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Endoscopic transnasal repair of choanal atresia
International Journal of Pediatric Otorhinolaryngology (2007) 71, 457—462
www.elsevier.com/locate/ijporl
Endoscopic transnasal repair of choanal atresia Eitan Yaniv a,d,*, Tuvia Hadar a,d, Jacob Shvero b,d, Yoram Stern b,c,d, Eyal Raveh b,c,d a
Nose and Sinus Institute, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel Department of Otolaryngology, Head and Neck Surgery, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel c Schneider Children’s Medical Center of Israel, Petah Tiqva, Isreal d Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel b
Received 28 July 2006; received in revised form 17 November 2006; accepted 17 November 2006
KEYWORDS Choanal atresia; Endoscopic transnasal repair; Mucoperichondrial flap
Summary Objectives: To present our experience with a new endoscopic technique for transnasal repair of choanal atresia. Methods: Seventeen patients aged 2 months to 13 years with choanal atresia, bilateral in 6 and unilateral in 11, underwent endoscopic repair using a mucoperichondrial flap developed from the nasal septum. The bony stenosis was opened with a surgical curette or drill, and the raw surface was covered by the flap. All patients in these case series with bilateral atresia had been treated with dilatation at birth and had restenosis. Results: A total of 23 choanae were operated. Follow-up ranged from 10 to 60 months. There was one case of complete restenosis and one of partial restenosis, for a success rate of 91%. Conclusions: Endoscopic repair of choanal atresia is a safe and rapid procedure even in very young children, with no complications and a high rate of success. # 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Choanal atresia, first described by Roeder in 1755, is a narrowing or obliteration of the posterior nasal aperture in newborns [1]. The reported incidence is 1 in * Corresponding author at: Nose and Sinus Institute, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel. Tel.: +972 3 937 6451; fax: +972 9 743 5214. E-mail address: [email protected] (E. Yaniv).
5000—7000 births [2], with a female predominance [3]. About 45% of cases occur bilaterally. Because newborns are obligate nasal breathers [2], bilateral choanal atresia (BCA) requires urgent intervention for respiratory distress. Unilateral choanal atresia (UCA) is not immediately life-threatening; symptoms include unilateral nasal congestion and mucoid rhinorrhea. Infrequently, UCA may present with upper airway obstruction. The anatomy of choanal atresia may be bony, mixed bony-membranous, or pure
0165-5876/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2006.11.012
458 membranous, although the latter is apparently rare [4]. The surgical treatment of congenital choanal atresia is one of the more challenging endeavors in pediatric otolaryngology. Among the numerous methods suggested, the currently most popular are the transpalatal approach [5,6], transseptal approach [7,8], and endoscopic transnasal approach [9,10]. Factors that influence the method selected and its subsequent success include patient age, nasopharyngeal size, thickness of the deformity, bilateral versus unilateral atresia, use of postoperative stenting, surgeon’s personal preference, and presence of other anomalies, such as those in CHARGE syndrome (coloboma, hearing deficit, choanal atresia, growth retardation, genital defects, and endocardial cushion defect). Restenosis may occur after surgical correction. In a 1986 review, Pirsig [6] reported a wide range of restenosis rates, from 0% to 85%. However, many authors fail to comment on the need for postoperative dilatation at all [11]. The aim of the present study was to describe an endoscopic surgical technique that may decrease the rate of restenosis in surgery for choanal atresia.
2. Material and methods The study group consisted of 17 patients with choanal atresia who were treated by the endoscopic transnasal approach at the Schneider Children’s Medical Center of Israel from March 1999 to October 2004. Their files were reviewed for background characteristics, perioperative data, and outcome.
2.1. Treatment approach All children at our center with bilateral choanal atresia are treated with dilatation at birth or during the first week of life. In cases of failure, treatment is administered according to the severity of symptoms. Patients with significant airway obstruction are treated immediately. If the patient is thriving, and there is no dyspnea, and the only residual symptom is chronic rhinitis, we perform revision surgery at around 2 years of age. Children with UCA usually do not have severe airway difficulties, and surgery can be done at around 2 years of age.
