[The surgery of the tip of the nose]

Surgery of the nasal tip has stimulated the creation of more surgical techniques than any other aspect of rhinoplastic surgery, to achieve an improved shape that seems natural while enhancing the balance and harmony of the face. The region described as tip of the nose is extremely varied from person to person, because of the different shape of its anatomical structures. For that reason to obtain a good result is necessary for the surgeon the perfect knowledge of the anatomy, the acquisition of surgical concepts and technical skill. The purpose of this paper is to describe the anatomy, the surgical technique and the principal method to correct the most common defects of the nasal tip; some of these proposed by many Authors are also discussed critically. Concerning the anatomy, the Authors describe the upper and the lower lateral cartilages, the lateral and medial crura of the alar cartilages, that form the "dome", the sesamoid complex: smaller cartilage that support the lateral crus, the septum cartilage, their ligaments and the maxillary spine. Are also exposed some concepts regarding the weak triangle of Converse and, in general, the soft tissues of the nasal tip. They also described some basilar incisions to approach the tip cartilage: marginal, intercartilaginous, intracartilaginous and transfixion. This surgical techniques allow to modified the cartilages that can be corrected in different manner. Some of these modifications concerning alar cartilages, septal cartilage, area of dome cartilage, and the most common techniques to operated on it, eversion and luxation, are also exposed. The last part of the paper concerning: a) the exposition of some anesthetical problems and their surgical approach; b) the description and discussion of some surgical techniques proposed in the literature by many Authors. Regarding the most common necessities to modified the nasal tip we include: a) to change the tip projection: in its two opposite directions, increasing and decreasing, where the first purpose is one of the most difficult objectives in tip surgery, using the medial cruras or in more difficult cases a colummellar strut; b) to reduce tip fullness, that normally requires a partial resection and/or a weakening of the lateral crura; c) to alter tip rotation: normally to obtain a upward, rarely for a down ward rotation to increase the length of the nose. In this case all these modifications are described following the theoretical concept of tripod, where the nasal tip is considered mechanically as a tripod with a lower leg represented by the medial crura and the two upper legs of the two lateral cruras.

Treatment of patients with arthrosis of the temporomandibular joint by infiltration of sodium hyaluronate: a preliminary study

Patients with degenerative disease of the temporomandibular joint (TMJ) who did not respond to conservative medical therapy (splint therapy, selected grinding or physiotherapy) can be treated by arthrocentesis, which is associated with intra-articular injections of sodium hyaluronate (Hyalgan). In this study, we treated ten dysfunctional patients with degenerative joint disease (DJD) who had been diagnosed clinically and had had the diagnosis confirmed by MRI. All subjects presented impaired mouth opening, joint pain at rest and on movement and impaired masticatory efficiency. We performed one cycle of five infiltrations with joint arthrocentesis and the injection of sodium hyaluronate at weekly intervals. The following parameters were assessed before and after infiltration and at follow-up after 6 months: mouth opening (with a mean of between 36.5 mm and 41.9 mm); sideways movements (to the right 4.9 mm to 8.9 mm and to the left 4.7 mm to 9.2 mm); pain at rest (VAS=1.8 to 0.5) and on movement (VAS=7.8 to 1.1); masticatory efficiency (VAS=5.7 to 8.6); subjective judgement of the functional TMJ limitation level (from 2.8 to 0.8); judgement of efficacy (from 2.4 to 3.2); judgement of tolerability to the therapy (from 2.0 to 3.1). The therapeutic benefits observed can be attributed both to joint arthrocentesis and to the characteristics of sodium hyaluronate itself. All the parameters considered revealed a statistically significant positive variation that persisted over time ( P<0.05). The results obtained by this minimally invasive, fast and easy technique proved to be valid and lasting. This infiltration technique using sodium hyaluronate looks very promising for patients affected by symptomatic DJD who do not respond to conservative medical therapy, reflecting similarly encouraging findings in the orthopaedic treatment of degenerative knee pathology.

