Endoscopic repair of choanal atresia: practical operative technique

Stenting versus stentless repair for bilateral choanal atresia: A systematic review of the literature

BACKGROUND

Bilateral choanal atresia requires prompt surgical intervention. Surgeons have historically used stents in the repair process, however their efficacy has come into question in recent years. We performed a systematic review to investigate, primarily, whether stents enjoy more favourable outcomes compared to stentless repair. We also explored the use of operative adjuncts, such as steroids, antibiotics, mitomycin C and KTP laser.

METHODS

We performed a search of the Medline and Embase databases using a search strategy developed with the assistance of an academic librarian. Only full peer reviewed articles were included. Abstracts, posters, case reports and proceedings of academic conferences were excluded.

RESULTS

We identified 48 unique articles for inclusion, composed of a meta-analysis, two randomised control trials and 45 case series. Pooled analysis of the two randomised control trials yielded no statistically significant difference in choanal patency between stented and stentless repair, but a statistically significant reduction in complications, specifically granulation tissue formation, was found in stentless repair. Data from case series were, overall, of mixed quality, making factors contributing to successful outcomes difficult to elucidate.

CONCLUSION

Overall, there is a lack of high quality evidence to support the use of either a stented or stentless approach to bilateral choanal atresia repair, however stentless repair may experience fewer complications. Operative techniques, such as the use of mucosal flaps, are worthy of future study. Authors call for future high quality randomised control trials to investigate this uncommon but important condition.

Prognostic Factors and Management of Patients with Choanal Atresia

OBJECTIVE

To analyze prognostic factors in the management of patients with choanal atresia.

STUDY DESIGN

This is a review of 114 patients operated on for choanal atresia in a tertiary care center between November 1986 and November 2016, including clinical characteristics, surgical management, and postoperative course with final nasal patency. The data were collected in a database that was updated over time.

RESULTS

Among the 114 patients, 78 were female, 77 presented with unilateral choanal atresia, and 37 presented with bilateral unilateral choanal atresia, corresponding to 151 nasal fossae. Forty-seven patients had associated abnormalities (41.2%), including CHARGE, diagnosed in 20 children (17.5%). At the end of follow-up, 91 patients (79.8%) had normal choanal patency. The identified risk factors of surgical failure were age <6 months (P = .004), weight <5 kg (P = .007), and bilateral choanal atresia (P < .001). The type of atresia, presence of associated abnormalities, surgical approach, stenting, and use of mitomycin were not significantly linked with the surgical results.

CONCLUSIONS

This series highlights the importance of the timing of surgery, which is guided by the clinical ability of the infant to tolerate the procedure. Endoscopic approaches are widely performed, but a transpalatal approach, necessary in some cases of bilateral choanal atresia, does not alter the results. Unilateral choanal atresia surgery should be delayed after age 6 months and/or weight >5 kg when possible.

Surgical treatment of choanal atresia with transnasal endoscopic approach with stentless single side-hinged flap technique: 5 year retrospective analysis

INTRODUCTION

Choanal atresia is a rare congenital malformation of the nasal cavity characterized by the complete obliteration of the posterior choanae. In 67% of cases choanal atresia is unilateral, affecting mainly (71%) the right nasal cavity. In contrast to the unilateral form, bilateral choanal atresia is a life-threatening condition often associated with respiratory distress with feeding and intermittent cyanosis exacerbated by crying. Surgical treatment remains the only therapeutic option.

OBJECTIVE

To report our experience in the use of a transnasal endoscopic approach with stentless single side-hinged flap technique for the surgical management of choanal atresia.

METHODS

A 5 year retrospective analysis of surgical outcomes of 18 patients treated for choanal atresia with a transnasal technique employing a single side-hinged flap without stent placement. All subjects were assessed preoperatively with a nasal endoscopy and a Maxillofacial computed tomography scan.

RESULTS

Ten males and eight females with a mean age at the time of surgery of 20.05±11.32 years, underwent surgery for choanal atresia. Fifteen subjects (83.33%) had a bony while 3 (26.77%) a mixed bony-membranous atretic plate. Two and sixteen cases suffered from bilateral and unilateral choanal atresia respectively. No intra- and/or early postoperative complications were observed. Between 2 and 3 months after surgery two cases (11.11%) of partial restenosis were found. Only one of these presented a relapse of the nasal obstruction and was subsequently successfully repaired with a second endoscopic procedure.

CONCLUSION

The surgical technique described follows the basic requirements of corrective surgery and allows good visualization, evaluation and treatment of the atretic plate and the posterior third of the septum, in order to create the new choanal opening. We believe that the use of a stent is not necessary, as recommended in case of other surgical techniques involving the use of more mucosal flaps.

Unilateral blindness: a unique complication of choanal atresia surgery

OBJECTIVE

To report a unique case of unilateral blindness secondary to transnasal endoscopic surgery and stenting for right choanal atresia.