2.2. Surgical technique and postoperative care Presurgical axial computed tomography scans are done in all cases. Surgery is performed under
E. Yaniv et al.
Fig. 1 Illustration of the nasal septum and flap size at the back of the septum.
general anesthesia with the patient orally intubated. The nasal cavities are decongested and anesthetized using cotton pledgets saturated with a mixture of lidocaine 1% and adrenaline 1:100,000. After the secretions are aspirated, the nasal cavities are inspected endoscopically, in most cases with a 4 mm telescope. Infrequently, it is necessary to use only the 2.7 mm telescope. A mucosal-perichondrial—periosteal flap is formed at the posterior part of the septum and atretic choana by vertical semicircular incision of the septal mucosa, such that is based posteriorly at the septa-atretic-plate junction, with its apex located anteriorly at the septum (Fig. 1). This ensures that the size of the flap is longer than the depth of the atretic area. The perichondrium and periosteum are elevated from the nasal septum and floor of the atretic area and folded towards the lateral nasal wall (Fig. 2). The blocked area is opened with a bone curette or drill, depending on its thickness, down to the nasopharynx, to create a wide choanal opening. In some children, the posterior part of the septum is removed as well in order to enlarge the airway. The flap is folded backwards and laterally toward the nasopharynx to cover at least 50% of the lateral raw surface of the newly formed choana (Fig. 3). The perichondrium/periosteum of the flap remains in contact with the denuded bone, and the mucosa faces the lumen. In patients with bilateral atresia, the same procedure is repeated on the other side. In patients with hypertrophy of the ipsilateral or contralateral concha, partial conchotomy is performed on the involved side. At the end of the operation, a Portex endotracheal tube stent (usually no. 3.5 for neonates and larger,
Endoscopic transnasal repair of choanal atresia
459 removal is usually performed under short general anesthesia. At follow-up, nasal breathing is assessed, and the nose is usually examined with a flexible endoscope if the child is symptomatic. In some children, general anesthesia is necessary for a comprehensive examination.
3. Results (Table 1)
Fig. 2 The mucoperichondrium flap is folded to the lateral wall of the nose to expose the bony choanal atresia.
by age) is inserted into the nose and attached to the anterior septum with 4—0 nylon sutures. We insert the biggest tube possible that does not cause too much pressure either on the nostril or the choana. The posterior part of the stent is located at the new opening of the choana, allowing the patient to breathe through the nose while holding the mucosal flap in place. The stents are left in place for 6 weeks. The parents are instructed to irrigate the child’s nose and stent with normal saline four times daily. Stent
The study group included 8 male and 9 female patients aged 2 months to 13 years at the time of surgery. Six had BCA and 11 UCA, 8 on the left side and 3 on the right, for a total of 23 choanae. Children in whom BCA procedures were successful at birth were not included in the present case series of endoscopic surgical repair. Medical comorbidities included CHARGE syndrome, coloboma, cleft palate, hypercoagulability with spina bifida, severe sensorineural hearing loss, and down syndrome with combined heart defect (1 patient each). Four patients with UCA had contralateral conchal hypertrophy in the ‘‘open’’ nostril which led to nasal contralateral obstruction. All children had severe nasal symptoms that did not improve with medical therapy. Two of the six patients with BCA were referrals, and four were treated by us from day 1. Of two children with BCA had been operated on as neonates by another surgeon, in 1990 and 1994; a third (with CHARGE syndrome and severe cardiac involvement) had had three dilatation procedures; and a fourth had failed a trial of laser surgery at another hospital. There were no surgery-related complications, and all children tolerated the stents well. The duration of follow-up ranged from 10 to 60 months. Surgery was considered successful if the child showed bilateral nasal breathing with no symptoms of airway obstruction or alleviation of chronic nasal discharge. There was one case of complete restenosis and one of partial restenosis, for a success rate of 91%. Two children developed midnasal synechiae. They appear to be managing well and have not yet undergone synechotomy.
