[Diagnostics and management of choanal atresia]. / Diagnostik und Management der Choanalatresie.

Choanal atresia is a rare malformation that represents a special challenge. While bilateral choanal atresia usually needs to be surgically treated within a few days of birth, the intervention for one-sided choanal atresia can be postponed for years. Treatment planning requires adequate imaging (CT or MRI), which also serves to exclude other skull base malformities. Surgical treatment currently focuses on transnasal endoscopic techniques. Simultaneous resection of the parts of the vomer involved in the atresia seems to be important surgical success. Postoperative stenting is still controversially discussed. Postoperative application of corticosteroid nasal sprays and saline nasal rinsing for several weeks is of great importance. Due to the rarity of the diagnosis, the absence of prospective randomized controlled trials does not allow definitive statements regarding the optimal surgical technique or stenting.

Novel Application of Steroid Eluting Stents in Choanal Atresia Repair: A Case Series.

PURPOSE: To describe the application of mometasone furoate eluting sinus stent technology in the treatment of choanal atresia (CA) in the hopes of preventing postsurgical stenosis. METHODS: We analyzed 3 consecutive patients aged 4 days to 16 years undergoing repair of CA at a tertiary pediatric hospital. Mometasone furoate eluting sinus stents were placed intraoperatively. Postoperative need for revision surgery as well as routine surveillance endoscopy were used to determine success of surgery. RESULTS: Three patients of varying age and etiology underwent successful repair of choanal atresia/stenosis. The steroid eluting sinus stent was deployed successfully in all 3 cases. There was no identifiable restenosis in any of the 3 patients with 12-month follow-up. There were no complications noted throughout the follow-up period. CONCLUSIONS: Choanal atresia is a rare disorder that can prove difficult in postsurgical management. In our case series, mometasone furoate eluting stents were effective and safe for the management of this disease process. Further prospective studies are needed to determine the exact safety profile, long-term consequences, and efficacy of steroid eluting sinus stents in the pediatric population.

Management of congenital choanal atresia: a pedodontist's role.

Choanal atresia is a rare cryptic congenital anomaly with developmental failure of the nasal cavity to communicate with the nasophaynx, resulting in a significant physiological and anatomical alteration of the dento-facial complex. It is considered as a life-threatening or lethal congenital malformation in an obligatory nasal breathing neonate. Elective transnasal endoscopic repair is the most preferred and minimally invasive procedure to correct this anomaly. This case report describes the multi-disciplinary team approach that included pedodontists to manage the case of a 6-month-old infant with choanal atresia suffering from breathlessness, feeding difficulty, and disturbed sleep.

Atresia de coanas, revisión y una mirada desde la evidencia / Choanal atresia, review and a look from the evidence

La atresia de coanas es la anomalía congénita nasal más común. Cuando es bilateral, se presenta con dificultad respiratoria desde el nacimiento. La atresia unilateral se manifiesta con insuficiencia ventilatoria y rinorrea unilateral, pudiendo pasar inadvertida. El diagnóstico se sospecha ante la ausencia de paso de aire en las fosas nasales y la imposibilidad de hacer progresar una sonda nasogástrica. Se confirma mediante examen endoscópico y tomografía computarizada. El tratamiento definitivo es quirúrgico, existiendo diferentes técnicas y vías de abordaje. Se presenta una revisión de la literatura, con especial énfasis en el tratamiento pos-quirúrgico con stents y mitomicina-C a través de una mirada desde la evidencia.

Choanal atresia is the most common congenital nasal anomaly. When bilateral, it presents with respiratory distress at birth. Unilateral atresia is manifested by respiratory failure and unilateral rhinorrhea, and may go along unnoticed. Diagnosis is suspected in the absence of airflow in the nasal cavity and for the inability to advance a nasogastric tube. Diagnosis is confirmed by endoscopic examination and computed tomography. The definitive treatment is surgical, and there are different techniques and surgical approaches. A review of the literatureis presented, with special emphasis onthepost-surgical treatmentwithstents and Mitomycin-Cview from the evidence.