CASE REPORT

A 24-year-old man was referred with right eye blindness and acute headache, occurring immediately after transnasal endoscopic surgical repair of unilateral right choanal atresia with placement of an endonasal stent. Maxillo-facial computed tomography with three-dimensional reconstruction showed the endonasal stent entering the right nostril, passing through the lamina papyracea into the orbit and running anterior to the optic foramen towards the superior orbital fissure. Despite stent removal and medical treatment (ceftriaxone and dexamethasone), permanent right eye blindness secondary to an irreversible lesion of the optic nerve was diagnosed. At three-month follow up, an uncommon, complete fibrous obliteration of the right nasal fossa was noticed.

CONCLUSION

To the best of our knowledge, this is the only published report of unilateral blindness following transnasal endoscopic stenting for right choanal atresia. Causes of this complication, and ways of avoiding it, are discussed.

Surgery for congenital choanal atresia

BACKGROUND

Congenital choanal atresia is a rare abnormality characterized by unilateral or bilateral lack of patency of the posterior end of the nasal cavity. With an incidence of 1:5000 to 1:8000 births, it is twice as prevalent in females as it is in males. Surgical procedures aim to provide adequate functional choanal patency and a low rate of restenosis, avoid harm to any structure in development, enable shorter surgery and hospitalization times, and minimize morbidity and mortality.

OBJECTIVES

To evaluate the effectiveness and safety of the available surgical techniques for the treatment of congenital choanal atresia in patients with unilateral and bilateral atresia.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the search was 31 January 2011.

SELECTION CRITERIA

We planned to include parallel randomized or quasi-randomized controlled trials testing surgical approaches for the treatment of congenital atresia (irrespective of gender and age) that evaluated normal/adequate respiratory function (self reported or preserved nasal airway) and restenosis as the main primary outcomes. We did not consider reoperation and non-congenital atresia (e.g. traumatic, iatrogenic atresias) for inclusion.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the titles and abstracts of the identified articles to determine potential relevance. For dichotomous and continuous variables, we planned to calculate risk ratios (relative risks; RR) and mean differences (MD) with 95% confidence intervals (CI), respectively. We planned to use the random-effects model since we were expecting substantial clinical and methodological heterogeneity.

MAIN RESULTS

No randomized controlled trials were identified. From the 120 reports retrieved using our search strategy, 46 primary studies had the potential to be included since they had tested surgical approaches for choanal atresia. However, we excluded all of them during the final selection process because their study designs did not meet our inclusion criteria.

AUTHORS' CONCLUSIONS

There is no definitive evidence, based on randomized controlled trials, to demonstrate the potential advantages and disadvantages of any specific surgical technique for patients with choanal atresia. Specialists should unify their efforts in multicenter randomized controlled trials that test the effectiveness and safety of different surgical techniques in patients with choanal atresia.

The use of adjunctive topical mitomycin in endoscopic congenital choanal atresia repair

OBJECTIVE

To evaluate the efficacy of topical mitomycin in providing the patency of the neochoanae in children undergoing transnasal endoscopic congenital choanal atresia (CA) repair.

METHODS

A retrospective analysis of surgical results in CA patients who were treated in Selcuk University, Meram Medical Faculty, Department of Otolaryngology between November 2002 and November 2009 was performed. All patients underwent transnasal endoscopic approach using nasal telescopes and traditional sinus instrumentation together with a microdebrider. Mitomycin was used according to the senior surgeon's preference, and certainly not in a randomized fashion. After completion of surgery, mitomycin 0.4 mg/ml was applied to the neochoanae for 3 min. Postoperative stenting was performed in all patients.

RESULTS

CA was unilateral in 8 subjects (mean age 71.8+/-41.7 months; range 18 months-144 months) and bilateral in 12 subjects (mean age 4.6+/-1.3 days; range 3-7 days). Among the subjects, 75% was female in both groups. Fourteen subjects under endoscopic repair without mitomycin, whereas mitomycin was used in 6 patients (4 bilateral, 2 unilateral). Stents were left at least 3 weeks postoperatively (mean 31+/-10 days; range 21-45 days). The patients were followed-up at least 6 months (range 6-72 months). No symptomatic restenosis requiring further dilatations was seen in patients treated with preoperative mitomycin, whereas restenosis was detected in 6 subjects (42.9%) treated without mitomycin postoperatively within 6 months period (Fisher's Exact Test 2-sided, p=0.12). These subjects underwent revision endoscopic repair with mitomycin and had no need for further dilatations with acceptable control of symptoms during a follow-up period ranging between 14 and 78 months.

CONCLUSION

Mitomycin improves the surgical treatment outcome of CA and reduces the rate of restenosis significantly without any complications. However, further prospective randomized studies are needed to fully investigate the benefits of mitomycin therapy in CA surgery.