4. Discussion
Fig. 3 Illustration of the new choana at the end of surgery. The flap is folded down to the nasopharynx (arrows) to cover the lateral bony border of the new choana.
Ideally, the treatment procedure for choanal atresia should be safe, quick and simple, with minimal blood loss, a high rate of success, and minimal complications. The choice of a transnasal or transpalatal route remains controversial, as does the use of postoperative stenting [12]. Before the development of endonasal endoscopic techniques, the
460
Table 1 Background and perioperative data and outcome in 17 newborns with choanal atresia Patient no.
Laterality
Age at dilatation preop
Age at surgery
Duration of stenting
1 2 3 4 5 6 7
BCA UCA BCA UCA UCA UCA BCA
At birth
2 years 6 months 5 years 13 years 3 years 2 months 3.5 years
6 8 6 6 6 6 6
8
UCA
2 months
6 weeks
9 10
UCA BCA
2 years 3 months
6 weeks 6 weeks
11 12 13 14 15 16 17
UCA UCA UCA BCA BCA UCA UCA
10 years 2 months 1 year 10 years 6 months 6 years 3 years
6 6 6 6 6 6 6
3 weeks
At birth and two more times
At birth
At birth At birth At birth
weeks weeks weeks weeks weeks weeks weeks
weeks weeks weeks weeks weeks weeks weeks
Medical comorbidity Concha hypertrophy Coloboma, DNS Down syn., cardiac anomaly Concha hypertrophy CHARGE syn. Cleft palate, concha hypertrophy DNS
Hyper-coagulabity, spina bifida Concha hypertrophy Sensorineural hearing loss Synechiae
Outcome Satisfactory Satisfactory Satisfactory Restenosis Satisfactory Satisfactory Satisfactory, left side; partial stenosis, right side Satisfactory Satisfactory Satisfactory; synechiae, right side Satisfactory Normal Midnasal synechiae Satisfactory Satisfactory Satisfactory Midnasal synechiae
BCA: bilateral choanal atresia; UCA: unilateral choanal atresia; DNS: deviated nasal septum.
E. Yaniv et al.
Endoscopic transnasal repair of choanal atresia transpalatal approach was considered the most appropriate and successful for both BCA and UCA in children of all ages, and for revision in cases of failed transnasal procedures [13]. However, the transpalatal approach was associated with several adverse effects, including palatal fistulas, maxillofacial growth disturbances, perioperative bleeding, and postoperative pain [11]. Since 1990, some studies have reported high success rates for endoscopic techniques using either an otologic drill or conventional instruments [14—16], but their conclusions were based mainly on small numbers of children with UCA [14—16]. More recently, Lazar and Younis [17], using transnasal endoscopy with conventional instruments, reported two failures, both in newborns with BCA. Therefore, this technique was assumed to be suitable for older children with UCA [18]. In newborns with BCA, it is our departmental practice to first attempt dilatation and stenting. In most cases, we manage to dilate the choana by inserting a metal guide followed by a plastic tube. Even though the majority of BCAs have a bony component, in newborns the bone is either very thin or incompletely fused, as reported by Gujrathi et al. [19]. This makes the procedure relatively easy to perform. Like in other hospitals, our success rate for dilatation is reasonably good [19]. We operate only on those patients who have restenosis after dilatation. In newborns with UCA, elective surgery is the first choice, because the condition is usually not life-threatening. Surgery is usually done at 2 years of age unless the child has significant symptoms before that. Since 1999, we have performed all surgeries by the endoscopic transnasal technique. In the natural healing process of denuded bone, the formation of granulation tissue is followed by epithelialization. Restenosis is caused by excessive growth of granulation tissue and fibrotic scar formation. To avoid that possibility, we sought a technique that would cover as much of the denuded bone as possible with normal epithelium. As granulation tissue develops mainly from the lateral borders, it was important to cover this area [11]. The endoscopic transnasal technique used here successfully preserved the mucoperichondrial flap which was used to cover about 50% of the new choana. Folding the flap toward the lateral nasal wall did not interfere with fenestration of the bone with the drill, even in very small infants. Our group of patients was quite heterogeneous in term of age and type of atresia (unilateral or bilateral). Nevertheless, we found that the technique was successful in both infants aged 2 months and young adults, as well as for both UCA and BCA. The mucoperichondrial flap at the back of the septum in the very young