Differential expression and topography of adhesion molecules in laryngeal and oropharyngeal carcinomas

This work describes the different patterns of expression of integrins and extracellular matrix proteins in normal and transformed mucosa in laryngeal and oropharyngeal carcinomas. Samples from each tumor group were sectioned and examined by immunohistochemistry using monoclonal antibodies raised against integrin chains (alpha2, alpha3, alpha6, beta1 and beta4) and their ligands (laminins 1 and 5, collagen type IV and two fibronectin isoforms: ED-A and ED-B). Controls were provided by samples of tumor-free laryngeal and oropharyngeal mucosa that had been removed during the surgical procedure. We found that the known distinct topographical pattern of integrins and the continuity of basement membrane components was altered in both groups but that the extent of changes was significantly more marked in oropharyngeal tumors, which are known to be more infiltrating and diffusive and to have a bad prognosis. These molecular patterns of expression can be used as an additional prognostic factor as they suggest a greater biological tumor aggressiveness of oropharyngeal tumors. We suggest that performing immunohistochemical analysis on biopsy samples may help in selecting the correct therapeutic strategy for these tumors and enable more accurate follow-up. The above-mentioned molecules may become part of the diagnostic toolbox of head and neck surgical pathologists.

Bezold's abscess in children: case report and review of the literature

The introduction of antibiotics in the treatment of suppurative otitis media has significantly decreased the incidence of complications. Reports of Bezold's abscess secondary to this disorder are rare, particularly in infants and young children, in whom mastoid bone pneumatization is not yet complete. We present a case of Bezold's abscess occurring in a child aged 18 months. The literature is reviewed and methods to accurately diagnose this complication are emphasized.

Langerhans' cell histiocytosis: temporal bone involvement

In Langerhans' cell histiocytosis, radiological findings on temporal bone involvement show destructive bone lesions involving the mastoid, with the squamous part and middle ear less affected. Computed tomography (CT) is the preferred imaging modality for describing the extent of temporal bone involvement. CT also has an important role in monitoring disease activity and response to treatment. Bone scintigraphy seems to be less sensitive than radiography in detection of these lesions.

Role of nasal valve in the surgically corrected nasal respiratory obstruction: evaluation through rhinomanometry

The aim of this study was to evaluate the improvement of nasal flow and the fall of nasal resistance in 50 patients that underwent rhinoseptoplasty in our department and discuss the relative importance of valvular and septal deformities in nasal airway obstruction. Fifty consecutive patients underwent rhinoseptoplasty to improve nasal obstruction caused by severe septal deviation, external or internal valvular incompetence, or any combination of the three. We excluded patients with minor septal curvatures, septal perforations, or turbinate hypertrophy. Preoperative and postoperative rhinomanometry was performed on all 50 patients. In all 50 patients, septal and/or valvular surgery lowered nasal resistance in 90% of cases. Septoplasty alone with medial and basal osteotomies did not improve nasal flow (p < 0.4), whereas the correction of valvular obstruction alone increased nasal airflow in a statistically significant way (p < 0.0001). Moreover, patients with both valvular incompetence and septal deviation represented the group in which the greatest preoperative obstruction and the greatest postoperative improvement occurred. Nasal valvular function should be assessed with rhinomanometry in all preoperative rhinoplasty patients with airway obstruction. In many cases, valvular effects may surpass septal deviation as the primary cause of nasal airflow obstruction.

Tympanic membrane displacement analyser tracing modifications induced by glycerol in Menière's disease

The aim of the study was to detect inner ear fluid pressure changes induced by glycerol in Menière's disease (MD) by means of a tympanic membrane displacement analyser (TDA). The study group consisted of 25 MD patients. The Vi (maximum inward displacement of the tympanic membrane) and the Vm (mean displacement of the tympanic membrane) were measured at 10, 20 and 25 dB above the stapedial reflex threshold. Each patient received therapy based on glycerol. The control group consisted of 20 patients with non-hydropic sudden hearing loss. At 20 and 25 dB above stapedial threshold MD patients had lower Vi values before therapy. After glycerol, we observed a Vi increasing in the hydropic ears in 68-96 per cent of patients. Since a Vi improvement implies a reduction of perilymph pressure, our results confirm the effectiveness of Vi in detecting specific action of glycerol in MD.

Violence against women and the assaulted staff action program

Women have been subjected to high rates of victimization at home, in the community, and at work. An earlier study found female inpatient staff to be at risk for same-gender patient assaults in psychiatric hospitals and female community residential staff to be at increased risk for assaults from male patients in residences. This study sought to revisit the original 2-year findings during a subsequent 6-year period. Inpatient and community assault data were gathered within the context of the Assaulted Staff Action Program (ASAP), a post-incident crisis response approach. Female inpatient staff were again found to be at increased risk in both inpatient and community settings. However, in this second study, female community residential staff were found to be at increased risk for assault from both male and female patients. The findings and their implications are discussed.