A 13-year experience and predictors for success in transnasal endoscopic repair of congenital choanal obliteration

OBJECTIVE

To express a 13-year experience in transnasal endoscopic repair of congenital choanal obliteration and to analyze the different predictors that may affect the surgical outcome.

DESIGN

Retrospective clinical study.

SETTING

Otolaryngology Department, Tanta University Hospital, Egypt.

PATIENTS AND METHODS

Over a 13-year period (from January 1996 to December 2008), 54 children aged between 7 day and 14 year old at the time of surgery underwent transnasal endoscopic repair of an unilateral (32 cases) and bilateral (22 cases) congenital choanal obliteration using conventional instruments and microdebrider/drill to remove the atretic plate, bony boundaries, and vomer. A laterally based mucosal flap was routinely used to resurface most of the raw areas of the lateral and superior borders of the created choana followed by shortened period stenting (5-7 days). Patients were then clinically and endoscopically monitored for nasal obstruction and healing for a mean follow-up of 46+/-6 months. Demographic characteristics of these patients, associated anomalies, surgical technique, postoperative stenting, complications, postoperative care, and surgeons' learning curve were discussed in the light of the findings of the surgical outcomes.

RESULTS

There were 33 females (61.1%) and 21 males (38.9%). A total of 12 patients (22.2%) presented with associated anomalies. There were no major intra-operative or postoperative complications. The success rate for bilateral choanal obliteration was 86.4% and for unilateral choanal obliteration 96.9% with an overall success rate 92.3%. Revision surgery of the relapsed cases using the same technique without mucosal flap was successful 100%.

CONCLUSION

Transnasal endoscopic repair of congenital choanal obliteration is an easy and evolving technique with adequate safety and high success rate. Early diagnosis and good preparation of the patients for surgery, adequate resection of the bony boundaries of the obliterated choana and vomer, shortened period nasal stenting, strict early and late follow-up, and the growing experience of the surgeons, all were prognostic factors for success. Associated anomalies and use of mucosal flap did not seem to affect the prognosis. Inadequate bone resection, bilaterality, pure bony obliteration, the younger the age of the patient, and early developing experience of the surgeons, all were possible predictive factors for relapse.

Transnasal endoscopic repair of choanal atresia: results of 13 cases and meta-analysis

Transnasal endoscopic approach for the repair of choanal atresia (CA) has gained favor in recent years. However, the studied cohorts are too small to make a comprehensive comment on this approach. The aim of this study was to evaluate the effects of different techniques, used for the removal of CA under endoscopic guidance, on surgical outcome and effectiveness of transnasal endoscopic approach in these patients as a whole. We present the results of transnasal endoscopic repair of CA in 13 patients and made a meta-analysis of similar studies in the literature. Mean success rate with transnasal endoscopic repair was 85.3% in a total of 238 cases in 20 studies that met the inclusion criteria. Only the history of previous surgery for CA seemed to significantly decrease the postoperative success rate (P = 0.029). Rate of revision surgery did not significantly differ between mixed, bony, or membranous atresia (P = 0.395). Likewise, simple perforation or complete excision of the atretic plate under endoscopic view (P = 0.513), use or no use of mucosal flap to seal the denuded bone of the choana (P = 0.472), and postoperative stenting or no stenting (P = 0.252) have proved not to considerably have influence on the surgical outcome. Death of perioperative bleeding was the single major complication in 1 case among all of the study groups. In conclusion, types of CA, excision method, and stenting have no significant effect on surgical outcome of CA. Irrespective of the technique used for the excision and the repair of atretic plate, transnasal endoscopic approach with higher success rate and minimal postoperative morbidity is a good choice for the repair of CA.

Technique for fabrication of splint preventing postsurgical restenosis in choanal atresia

Choanal atresia, a congenital narrowing or obstruction of the nasal airway caused by significant respiratory distress in neonates, may require emergency intervention. Although atresia can be repaired surgically, restenosis is a common complication with this procedure. To prevent this, tubes are inserted into the nasal cavity immediately after surgery. This article describes a technique for preparing individual surgical splints designed to prevent postsurgical obstruction of the nasal cavity.

Endoscopic treatment of congenital choanal atresia

This report outlines the effectiveness of the transnasal endoscopic approach for the treatment of congenital choanal atresia. Fourteen patients with age between 5 days and 15 years were treated using this approach by means of 0 and 30 degrees 4 or 2.7 mm telescopes: three cases were bilateral while 11 were unilateral. The time of stenting ranged from 3 to 6 days (mean 4 days) in the three newborn patients and between 1 and 2 weeks (mean 1 week) in the other nine patients. In the last two cases, stenting was not carried out. The overall follow-up period ranged from 2 to 64 months (mean 31 months). Only one restenosis was observed in this series 2 months after surgery. This restenosis was successfully treated by endoscopic revision. The authors believe that a correct repositioning of mucosal flaps after the resection of the atretic plate is of paramount importance in avoiding restenosis of the neochoana and in reducing the time and/or the use of stenting.