461 children was very thin, and when folded down to the nasopharyngeal narrowing, the new choanal diameters measured about 1 mm or less. In the five patients with contralateral inferior conchal hypertrophy, we performed a partial conchotomy (mucotomy), with good long-term results. This is noteworthy because inferior conchal hypertrophy can lead to early severe symptoms of airway obstruction and failure to thrive, which are not typical of UCA. Our overall success rate was 91% (21 of 23 choanae) at the first procedure. This rate is very good compared with the reported rates of 75% (of eight patients) [3] and 80% [18] (of 40 patients) for the endoscopic transnasal technique. Schoem [20] had no cases of restenosis, but 78% of his patients required removal of granulation tissue with a microdebrider 3—4 weeks after surgery. Pasquini et al. [21] used a very similar technique to ours in 19 patients, with a 6% restenosis rate; three patients required granulation tissue debridement. Two of our patients had synechiae in the midnose (not in the atretic area). Both are managing well, so we have not yet opened the synechiae. We kept the stents in place for 6 weeks, according to the common practice. Recently, on reviewing our experience, we came to the conclusion that the stent was merely functioning to keep the mucosal flap in place and that a shorter interval would suffice. We have since operated on two children with stenting for only 3 days with good short-term results. In conclusion, the endoscopic repair of choanal atresia is quick, with minimal blood loss, minimal complications, and a high rate of success. This study indicates that rotating the mucoperichondrial flap towards the newly made choana improves the end results.
Acknowledgment We want to thank Miss Adva Hadar for drawing the figures.
References [1] V.L. Cumberworth, B. Diazeri, I.S. Mackay, Endoscopic fenestration of choanal atresia, J. Laryngol. Otol. 109 (1995) 31— 35. [2] D.S. Samadi, U.K. Shah, S.D. Handler, Choanal atresia: a twenty-year review of medical comorbidities and surgical outcomes, Laryngoscope 113 (2003) 254—258. [3] Y.W. Khafagy, Endoscopic repair of bilateral congenial choanal atresia, Laryngoscope 112 (2002) 316—319.
462 [4] O.E. Brown, P. Pownell, S.C. Manning, Choanal atresia: a new anatomic classification and clinical management options, Laryngoscope 106 (1996) 97—101. [5] H. Owens, Observations in treating twenty-five cases of choanal atresia by the transpalatine approach, Laryngoscope 75 (1965) 84—104. [6] W. Pirsig, Surgery of choanal atresia in infants and children: historical notes and updated review, Int. J. Pediatr. Otorhinolaryngol. 11 (1986) 153—170. [7] R.J. Carpenter, H.B. Neel, Correction of congenital choanal atresia in children and adults, Laryngoscope 87 (1987) 1304— 1311. [8] Y.P. Krespi, S. Husain, T.M. Levine, D.L. Reede, Sublabial transseptal repair of choanal atresia or stenosis, Laryngoscope 97 (1987) 1402—1406. [9] J.A. Stankiewicz, The endoscopic repair of choanal atresia, Otolaryngol. Head Neck Surg. 103 (1990) 931—937. [10] E. Deutsch, M. Kaufman, A. Eilon, Transnasal endoscopic management of choanal atresia, Int. Pediatr. Otorhinolaryngol. 40 (1997) 19—26. [11] B.W. Holland, W.F. McGuirt, Surgical management of choanal atresia, Arch. Otol. Head Neck Surg. 127 (2001) 1375—1380. [12] A.H. Park, J. Brockenbrough, J. Stankiewitz, Endoscopic versus traditional approaches to choanal atresia, Otolaryngol. Clin. North Am. 33 (2000) 77—90.
