Combination of the endoscopic septonasal flap technique and bioabsorbable steroid-eluting stents for repair of congenital choanal atresia in neonates and infants: a retrospective study

A Modified Single-Stage Endoscopic Repair for Bilateral Choanal Atresia

The work illustrates a step-by-step surgical approach to demonstrate technical feasibility of a single-stage endoscopic repair for bilateral choanal atresia with adjuvant bioabsorbable steroid-eluting stent placement to safely mitigate unique perioperative challenges in the pediatric population. Laryngoscope, 2024.

Steroid-Eluting Implants: An Adjunctive Therapy After Double-Stage Laryngotracheal Reconstruction

OBJECTIVES

The primary objective is to describe a case in which a steroid-eluting implant was utilized to help prevent postoperative granulation and restenosis in a patient who underwent double-stage laryngotracheal reconstruction (dsLTR) for subglottic stenosis.

METHODS

This case presents a 3-year-old female who underwent dsLTR with anterior cartilage graft placement and posterior sagittal split for subglottic stenosis. A silicone stent was placed at the time of the dsLTR. After stent removal, direct laryngoscopy and bronchoscopy (DLB) was performed at 4 to 5 week intervals. These visits revealed a significant amount of supraglottic and glottic edema, and granulation tissue at the proximal aspect of the graft contributing to airway obstruction and restenosis. This was treated twice with CO2 laser excision, balloon dilation, and triamcinolone injection. On the third treatment with these modalities, a mometasone furoate implant was inserted as an adjunctive therapy. The implant was inserted to lateralize the vocal folds, prevent webbing, and to extend to the narrowed area within the subglottis to prevent granulation and restenosis. These same treatments were repeated at the fourth visit with another mometasone furoate implant of a smaller size placed in the same location.

RESULTS

Findings on DLB since treatment with the steroid-eluting implants have shown persistent granulation tissue limited to the tracheostomy stoma site. Treatments with CO2 laser, balloon dilation, and triamcinolone injection have continued, with occasional use of silver nitrate cautery at the external stoma site. There has not been any significant evidence of edema, granulation, or stenosis in the glottis or subglottis to require another steroid-eluting implant.

CONCLUSIONS

Steroid-eluting implants appear to be a safe and effective adjunctive therapy in the routine surveillance of pediatric patients with a tracheostomy who have undergone dsLTR. They may help combat granulation formation and restenosis seen in some dsLTR patients.

[Clinical Management of Choanal Atresia]

Choanal atresia (CA) is a rare congenital anomaly of the nasal airway with an incidence of 1/5000 to 1/9000, which may occur unilateral (uCA) or bilateral (bCA). bCA manifests as an acute emergency immediately after birth by airway obstruction and paradoxical cyanosis, whereas uCA may present with a heterogeneous clinical picture in addition to unilateral nasal airway obstruction. Fiber endoscopic examination and cranial computed tomography are the gold standard in the diagnosis of CA. CA often occurs in association with congenital malformation syndromes, among which CHARGE syndrome stands out. Due to cardiopulmonary instability and difficult intubation conditions, syndromic CA patients should be considered as a separate risk group. After securing the airway, bCA must be treated surgically without delay, whereas correction of uCA should not be performed until after six months of age. Endoscopic techniques are the surgical standard in the treatment of CA. Different approaches can be distinguished: transnasal puncture of the atresia plate with subsequent extension medially and laterally, creation of a septal window with subsequent resection of the posterior vomer and atresia plate, and elevation of mucoperiosteal flaps with subsequent opening of the atresia plate. The transpalatal approach should only be employed in anatomically complex cases. The use of conventional choanal stents in the primary treatment of CA is increasingly rejected and should be reserved for high-risk constellations. Similarly, local application of mitomycin C should be avoided.

Safety profile and efficacy of high-dose topical mitomycin-C for choanal atresia repair: A prospective cohort study

OBJECTIVES

To study the effect of dose-adjusted mitomycin-c (MMC) on the recurrence rate of choanal atresia (CA), and the complication rate associated with this concentration.

METHODS

This prospective cohort study was conducted between May 2012 and March 2020 at a tertiary referral center. It included patients of all ages who were diagnosed with CA and scheduled to undergo surgical repair. The MMC group received 4.0 mg/mL of topical MMC. Both groups were followed up for the surgical outcomes and complication rates.

RESULTS

Twenty-one patients (15 females) underwent 25 CA repair procedures. The mean age was 44.85 months (standard deviation = 72.85). MMC was used in 12 (57.1%) of 21 patients. Revision CA repair was warranted in three of the nine patients who did not receive topical MMC compared to one of the 12 patients who received topical MMC. The MMC group required 1.08 ± 0.29 surgeries (range, 1-2), whereas the non-MMC group required 1.44 ± 0.73 surgeries (range, 1-3). Functional success was achieved in 17 (81%) patients who remained symptom-free until their last follow-up visit.

CONCLUSION

High-concentration MMC was considered safe in the pediatric and adult populations. Although high-concentration MMC could reduce the need for revision surgery, further studies are required to determine whether the effect is significant in a larger sample population.

Choanal Atresia Repair With Stents and Flaps: A Systematic Review Article

Background

Choanal Atresia is an obliteration by an atretic plate of the posterior choanae due to a failure of the bucconasal membrane to rupture. The insertion of stents post choanal atresia repair is familiar. Still, there are limited studies in the literature that specify the time to remove it, the best materials, and the effectiveness of each kind.

Objective

Our study aims to compare different types of choanal atresia stents and flaps and the outcome of different kinds of stents and flaps that use post-operatively. Also, to assess the risk of restenosis post-operatively with varying types of Stent and flaps.

Methods

A systematic review via databases for different types of stents and flaps used in choanal atresia, including 31 studies with precise technique, variety of stents, restenosis rates, and risk factors (unilaterality, the component of the atretic plate). And about 10 different approaches to flaps reconstruction were mentioned.

Results

According to the data, we observed a successful rate of choanal atresia repair by using the ordinary ETT post-operatively ranged from 28 to 94.2%, which could be explained due to many factors. Post-operative Instructions on care and suctioning provided a good impact. Other types of stents found in case series like steroid eluting stents, Nelaton catheters, Silastic stents, or modified ETT have a promising future during 26 to 39 weeks follow-up. Still, they need further studies with randomization and more data. Flaps with different approaches and techniques showed promising results and fewer complication rates with or without stents, also now have been used in practice providing suitable alternatives for stents.

Conclusion

The original types of choanal atresia stents were shown to have a wide variety of results, while innovative materials of stents showed promising results, however, in relatively small case studies. Flaps were now used in practice giving other choices for stents with fewer complications, better healing, and new choana formation.