Choanal atresia

1. CHOANAL ATRESIA
DR JOEL G MATHEW, DLO
LOURDES HOSPITAL, KOCHI

2. • Absence of communication between the
posterior nasal cavity and the nasopharynx.
• Incidence: 1 in 7000 live births.
• 2/3 of cases are unilateral
• More common on the right side.

3. Associated anomalies
CHARGE syndrome
Polydactyly
Nasal, auricular and palatal deformities
Crouzon syndrome
Treacher collins syndrome,
Apert’s syndrome
Craniosynostosis
Microcephaly
Hypoplasia of the orbit and midface
Cleft palate
Hypertelorism

4. Theories of Development
• Persistence of the buccopharyngeal
membrane from the foregut,
• Persistence of the nasobuccal membrane of
Hochstetter
• Abnormal persistence of mesoderm-forming
adhesions in the choanal region,
• Misdirection of mesodermal fl ow secondary
to local factors.
Prenatal US in coronal section
shows a single ballooned nostril.

5. Clinical Features

6. Bilateral choanal atresia
• Bilateral choanal atresia is a medical emergency.
• Child has the characteristic cyclic apnea,
cyanosis, and respiratory distress, which are
temporarily relieved by crying.
• Bilateral choanal stenosis can present later in
life with mouth breathing, recurrent sinusitis,
chronic rhinorrhea, otitis media, failure to
thrive, and defects of speech.

7. Unilateral choanal atresia
• Present with unilateral nasal discharge
and nasal obstruction.
• On anterior rhinoscopy, the occluded
nasal cavity is typically filled with
thick, tenacious secretions.

8. Diagnosis
• Typical clinical features/Neonatal
screening
• Neonatal screening: Failure to pass a
6F catheter through the nose into the
nasopharynx (32mm)
• Endoscopy -occluded nasal cavity is
typically filled with thick, tenacious
secretions.

9. • Before CT, dionosil oil used to be
instilled in the nasal cavity, and a
lateral view X-ray taken.
• Failure of oil to enter the
nasopharynx was taken as evidence
of posterior choanal atresia
• Echocardiogram, Renal USS,
Ophthalmologic and audiologic
evaluation to rule out associated
congenital defects Medial bowing and thickening of the lateral wall of the
nasal cavity, with impingement at the level of the anterior
aspect of the pterygoid plates

10. • Differentiate bony from membranous atresia.
• Types:
• Pure bony
• Mixed bony-membranous
• Pure membranous
CT scan is the investigation of choice

11. • Identifies other associated features:
• diminished nasal airway secondary to septal
deflection toward the obstructed side
• widened vomer,
• medial bowing of the lateral nasal wall,
• narrowing of the nasopharynx.
Acoustic rhinometry represents a new and valuable tool in the diagnosis of congenital choanal atresia.

12. TREATMENT
• Early surgical approach to bilateral atresia.
• Unilateral atresia with significant symptoms
is operated soon after diagnosis.
• Preoperative planning – with CT scan:
• Management of membranous is less complex
• Identifies alterations in posterior septum,
configuration of lateral nasal wall and
nasopharynx.

13. • Small Lempert curette or urethral sound is
passed through nose to puncture the
atretic plate
• Stent is inserted to prevent restenosis.
• Usually requires repeated revisions or
dilatations.
• Complications include CSF leak and
meningitis.
• Blind technique
• Superceded by endoscopic technique
Transnasal puncture technique

14. • Modified Trendelenberg position with
shoulder extended.
• Mucoperiosteum of palatal bone elevated.
• Muscular aponeurosis and nasopharyngeal
mucosa of soft palate is incised.
• Palate is retracted towards nasopharynx.
• Bony atresia plate and posterior third of
vomer removed with rongeur or curette.
• Soft Silastic stents inserted and left in place
for 2 months for healing and preventing
restenosis.
• Palatal flap closed.
Transpalatal technique

15. • Helpful in neonates with unfavourable
nasal anatomy or craniofacial anomalies.
• Sublabial incision into mucosa of floor
of nose.
• Septum exposed.
• Atretic plate exposed and removed.
Sublabial Transseptal repair

16. • A cotton pledget soaked in
oxymetazoline placed in nasal cavity to
decongest.
• 2.5 to 4.4 mm scope placed in nasal
cavity.
• Atretic plates and vomer is removed
with powered instrumentation.
• A backbiting rongeur introduced
nasally removes a part of vomer.
• Video
Transnasal endoscopic technique

17. Stents
• Traditional part of the postoperative management.
• Stents are not always necessary after endoscopic
surgery.
• No clear-cut evidence that stents prevent stenosis
after removal.
• Avoid injury to the alar and septal cartilages .
• Advisable in children with a higher risk of failure
including neonates and bilateral choanal stenosis.
• Some series show adverse effects of stenting in
children with unilateral stenosis.

18. • Antibiotics
• Suctioning and cleaning of stents to ensure patency.
• Control crusting
Postoperative Management