E. Yaniv et al. [13] S. Bobin, Y. Manach, P. Contencin, P. Narcy, Imperforation choanale de l’enfant intert de la voie transpalatine (a propos de 30 observations), Ann. Otolaryngol. Chir. Cervicofac. 100 (1983) 371—374. [14] A. Freng, Surgical treatment of congenital choanal atresia, Ann. Otol. Rhinol. Laryngol. 87 (1978) 346—348. [15] J.A. Stankiewicz, The endoscopic repair of choanal atresia, Otolaryngol. Head Neck Surg. 103 (1990) 931—937. [16] R. Kamel, Transnasal endoscopic approach in congenital choanal atresia, Laryngoscope 104 (1994) 642—646. [17] R.H. Lazar, R.T. Younis, Transnasal repair of choanal atresia using telescopes, Arch. Otolaryngol. Head Neck Surg. 121 (1995) 517—520. [18] T. Van Der Abbeule, H. Francois, P. Nanacy, Transnasal endoscopic treatment of choanal atresia, Surgery 128 (2002) 936—940. [19] C.S. Gujrathi, S.J. Daniel, A.L. James, V. Forte, Management of bilateral choanal atresia in the neonate: an institutional review, Int. J. Pediatr. Otol. 68 (2004) 399—407. [20] S.R. Schoem, Transnasal endoscopic repair of choanal atresia: why stent? Otolaryngol. Head Neck Surg. 131 (2004) 362—366. [21] E. Pasquini, V. Sciarretta, D. Saggese, C. Cantaroni, G. Macri, G. Farneti, Endoscopic treatment of congenital choanal atresia, Int. J. Pediatr. Otol. 67 (2003) 271—276.
www.elsevier.com/locate/ijporl
Endoscopic transnasal repair of choanal atresia Eitan Yaniv a,d,*, Tuvia Hadar a,d, Jacob Shvero b,d, Yoram Stern b,c,d, Eyal Raveh b,c,d a
Nose and Sinus Institute, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel Department of Otolaryngology, Head and Neck Surgery, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel c Schneider Children’s Medical Center of Israel, Petah Tiqva, Isreal d Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel b
Received 28 July 2006; received in revised form 17 November 2006; accepted 17 November 2006
KEYWORDS Choanal atresia; Endoscopic transnasal repair; Mucoperichondrial flap
Summary Objectives: To present our experience with a new endoscopic technique for transnasal repair of choanal atresia. Methods: Seventeen patients aged 2 months to 13 years with choanal atresia, bilateral in 6 and unilateral in 11, underwent endoscopic repair using a mucoperichondrial flap developed from the nasal septum. The bony stenosis was opened with a surgical curette or drill, and the raw surface was covered by the flap. All patients in these case series with bilateral atresia had been treated with dilatation at birth and had restenosis. Results: A total of 23 choanae were operated. Follow-up ranged from 10 to 60 months. There was one case of complete restenosis and one of partial restenosis, for a success rate of 91%. Conclusions: Endoscopic repair of choanal atresia is a safe and rapid procedure even in very young children, with no complications and a high rate of success. # 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Choanal atresia, first described by Roeder in 1755, is a narrowing or obliteration of the posterior nasal aperture in newborns [1]. The reported incidence is 1 in * Corresponding author at: Nose and Sinus Institute, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel. Tel.: +972 3 937 6451; fax: +972 9 743 5214. E-mail address: [email protected] (E. Yaniv).