[Transtympanic gentamicin in Ménière's disease: evaluation of the quality of life]

Different methods have been proposed for the management of intractable Ménière's disease. Over the past years a selection has been made based on the effectiveness and the side effects of the surgical techniques and only a few procedures are routinely used in modern practice. After a period of success, endolymphatic sac surgery is now being progressively abandoned in the aftermath of criticism on its real effectiveness. Vestibular neurectomy is considered an effective method for relieving vertigo but it is an invasive procedure and the risk of complications is not absent. Transtympanic gentamicin is now considered a real alternative approach to the treatment of vertigo in Ménière's disease. The literature reports a high incidence of success with this method, similar to that of vestibular neurectomy, and the only complication being some hearing loss encountered in a few cases. Strategies differ in the gentamicin treatment of Ménière's disease. In the past gentamicin was administered on a daily basis until an effect on the labyrinth was seen. Recently some authors have administered lower amounts of gentamicin for just two or there days. Such treatment appears to control vertigo equally well without causing labyrinthine areflexia although this is not supported in the literature by prolonged follow-ups. The authors discuss the results obtained with a low dosage transtympanic administration of gentamicin in a series of 29 patients followed up for two years. The impact of this form of therapy on quality of life was evaluated through a questionnaire prepared following the criteria of the American Academy of Otolaryngology Head and Neck Surgery. In all cases, the score improved at the end of follow-up.

[Objective evaluation of dysphonia. Possibilities and limitations]

Today clinical evaluation of the presence and extent of dysphonia is still essentially based on subjective-perceptive criteria. The lack of objectivity and the one-sidedness of such an approach reinforces the desire for a quantitative, objective determination of dysphonia which could aid in making an modern, unequivocal evaluation of the presence, extent and variations in time of this disorder both upon onset and after treatment. The purpose of the present research was to determine the reliability, possibilities and limitations of an objective, parametric procedure to evaluate both the normal and pathological voice. This procedure is based on the detection of the relationship between the noise and harmonic portions in the voice (the Yumoto H/N ratio). The study involved a group of 208 subjects (148 with dysphonia and 60 normal) and the procedure was applied using computerized digital sonography and dedicated algorithms. The results of this research showed that the vocal analysis procedure developed by Yumoto is not only simple but also highly sensitive, providing an objective study of dysphonia. In fact, the comparison between the average H/N ratio recorded in our patients (1.697 dB) is significantly different from that recorded in the normal subjects (11.169 dB) (p < 0.001). This also showed a clear discrimination between the two groups with no borderline or overlapping data found. The initial evaluation does not appear to establish a relationship between abnormal H/N ratio values and the type of pathology although greater morphological destruction of the vocal cords corresponds to worse vocal quality and therefore increased noise. For the data obtained to be valid, a necessary condition is the application of a strict, precise, correct sampling and analysis method following well-defined rules. Finally, the values obtained can serve as a basis for the construction of an objective instrumental voice measurement protocol that can be used in forensic evaluation of dysphonia. Standardization of the regulations is essential to such a project.

[Cricohyoidoepiglottopexy : deglutition in 44 cases]

The present work reviews the authors personal experience and applies a meta-analysis of the data in the literature (approximately 800 cases) to better focus on the opportunities and difficulties involved in the Majer-Piquet technique. Particular attention is focused on the problems involved in deglutition. The study involves 44 patients who underwent cricohyoidoepiglottopexy (CHEP) between 1989 and 1998. Given that surgical and rehabilitation techniques have been refined over the years, to better analyze the functional results, the data were separated into two subsequent periods. Of the 23 patients who underwent surgery between 1989 and 1992 (group I), 6 were benefited from bilateral preservation of the arytenoids while this was only possible in two of the 21 cases operated in the second period from 1993 to 1998 (group II). Functional rehabilitation was started earlier in the second group and was routinely monitored with digital viedeofluorography. The average recovery time was 34 days for group I and 27 days for group II. The tracheostomy closed in an average 91 days vs. the 13 days found by the meta-analysis of the literature. The authors normally leave the tracheostoma in place for a long time, even when closed with an easily removed plug, and only perform plastic surgery when the patient has shown stable deglutition for several weeks. The naso-gastric tube was removed from both groups of patients after an average 16 days while the review of the literature shows an average 21 days. On the whole the authors record good deglutition in 41 of the 44 cases (93.18%) with adequate deglutition in the remaining 3 cases. Likewise the literature reports good deglutition in 86.4% of the cases. The only difference found between the two groups of patients was a quicker recovery in the second group; there were no qualitative differences. The results are described and discussed. In conclusion, the present experience places CHEP in favorable light as long as the limits inherent to the method are recognized. However, these limitations relegate the technique to a "sporadic" role and the review of the literature appears to confirm this attitude.

