston, M ass.

aAc t i ve S ta f f, M a ine M ed ica l Center.b Di rec to r , D iv i s ion o f Removab le Pros thodont i cs , and Head, D iv i -

s ion of M axi l lo fac ial Prosthet ics , Tuf ts U nivers i ty Scho ol of D en-

t al M e d i c i n e .

J Prosthe t D ent 200 0;83 :456-8 .

Fig. 1. I l l ust ra t i on o f bo ny o r m em branou s b loc k age o f pos-ter ior nasal cav i ty . B lockage c reates choanal a t res ia condi -t ion that prevents a i r f rom f lowing through nasal area. Pros -t h e s i s i n p l a c e d e m o n s t r a t e s d o w n w a r d p o s i t i o n o fm and ib le t o k eep o ral a i rway open and to a l l ow o ra l b reath -ing .

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CLINICAL REPORT

A medically unstable infant diagnosed with bilateral

choanal atresia with a standard pediatric type of airway

was referred for a custom-made prosthetic airway.

Unfortunately, because of the size and shape of the

infants mouth, severe irritation and ulceration of the

hard/ soft palate resulted when using the commercially

available pediatric airways. In addition, the standard

pediatric airway did not maintain a consistent open air-

way, creating periodic episodes of cyanosis. The chal-

lenge was to fabricate a custom-fitted airway that

would reposition the mandible downward and maintain

a consistent airway without gagging the infant or caus-

ing irritation and/ or ulceration of the palate.

An intraoral impression was made of the maxillary

arch using a custom-made infant tray with irreversible

hydrocolloid impression material. The impression was

poured in standard type III dental stone (Labstone

Buff, Modern Materials, South Bend, I nd.) . An acrylic

autopolymerizing type II, class I resin (Perm reline and

repair resin, Akron, Ohio) stint similar to an edentulous

H I C KEY A N D V ERG O TH E JO U RN A L O F PRO STH ETI C D EN TI STRY

A PRI L 2 0 0 0 4 5 7

Fig. 2. A i rw ay in l ow er pos i ti on o f p i c tu re w as sec t i oned and rec on tou red to f i t p ros thesi s.T issue and sm oo th sur face v iew of pro sthesis i l lus t rates bo th po ster ior and anter ior ex tent o fbreath ing a i rway .

Fig. 3. Pros thes is in p lace prov ides more patent ora l a i rwayfor th is pat ient .

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TH E JO U RN A L O F PRO STH ETI C D EN TI STRY H I C KEY A N D V ERG O

4 5 8 V O LU M E 8 3 N U M BER 4

baseplate was constructed on the stone cast. A standard

pediatric airway (Portex, Keene, N.H .) selected with a

curve that was compatible to the infants palatal con-

tour was sectioned and attached to the stint with

autopolymerizing acrylic resin (Fig. 2). The tongue

surface of the custom airway was highly polished to

prevent irritation to the tongue. The posterior extentof the prosthetic airway was finished just beyond the

junction of t he hard / soft palate to prevent the posteri-

or tongue from occluding the airway. The sectioned

tube extended beyond the lips so the infant was unable

to make lip closure and occlude the airway anteriorly.

The prosthet ic airway was retained using standard den-

ture adhesive (Fig. 3).

SU MMARY

The rationale and clinical/ laborator y techniques to

fabricate a custom-made pediatric airway for an infant

diagnosed with choanal atresia was described. When

compared with the standard pediatric airway, the cus-tom -made airway maintained a consistent patent airway

that was comfortable and atraumatic. The custom-

made airway assisted the physician in stabilizing the

infant medically so that surgical correction could be

performed.

REFERENCES

1 . M untz H R . P i t fal l s to l ase r co r rec t i on o f choana l a tresia . Ann O to l Rh ino l

L a ry n g o l 1 9 8 7 ; 9 6 : 4 3 - 6 .

2 . S ingh B. B i l a te ra l choana l a t res ia : key to success w i th the t ransnasa l

approach . J La ryngo l O to l 1990 ;104 :482 -4 .

3 . Con ig l i o JU , Manz ione JV, H engere r AS. Ana tom ic f i nd ings and man age-

ment o f choan a l a t resia and the CHA RGE assoc ia t i on . Ann O to l Rh ino l

L a ry g n o l 1 9 8 8 ; 9 7 : 4 4 8 - 5 3 .

4 . Presco t t CA. Exper ience w i th b i l a te ral congen i ta l a t resia o f the pos te r i o rnasal choanae . J La ryngo l O to l 1986 ;10 0 :1255 -61 .

5 . N a r u l a A A , A m b e g a o k a r A G . C h o a n a l a t re si a : e ar l y m a n a g e m e n t a n d a n

assoc ia t i on w i th m arb le bone d i sease . J La rygno l O to l 1986 ;100 :959 -63 .

6 . Ferguson JL , Nee l H B 3d . Cho ana l a t resia : t reatmen t t rends i n 47 p a t i en ts

o v e r 3 3 y e a r s. A n n O t o l R h i n o l L a r y gn o l 1 9 8 9 ; 9 8 : 1 1 0 - 2 .

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D R T H O M A S J. V ERGO JR

D I VI SI O N O F M AXIL L O FACIAL PROSTH ETICS

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O N E KNEELAN D ST

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FA X : (617)636-6583

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