5000—7000 births [2], with a female predominance [3]. About 45% of cases occur bilaterally. Because newborns are obligate nasal breathers [2], bilateral choanal atresia (BCA) requires urgent intervention for respiratory distress. Unilateral choanal atresia (UCA) is not immediately life-threatening; symptoms include unilateral nasal congestion and mucoid rhinorrhea. Infrequently, UCA may present with upper airway obstruction. The anatomy of choanal atresia may be bony, mixed bony-membranous, or pure
0165-5876/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2006.11.012
458 membranous, although the latter is apparently rare [4]. The surgical treatment of congenital choanal atresia is one of the more challenging endeavors in pediatric otolaryngology. Among the numerous methods suggested, the currently most popular are the transpalatal approach [5,6], transseptal approach [7,8], and endoscopic transnasal approach [9,10]. Factors that influence the method selected and its subsequent success include patient age, nasopharyngeal size, thickness of the deformity, bilateral versus unilateral atresia, use of postoperative stenting, surgeon’s personal preference, and presence of other anomalies, such as those in CHARGE syndrome (coloboma, hearing deficit, choanal atresia, growth retardation, genital defects, and endocardial cushion defect). Restenosis may occur after surgical correction. In a 1986 review, Pirsig [6] reported a wide range of restenosis rates, from 0% to 85%. However, many authors fail to comment on the need for postoperative dilatation at all [11]. The aim of the present study was to describe an endoscopic surgical technique that may decrease the rate of restenosis in surgery for choanal atresia.
2. Material and methods The study group consisted of 17 patients with choanal atresia who were treated by the endoscopic transnasal approach at the Schneider Children’s Medical Center of Israel from March 1999 to October 2004. Their files were reviewed for background characteristics, perioperative data, and outcome.
2.1. Treatment approach All children at our center with bilateral choanal atresia are treated with dilatation at birth or during the first week of life. In cases of failure, treatment is administered according to the severity of symptoms. Patients with significant airway obstruction are treated immediately. If the patient is thriving, and there is no dyspnea, and the only residual symptom is chronic rhinitis, we perform revision surgery at around 2 years of age. Children with UCA usually do not have severe airway difficulties, and surgery can be done at around 2 years of age.
2.2. Surgical technique and postoperative care Presurgical axial computed tomography scans are done in all cases. Surgery is performed under
E. Yaniv et al.
Fig. 1 Illustration of the nasal septum and flap size at the back of the septum.
general anesthesia with the patient orally intubated. The nasal cavities are decongested and anesthetized using cotton pledgets saturated with a mixture of lidocaine 1% and adrenaline 1:100,000. After the secretions are aspirated, the nasal cavities are inspected endoscopically, in most cases with a 4 mm telescope. Infrequently, it is necessary to use only the 2.7 mm telescope. A mucosal-perichondrial—periosteal flap is formed at the posterior part of the septum and atretic choana by vertical semicircular incision of the septal mucosa, such that is based posteriorly at the septa-atretic-plate junction, with its apex located anteriorly at the septum (Fig. 1). This ensures that the size of the flap is longer than the depth of the atretic area. The perichondrium and periosteum are elevated from the nasal septum and floor of the atretic area and folded towards the lateral nasal wall (Fig. 2). The blocked area is opened with a bone curette or drill, depending on its thickness, down to the nasopharynx, to create a wide choanal opening. In some children, the posterior part of the septum is removed as well in order to enlarge the airway. The flap is folded backwards and laterally toward the nasopharynx to cover at least 50% of the lateral raw surface of the newly formed choana (Fig. 3). The perichondrium/periosteum of the flap remains in contact with the denuded bone, and the mucosa faces the lumen. In patients with bilateral atresia, the same procedure is repeated on the other side. In patients with hypertrophy of the ipsilateral or contralateral concha, partial conchotomy is performed on the involved side. At the end of the operation, a Portex endotracheal tube stent (usually no. 3.5 for neonates and larger,
Endoscopic transnasal repair of choanal atresia
459 removal is usually performed under short general anesthesia. At follow-up, nasal breathing is assessed, and the nose is usually examined with a flexible endoscope if the child is symptomatic. In some children, general anesthesia is necessary for a comprehensive examination.