Pharyngocutaneous fistula as a complication of total laryngectomy: review of the literature and analysis of case records

Pharyngocutaneous fistula is the most common complication of total laryngectomy. The management of this problem increases hospitalization time and delays initiation of postoperative radiotherapy, where indicated. To identify factors predisposing to the development of pharyngocutaneous fistula, we reviewed the postoperative courses of 293 patients who underwent total laryngectomy at our clinic. General factors taken into account were concurrent diseases such as diabetes, liver diseases, or chronic anemia; local factors included radiotherapy before and after surgery, preoperative tracheostomy, type of cervical lymph node removal, and method of pharyngeal closure. We then compared our data with those reported in the literature by other authors. Last, we applied the Fisher exact test to a correlation we found between the higher incidence of fistula in patients with diabetes, liver diseases, or anemia. The local factor that turned out to be statistically most significant for the development of fistula was preoperative radiotherapy.

[Videofluoroscopic study of deglutition in patients with multiple sclerosis]

Multiple sclerosis is a neurological disease that affects the I/II motor neurons of the CNS and its symptoms include oropharyngeal dysphagia. The onset and course of this dysphagia significantly conditions the progression of the disease. The present study evaluates the incidence on deglutition and type of alterations in a sampling of 10 multiple sclerosis patients of which 4 showed clinical signs of dysphagia. The results, obtained by combining quantitative (clinical severity) and qualitative (functional alterations) parameters showed that 9 of the 10 patients (90%) presented radiological abnormalities in the progression of the bolus. The conclusion drawn is that the high prevalence of dysphagia in multiple sclerosis, even if not always manifest clinically, justifies drawing up a standard protocol for radiological evaluation and clinical follow-up in order to screen those patients at greater risk of pulmonary complications and delay them as long as possible.

[Post-parotidectomy Frey's syndrome. Treatment with botulinum toxin type A]

The Frey's syndrome, manifest after parotid trauma, is characterized by head and neck hyperemia and abundant sweating of the hyperemic skin in response to gustatory stimuli. The use of the botulin toxin to treat the symptoms in patients with Frey's syndrome has been described in numerous studies. For some time up until now our Center has achieved excellent results using the group A botulin toxin to overcome the hypertonus of the cricopharyngeal muscle in patients who had undergone laryngectomy and were rehabilitated with voice button. We have sought to extend the use of this toxin to Frey's syndrome, a relatively frequent complication of parotidectomy. A total of 86 patients participated in the study: 41 males (47.6%) and 45 females (52.4%) ranging in age from 25 to 77 years (average age 51 years). Of these patients 7 (8.1%) had undergone post-operative radiotherapy. Of the 86 patients studied, 18 referred significant symptoms in terms of abundance and frequency. The syndrome was considered severe if the symptoms were present at each meal and if the patient indicated a significant worsening of his quality of life. Intermittent episodes were indicated by 22 patients. The remaining 46 (43.5%) did not complain of any symptoms. The exact extension of the cervicofacial gustatory sweating was evaluated using the Minor test and the involved region was divided into 1 square centimeters sections. The amount of skin surface involved ranged from 10 to 80 square centimeters. The type A neurotoxin was frozen and was reconstituted with a sterile saline solution at a final concentration of 2.5 UI/0.1 ml. The intracutaneous infiltration was performed without anesthesia, infiltrating 0.1 ml of solution, containing 2.5 UI of toxin into the center of each 1 square centimeters section. Statistical analysis was performed to evaluate the potential relationship between how long the treatment was effective, incidence of recurrence, seriousness of the crises and the following variables: age, sex, histology, cutaneous surface involved, injected dose of botulin toxin and post-operative radiotherapy. In the group of 18 patients with severe symptoms (20.9%) the benefit was immediate in all cases although the recurrence rate was 50%. The Frey's syndrome symptoms disappeared within 7 days of infiltration. In the group of 22 patients with less severe involvement (25.5%), the treatment gave positive, definitive results in 16 patients (72.7%). Those patients whose symptoms persisted were treated a second time with an infiltration of 2.5 UI per square centimeters. We feel that the use of the type A botulin toxin is the most appropriate treatment for the Frey's syndrome. In fact, such treatment offers the following advantages: it is effective within 7 days, has limited side effects, can be applied on an outpatient basis, is inexpensive and is positively considered by the patients.

