A new endoscopic surgical method for unilateral choanal atresia

Transnasal endoscopic neochoanal technique: An effective procedure for bilateral choanal atresia in adult female

Background

Surgery on bilateral choanal atresia surgery is challenging and this case is rare in adults. In addition, stenosis issue postoperatively is commonly seen.

Case presentation

Transnasal endoscopic neochoanal technique was performed on a 27 years old female with the detailed surgical procedure was described. Neither stent nor nasal tamponade was applied. Ten months follow-up revealed a patent-wide neochonae.

Discussion

Transnasal endoscopic neochoanal technique without stent and nasal tamponade can be considered the procedure of choice in the management of CA cases.

Conclusions

Transnasal endoscopic neochoanal technique is considered an effective surgical procedure on bilateral choanal atresia.

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Choanal atresia in adults is often related to the socioeconomic status of the patient.

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The transnasal endoscopic neochoanal technique is an effective procedure for choanal atresia.

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Low socioeconomic status may cause a delay in diagnosis and thus management of choanal atresia.

Surgical Management of Choanal Atresia With Intranasal Hegar's Dilator and Transnasal Endoscopic Excision: A 20-year Retrospective Comparative Study

Background

Although choanal atresia (CA) was first described 250 years ago, its description and understanding remain incomplete, as is the distinction between unilateral and bilateral CA. Among the surgical techniques introduced to manage this condition are intranasal Hegar’s dilator (IHD) and transnasal endoscopic excision (TNEE).

Objectives

This study retrospectively evaluated the outcomes and effectiveness of IHD and TNEE in the treatment of patients with CA, including differences in the incidence of re-stenosis with these techniques.

Methods

Patients diagnosed with CA who underwent surgical interventions in the Otolaryngology Department of Al-Noor Specialist Hospital, Makkah, Saudi Arabia, between 1997 and 2017 were analyzed. Postoperative outcomes including re-stenosis rates were compared in patients who underwent IHD and TNEE. Factors associated with patient outcomes were analyzed, including ages at diagnosis and surgery, nationality, gender, type of atresia (unilateral/bilateral and bony/membranous/mixed), surgical intervention (IHD or TNEE), and re-stenosis and need for revision surgery after IHD and TNEE.

Results

A total of 30 patients were diagnosed with CA, including 21 (70%) girls and 9 (30%) boys. Of them, 18 (60%) patients were diagnosed at younger than one month of age, 28 (93%) were Saudi nationals, and 20 (67.70%) were aged younger than three months at the time of surgery. Of these 30 patients, 17 (56.70%, all Saudi nationals) underwent IHD, and 13 (43.30%), including 15 Saudi nationals, underwent TNEE. The 17 patients who underwent IHD included 13 (76.50%) girls and 4 (23.50%) boys, whereas the 13 patients who underwent TNEE included 8 (61.50%) girls and 5 (38.50%) boys. Fifteen patients (50%) had mixed-type CA, nine (30%) had bony-type CA, and six (20%) had membranous-type CA. Twenty-six (86.67%) patients underwent primary surgery, whereas four (13.33%) underwent revision surgery; of the latter, three (75%) had undergone primary IHD, and one had undergone primary TNEE. Only one (3.33%) patient experienced re-stenosis after revision surgery, which consisted of IHD. Twelve patients (40%) underwent stenting, with one developing re-stenosis. The relationships between surgical approach and re-stenosis after primary and secondary surgery were not statistically significant.

Conclusion

The outcomes in patients with CA treated with IHD and TNEE are comparable. Rates of re-stenosis and need for revision surgery do not differ significantly in patients treated with these surgical approaches.

Immediate versus delayed surgery in congenital choanal atresia: A systematic review

OBJECTIVES

To evaluate immediate versus delayed surgical intervention on treatment outcomes in the management of congenital choanal atresia.

METHODS

This study adhered to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines in reporting a systematic review of the literature. OVID Medline, EMBASE and Pubmed databases were searched using relevant key terms. Inclusion and exclusion criteria were designed to capture studies examining immediate versus delayed primary surgery for congenital choanal atresia. Timing of surgery was classified as immediate or delayed based on median age of intervention stratified by type of obstruction. Primary outcomes were primary treatment failure, respiratory function and mortality rates.

RESULTS

A total of 2765 abstracts were identified and screened by 2 independent reviewers. Of the 688 articles reviewed in full text, 23 articles met the study criteria and were subjected to quality assessment. The full study assessment and quality control measures yielded 23 studies (representing 362 patients) for pooled patient-level analysis in the systematic review. Primary treatment failures occurred in 24.8% of patients that underwent immediate surgery and 42.6% of patients that underwent delayed surgery for bilateral choanal atresia (p = 0.01). There were no differences in mortality rates (5.6% vs 4.2%; p = 1.00) or qualitative measures of respiratory function. There were no difference in treatment outcomes for patients with unilateral choanal atresia (p > 0.05).

CONCLUSIONS

Through an analysis of pooled individual patient data, this systematic review of the literature demonstrated that there was significantly higher rates of treatment failure in patients that underwent delayed surgery for bilateral choanal atresia. Clinical trials and large prospective cohort studies investigating outcomes following immediate and delayed surgical intervention will provide further insight into treatment strategies.

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.

Retrospective study of a series of choanal atresia patients

Introduction Although it has been more than 250 years since the first description of choanal atresia (CA), there are still doubts about this abnormality. The differences between unilateral and bilateral forms are seldom discussed.

Objectives Aggregate data from patients diagnosed with CA, grouping patients with unilateral and bilateral forms.

Methods Retrospective study.

Results Eighteen patients were included: 12 (66.6%) presented bilateral atresia, of which 77.8% were mixed bony-membranous type and 22.2% were pure bony type. From the 12 patients with bilateral atresia, 10 presented related malformations, 3 of whom had CHARGE syndrome (coloboma, heart defects, choanal atresia, retardation of growth and development, genitourinary problems, ear abnormalities). From the remaining 6 patients with unilateral atresia, only 2 showed malformations, 1 renal and 1 cardiac. All patients with unilateral atresia needed only 1 surgical procedure, and patients with the bilateral form needed a median of 2.85 interventions (p = 0.003). The median age of surgical procedure in the unilateral group was 6 years, ranging from 6 months to 18 years, and in the bilateral group was 25 days, ranging from 6 days to 6 years (p = 0.003). The median interval between diagnosis and surgery was 9 months in the unilateral group, ranging from 1 month to 18 years, and in the bilateral group was 1 day, ranging from 1 day to 2 months (p = 0.001).

Discussion and Conclusions Success rates with the endoscopic approach vary from 62 to 100%. Nonetheless, most of these reports present results without considering the number of compromised sides. In our opinion, unilateral and bilateral cases involve distinct patients (taking into account the related malformations), have diverging clinical presentations, and show discrepant restenosis rates and therefore could be considered in different groups of analysis.