3. Results (Table 1)
Fig. 2 The mucoperichondrium flap is folded to the lateral wall of the nose to expose the bony choanal atresia.
by age) is inserted into the nose and attached to the anterior septum with 4—0 nylon sutures. We insert the biggest tube possible that does not cause too much pressure either on the nostril or the choana. The posterior part of the stent is located at the new opening of the choana, allowing the patient to breathe through the nose while holding the mucosal flap in place. The stents are left in place for 6 weeks. The parents are instructed to irrigate the child’s nose and stent with normal saline four times daily. Stent
The study group included 8 male and 9 female patients aged 2 months to 13 years at the time of surgery. Six had BCA and 11 UCA, 8 on the left side and 3 on the right, for a total of 23 choanae. Children in whom BCA procedures were successful at birth were not included in the present case series of endoscopic surgical repair. Medical comorbidities included CHARGE syndrome, coloboma, cleft palate, hypercoagulability with spina bifida, severe sensorineural hearing loss, and down syndrome with combined heart defect (1 patient each). Four patients with UCA had contralateral conchal hypertrophy in the ‘‘open’’ nostril which led to nasal contralateral obstruction. All children had severe nasal symptoms that did not improve with medical therapy. Two of the six patients with BCA were referrals, and four were treated by us from day 1. Of two children with BCA had been operated on as neonates by another surgeon, in 1990 and 1994; a third (with CHARGE syndrome and severe cardiac involvement) had had three dilatation procedures; and a fourth had failed a trial of laser surgery at another hospital. There were no surgery-related complications, and all children tolerated the stents well. The duration of follow-up ranged from 10 to 60 months. Surgery was considered successful if the child showed bilateral nasal breathing with no symptoms of airway obstruction or alleviation of chronic nasal discharge. There was one case of complete restenosis and one of partial restenosis, for a success rate of 91%. Two children developed midnasal synechiae. They appear to be managing well and have not yet undergone synechotomy.
4. Discussion
Fig. 3 Illustration of the new choana at the end of surgery. The flap is folded down to the nasopharynx (arrows) to cover the lateral bony border of the new choana.
Ideally, the treatment procedure for choanal atresia should be safe, quick and simple, with minimal blood loss, a high rate of success, and minimal complications. The choice of a transnasal or transpalatal route remains controversial, as does the use of postoperative stenting [12]. Before the development of endonasal endoscopic techniques, the
460
Table 1 Background and perioperative data and outcome in 17 newborns with choanal atresia Patient no.
Laterality
Age at dilatation preop
Age at surgery
Duration of stenting
1 2 3 4 5 6 7
BCA UCA BCA UCA UCA UCA BCA
At birth
2 years 6 months 5 years 13 years 3 years 2 months 3.5 years
6 8 6 6 6 6 6
8
UCA
2 months
6 weeks
9 10
UCA BCA
2 years 3 months
6 weeks 6 weeks
11 12 13 14 15 16 17
UCA UCA UCA BCA BCA UCA UCA
10 years 2 months 1 year 10 years 6 months 6 years 3 years
6 6 6 6 6 6 6
3 weeks
At birth and two more times
At birth
At birth At birth At birth
weeks weeks weeks weeks weeks weeks weeks
weeks weeks weeks weeks weeks weeks weeks
Medical comorbidity Concha hypertrophy Coloboma, DNS Down syn., cardiac anomaly Concha hypertrophy CHARGE syn. Cleft palate, concha hypertrophy DNS
Hyper-coagulabity, spina bifida Concha hypertrophy Sensorineural hearing loss Synechiae
Outcome Satisfactory Satisfactory Satisfactory Restenosis Satisfactory Satisfactory Satisfactory, left side; partial stenosis, right side Satisfactory Satisfactory Satisfactory; synechiae, right side Satisfactory Normal Midnasal synechiae Satisfactory Satisfactory Satisfactory Midnasal synechiae
BCA: bilateral choanal atresia; UCA: unilateral choanal atresia; DNS: deviated nasal septum.