[Human olfactory mucosa biopsy with endoscopic technique: clinical and structural observations on neurosensory epithelium rearrangement]

Optical and electron microscopy have been widely used to study the structural features of olfactory epithelium in several Vertebrate species. To date, however, understanding of histopathological alterations in the human olfactory neuroepithelium has been quite limited due to the difficulty in obtaining well preserved, intact fragments of mucosa. The recent introduction of endoscopic biopsy techniques has made it possible to analyze this epithelium in greater detail. In the present work, endoscopic biopsy has been performed on samples from 10 rhinologically healthy subjects. The technique used proved quite simple and did not present any risks or complications. Moreover, all samples were well preserved, as confirmed by histology. In addition, the histological pictures suggest that normal rearrangement of neuroepithelium is not an uniform process but takes place following a zone pattern with distinct dynamics between neurosensorial and support cells. Greater diffusion of this technique would not only make it possible to use different techniques to gain more detailed knowledge of tissue structure, ultrastructure and dynamics in human neuroepithelium, but it would also provide improved diagnostic and forensic evaluation in cases of anosmia, disosmia and hyposmia.

[Revascularized jejunum loop in hypopharyngeal reconstruction: oncological and functional results]

The aggressiveness of hypopharyngeal cancer makes broad resectioning of the circular pharyngolaryngoesophageal segments necessary, followed by reconstruction to restore the anatomical gap created as fully as possibly creating a neoesophagus with thin walls that can easily be released. Over the years several procedures have been fine tuned for reconstruction of the upper digestive tract employing transposed viscera, miocutaneous pedunculated flaps, revascularized fascio-cutaneous or visceral free flaps. Currently the revascularized jejunum loop is one of the most commonly used methods in the reconstruction of the hypopharynx. Its popularity is due to some anatomical and physiological advantages: it requires transposition of a brief intestinal tract anatomically well adapted to the reconstruction site, ensuring rapid functional recovery. The authors report the oncological and functional results obtained in 25 patients who underwent circular pharyngolaryngectomy followed by reconstruction with a revascularized jejunum loop. The percentage of transplant survival was 90% and local and general complications were reduced to a minimum. The functional results--both in terms of deglutition and phonation--were satisfactory while patient survival (6-37 months follow-up) was in line with that reported by other authors for the same tumor (47%). Although prognosis for hypopharyngeal-esophageal neoplasms is still quite poor, this experience shows that circular pharyngolaryngectomy followed by reconstruction with autotransplant of the jejunum is an excellent choice since it offers the patient a prompt, acceptable functional recovery and a fair quality for his remaining life.

[Paranasal sinus mycoses]

In recent years there has been a marked increase in mycosis infections of the paranasal sinuses, attributed both to an increase in the survival of subjects at risk and improved diagnostic techniques (endoscopy, CT, MR) able to identify cases which had previously gone unrecognized and treated as aspecific chronic sinusitis. The present study involves 45 cases (4.3%) out of a total of 1050 patients who had undergone endoscopic surgery for sinusopathy between April 1994 and December 1998. Following the Katzenstein classification, the cases were broken down into non-invasive chronic mycoses or fungus ball (34 cases), allergic mycoses (7), chronic indolent invasive mycoses (3) and fulminating invasive mycosis (1 case). The mycetes most often involved was Aspergillus Fumigatus (76.9%). The recurrent symptom was facial algia, followed by nasal obstruction. Paranasal sinuses endoscopy did not modify the specific picture. CT presented such indicative signs as focal areas with non-homogeneous intensity, images of metal-like foreign bodies and endosinus calcifications in 84.4% of the cases. MR--performed in only 6 cases--always presented T2 images showing the typical signal void area corresponding to pathological lesions. All patients underwent endoscopic surgery of the paranasal sinus. The effectiveness of this treatment differed according to the clinical form. In the fungus balls surgery always resolved the pathology without requiring subsequent pharmacological treatment. In allergic mycosis, surgery improved the symptom of nasal respiratory obstruction but local drug treatment was required. With the aid of drug treatment, surgery resolved chronic indolent invasive mycoses and prevented the endocranial progression of complications. In the cases of fulminating invasive mycosis, timely surgery prevented the onset of endocranial complications and made it possible to perform antimycotic polychemotherapy to control the disease. This experience shows how important a protocol involving several different tests is in diagnosing the many clinical forms of paranasal sinus mycoses and distinguishing them from sinusopathies. Endoscopic surgery is indicated for all forms of paranasal sinus mycoses although the realistic objectives differ according to type.

