Yasser W. Khafagy, MD Professor of Otolaryngology Mansoura University Endoscopic Repair of Bilateral Congenital Choanal Atresia: 15 Years Experience Yasser W. Khafagy, MD Professor of Otolaryngology Mansoura University

Introduction It is a condition that describes narrowing or obliteration of the posterior nasal aperature It occurs in 1:7,000 to 8,000 births, of those 45% are bilateral Much more commonly in females Mostly bony or mixed, rarely purely membranous

Introduction High resolution CT scan is the definitive radiological study of choice. The useful parameters are vomer width, choanal air space, medial pterygoid plate projection into the choana

Ideal Procedure Restore normal nasal passage Avoid damage to any growing structures Be safe Short surgery time and hospitalization stay Minimal morbidity and mortality Endoscopic repair is more commonly used than other approaches ( transnasal, transpalatal, transseptal)

Objective Early experience with 9 cases was published in the Laryngoscope; (112:316-319, 2002) This study aims to present 15 years experience with treatment of bilateral congenital choanal atresia, report technique, results, pitfalls, complications

Patients and Methods A prospective study including 80 cases of bilateral congenital choanal atresia, treated at Mansoura University Hospital endoscopically in the period from March 1997 to March 2011 are reported. All cases were diagnosed clinically and referred by the attending pediatrician

Patients and Methods All cases had careful history, axial CT scanning CT scan is examined to confirm the diagnosis, assess the choanal area, vomer width, medial pterygoid projection, bone thickness, septum and lateral nasal wall. Complete preoperative work up including bleeding profile, pediatric and anesthetic consult. Preoperative counseling is important and very helpful (nature of the condition, treatment, postop care, expectation, 2nd look)

Membranous atresia Look at the size of choana

Mixed Aresia

Axial CT scan

Surgical Technique GA with endotracheal tube, moist cotton in the oropharynx, be careful not to put bulky gauze in the oral cavity this will narrow the nasopharynx especially over the soft palate. Supine position, Afrin nose drops, 4 mm, 0 degree nasal endoscope, few instruments are usually needed, Some otologic instruments will be helpful.

Surgical Technique Although the technique remains the same, some modifications were made as directed by the follow up for cases through the years. Incision is made in the posterior septum close to the atretic plate, using sickle knife radiofrequency needle, coblation needle

Incisions Left Right

Surgical Technique The incision extended to the atretic plate The mucosa over the atretic plate is removed, In cases with mixed atresia, the atretic plate is perforated with suction tip inferiorly and medially, Removal of the vomer is the most important step, Extralong burs, ear curettes, dissectors are used to create the neochoana

Surgical technique Extreme care to keep the cartilagenous septum intact, also extreme caution not to injure the alar cartilage by drill heat. Attention is then directed to the lateral boundary of the neochoana, in most cases drilling is required to obtain a good sized neochoana keeping in mind the continuous healing attempts of all tissues in the area of surgery!

Surgical Technique Stenting was always used, Portex endotracheal tube size 3-3.5 ( mm ID) The length is measured by suction tube, it is fixed through the floor of the nose sublabially Stenting was kept for about 6 weeks.

Post-operative care Early feeding is helpful for the baby and the mother! Patient discharge is determined after ped consult Parents are educated to use suction of the tubes Regular weekly examination

Second Look procedure Now it is done for the majority of infants 2 months after surgery Under GA, examination, and evaluation of the neochoana, re-widening, removal of new bone formation or soft tissue re-closure.

Results 80 infants (71 females, 9 males) Age at operation average 1 week, (1 day to 28 days) Weight average, 2.8 kg All except 3 were diagnosed at birth, 9 infants had assisted ventilation due to respiratory distress, in these cases extubation was done first before surgery.

Results 62 cases were mixed atresia, 16 cases were bony atresia, only two cases were membranous. In all cases atretic bone removal was done, the vomer was removed in all cases, lateral wall drilling was used in 55 cases. Average follow up was 6 years (6months to 13 years)

Complications and re-stenosis The most common is Re-stenosis (soft, bony or both). one cases had alar cartilage necrosis. One case had collumelar necrosis by the stent One case had septal perforation with depressed nose at age of 8. One patient had pin point palate perforation that heals spontaneously. Only one case died shortly after the procedure, she had profuse bleeding during removal od soft tissue over the atretic plate (hemorrhagic disease of the newborn was suspected). All are among the first 15 cases.

Re stenosis

Closure

Unilateral Stenosis

Drilling of lateral wall

Discussion “Choanal Obliteration” is more descriptive term than choanal atresia because the abnormally thick vomer and the medial pterygoid plates are more contributing to the problem than the atretic plate itself. In many cases, the closure of the choana is made by meeting of the medial and lateral walls with or without soft tissue or small bony plate

Discussion Removal of the atretic plate only or perforation of the central part of the choana on both sides will result eventually in re-closure Removal of the vomer or and drilling out of the medial pterygoid plates are crucial in management of these cases.

Discussion Careful review of the CT scan is important. Evaluation of the thickness of the obliterating components of the posterior choana and the width and height of nasopharynx for accurate surgical planning Infants tolerate only minimal blood loss, hence ; shortening of the procedure and avoiding working laterally is important

Discussion: Stent or not Stenting was used empirically in our series, The importance of stenting is debatable, even in our team. I have found that stenting would help to keep better breathing in the early postoperative period thus helping the child growth It is unknown if it helps in reducing the narrowing and keeping the mucosa in place after surgery however, solid evidence based studies are lacking.

Discussion Second look procedure is important in bilateral atresia, because of the small size of choanal space at this age in addition to the good rapid healing as well as active rapid growth in this age also predisopse to re-narrowing. Sometimes , polyps are formed at the edge of the choana, restenosis with bone is not also uncommon ( growth, healing)

Discussion Parent counseling is essential for assurence, postoperative care, explanation for the problem of re-stenosis Teissier et al. [2008] noted that gastroesophageal reflux disease (GERD), age younger than 10 days at the time of surgery (bilateral atresia) and insufficient postoperative endoscopic revision are predictive factors for restenosis.

Conclusions Endoscopic repair of bilateral choanal atresia meet the goals for efficacy, safety, and minimal effects on growth Second look procedure is recommended for better outcome Working in the infant nose is not difficult in the majority of cases Careful dealing with the septum, alar cartilages is important.

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