E. Yaniv et al.
Endoscopic transnasal repair of choanal atresia transpalatal approach was considered the most appropriate and successful for both BCA and UCA in children of all ages, and for revision in cases of failed transnasal procedures [13]. However, the transpalatal approach was associated with several adverse effects, including palatal fistulas, maxillofacial growth disturbances, perioperative bleeding, and postoperative pain [11]. Since 1990, some studies have reported high success rates for endoscopic techniques using either an otologic drill or conventional instruments [14—16], but their conclusions were based mainly on small numbers of children with UCA [14—16]. More recently, Lazar and Younis [17], using transnasal endoscopy with conventional instruments, reported two failures, both in newborns with BCA. Therefore, this technique was assumed to be suitable for older children with UCA [18]. In newborns with BCA, it is our departmental practice to first attempt dilatation and stenting. In most cases, we manage to dilate the choana by inserting a metal guide followed by a plastic tube. Even though the majority of BCAs have a bony component, in newborns the bone is either very thin or incompletely fused, as reported by Gujrathi et al. [19]. This makes the procedure relatively easy to perform. Like in other hospitals, our success rate for dilatation is reasonably good [19]. We operate only on those patients who have restenosis after dilatation. In newborns with UCA, elective surgery is the first choice, because the condition is usually not life-threatening. Surgery is usually done at 2 years of age unless the child has significant symptoms before that. Since 1999, we have performed all surgeries by the endoscopic transnasal technique. In the natural healing process of denuded bone, the formation of granulation tissue is followed by epithelialization. Restenosis is caused by excessive growth of granulation tissue and fibrotic scar formation. To avoid that possibility, we sought a technique that would cover as much of the denuded bone as possible with normal epithelium. As granulation tissue develops mainly from the lateral borders, it was important to cover this area [11]. The endoscopic transnasal technique used here successfully preserved the mucoperichondrial flap which was used to cover about 50% of the new choana. Folding the flap toward the lateral nasal wall did not interfere with fenestration of the bone with the drill, even in very small infants. Our group of patients was quite heterogeneous in term of age and type of atresia (unilateral or bilateral). Nevertheless, we found that the technique was successful in both infants aged 2 months and young adults, as well as for both UCA and BCA. The mucoperichondrial flap at the back of the septum in the very young
461 children was very thin, and when folded down to the nasopharyngeal narrowing, the new choanal diameters measured about 1 mm or less. In the five patients with contralateral inferior conchal hypertrophy, we performed a partial conchotomy (mucotomy), with good long-term results. This is noteworthy because inferior conchal hypertrophy can lead to early severe symptoms of airway obstruction and failure to thrive, which are not typical of UCA. Our overall success rate was 91% (21 of 23 choanae) at the first procedure. This rate is very good compared with the reported rates of 75% (of eight patients) [3] and 80% [18] (of 40 patients) for the endoscopic transnasal technique. Schoem [20] had no cases of restenosis, but 78% of his patients required removal of granulation tissue with a microdebrider 3—4 weeks after surgery. Pasquini et al. [21] used a very similar technique to ours in 19 patients, with a 6% restenosis rate; three patients required granulation tissue debridement. Two of our patients had synechiae in the midnose (not in the atretic area). Both are managing well, so we have not yet opened the synechiae. We kept the stents in place for 6 weeks, according to the common practice. Recently, on reviewing our experience, we came to the conclusion that the stent was merely functioning to keep the mucosal flap in place and that a shorter interval would suffice. We have since operated on two children with stenting for only 3 days with good short-term results. In conclusion, the endoscopic repair of choanal atresia is quick, with minimal blood loss, minimal complications, and a high rate of success. This study indicates that rotating the mucoperichondrial flap towards the newly made choana improves the end results.
Acknowledgment We want to thank Miss Adva Hadar for drawing the figures.
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