[Surgical revision of the lateral nasal wall]

The purpose of rhinosinus revision through endoscopic surgery is to resolve recurrent, residual pathologies in patients with drug-resistant symptoms and to prevent ocular and endocranial complications. Surgical revision proves quite complex because of the destruction of the anatomical structures. More over the presence of tougher scare tissue which bleeds easily increases the risk of iatrogenous complications. Axial and coronal-projection tomography without contrast medium must be performed prior to surgery. Endonasal orientation is ensured by six main reference points. Three of these points--nasal septum, upper edge of the choana and upper edge of the nasolacrymal duct--are nearly always present while the others may or may not be, depending on what sort surgery has been performed. The present work gives the guidelines for a correct approach to patients who have undergone many previous procedures.

[Maxillary ameloblastoma: a case report]

Ameloblastoma is a neoplasm of odontogenic origin. Although it is considered a benign lesion it presents some peculiarities including a high local recurrence rate, particularly after conservative surgery, and a high loco-regional invasiveness. The present work describes a case of ameloblastoma of the left maxillary sinus bordering on the homolateral nasal fossa. The male patient was admitted to the E.N.T. Dept II of the University of Turin in May 1998 and underwent left radical maxillectomy. The authors also review the literature on the topic.

Staffieri tracheo-oesophageal prosthesis for voice rehabilitation after laryngectomy: an evaluation of characteristics

Experimental results on voice prostheses used for the rehabilitation of patients that have lost their vocal function after total laryngectomy are presented. The purpose is to evaluate the difference in aerodynamic behaviour between Staffieri voice prosthesis and other commercial valves (Groningen standard, Groningen low pressure, Panje, Provox). Two different equipments for flow-rate measurement were designed and built to compare the performance of the valves. The valves have been experimentally tested under different conditions of airflow through the valve and tracheal side pressure. The data allow calculation of the airflow resistance, the parameter usually used to compare the performance of valves. The valves have also been experimentally tested under different conditions of fluid flow through the valve and oesophageal side pressure (reverse flow). Comparing the airflow resistance of Staffieri valves of different length L and different angular extension of the razor-thin silt alpha, it has been observed that the parameter alpha has a significant influence on the characteristics, while the effect of the length L is negligible. The airflow resistance of the Provox, Groningen low pressure and Staffieri alpha = 270 degrees valves are comparable; the Panje and Staffieri alpha = 180 degrees have similar behaviour; while the Groningen Standard is comparable to the Staffieri alpha = 90 degrees. Regarding reverse flow, it is pointed out that for most of the valves (Staffieri and commercial valves), at different oesophageal pressures the fluid flow is smaller than the flow that can be tolerated by patients without giving problems.

[The treatment of choanal atresia]

Choanal atresia occurs in approximately 1 out of every 8000 live births. In about 60% of these cases it is unilateral and is often associated with other major craniofacial anomalies or visceral malformations such as the so-called CHARGE syndrome (i.e. Choloboma, Heart defects, choanal Atresia, Retarded growth and development, Genital anomaly, and Ear defect with deafness) first described by Pagon in 1981. In newborns the clinical manifestations of choanal atresia consist of respiratory distress strictly related to the entity of nasal obstruction. Total bilateral congenial choanal atresia must, therefore, be considered a surgical emergency since nasal obstruction impedes the suction mechanism and hence normal feeding in the newborn. For this reason, prompt surgery is mandatory. The surgical approach employed in choanal atresia consists of both the trans-nasal and trans-palatal approaches. Between 1985 and 1997 31 patients with choanal atresia were treated in our department (16 males, 15 females; age range 2 days-5.5 years; mean 11.4 months). In 25 cases (80.6%) the malformation was bilateral. Associated anomalies were seen in 8 patients (25.8% of cases). All of these patients were treated using the trans-nasal approach, under general anesthesia, and endoscopic control. In 27 cases a trocar was employed to perforate the bony atresia and a stent was then positioned. Three patients underwent contact-laser resection of the stenosis without requiring any further stent and without any complications. None of these patients developed total recurrences, although after varying amounts of time, in 8 of the 27 patients operated using the trocar (29.6% of cases) a partial reduction of the airway occurred, the substenosis requiring dilatation with progressive Hegar dilators. In the remaining cases contact-laser therapy was associated with dilation. Three of the patients were treated by laser-therapy alone and none developed a recurrence. One patient dropped out of the follow-up for other serious malformations.