The efficacy of mitomycin and stenting in choanal atresia repair: a 20 year experience.

OBJECTIVE: To determine the efficacy of topical mitomycin and stenting in patients that have undergone endoscopic repair of choanal atresia. METHODS: Retrospective review of 37 endoscopic operations on pediatric patients for choanal atresia. RESULTS: Twenty-six sides were operated on in 17 patients; 37 total operations were performed. All 17 patients were repaired endoscopically with 1 patient requiring transpalatal revision surgery. Eight patients (47%) had a unilateral atresia and 9 (53%) were bilateral. Eleven total sides (42%) were treated initially with mitomycin. Eighteen percent of those sides required post-operative dilation vs. 40% of the sides not treated with mitomycin (p=0.39) and no patient in the mitomycin group required revision surgery compared to 20% of patients not treated with mitomycin (p=0.24). Significantly fewer sides in the mitomycin group (9%) developed granulation vs. those treated without (53%) (p=0.03). The average number of procedures performed (1.18 vs. 2.53; p=0.002) was significantly fewer in those patients treated with mitomycin vs. not. A greater amount of sides in the stent group developed granulation tissue (50% vs.0%; p=0.023). The average number of procedures performed was significantly greater in those patients treated with a stent (2.33 vs. 1.12; p=0.008). The average time spent in the hospital was significantly shorter (7.09 vs. 2.33 days; p=0.02) in those patients treated without stenting. CONCLUSION: Topical mitomycin is efficacious as an adjuvant therapy as it was associated with the formation of less granulation tissue, a lower rate of restenosis and fewer surgeries. Stenting was associated with significantly more procedures, greater formation of granulation tissue and longer overall hospital stays. However, consideration should be given toward stent placement in all neonates for the prevention of post-operative airway obstruction. LEVEL OF EVIDENCE: 2c.

Impact and workload implications on service provision with establishment of a neonatal complex airway service in Scotland.

The objective of this study was to assess if any changes have occurred in the utilization of neonatal services with referral for neonatal airway assessment and how this is related to the establishment of a National Complex Airway Service. A retrospective case-note review was performed for neonates referred for airway assessment from 2004-2010 inclusive. Seventy-nine neonates were referred from throughout Scotland; 10 in 2004-2006, 24 in 2007-2008 and 45 in 2009-2010. The mean gestational age was 35 weeks; 39% were preterm. Stridor was the most common reason for referral (46%). The most common diagnosis was airway malacia (38%). Fifty-three procedures were performed on the ward. In total, 64 microlaryngobronchoscopies were performed; 45 diagnostic and 19 interventional. The most common intervention was supraglottoplasty for airway malacia. Thirty-five separate airway procedures were undertaken. Additional investigations were frequently requested and co-morbidities were common. Since the establishment of the Scottish National Complex Airway Service in 2006, referrals for neonatal airway assessment have increased significantly. The reasons for this include a greater awareness of the service, improved treatment options and increased preterm survival. These neonates frequently have associated co-morbidities and require a repertoire of specialist input. This increase has significant implications for further service provision.

Balloon dilation for management of choanal atresia and stenosis.

OBJECTIVES: We describe our use of balloon dilation to repair choanal atresia in a series of patients. STUDY DESIGN: Case series. METHODS: We performed a retrospective review of patients who underwent repair of choanal atresia using dilation with high pressure, non-compliant airway balloons between January 2009 and September 2010. For primary cases, balloon dilation was used in conjunction with transnasal endoscopic puncture, and repair of bony stenosis with backbiting forceps and microdebrider drill. RESULTS: 5 patients underwent balloon dilation repair of choanal atresia or stenosis. 4 patients presented for primary repair, with a mean age of 2.9 months. 1 patient presented at 10 years of age for revision repair several years after previous attempts performed elsewhere. The average number of procedures was 3.6, with an average of 2 balloon dilations. There were no complications stemming from balloon dilation. Follow-up ranged from 3 to 24 months. All patients demonstrated choanal patency on last follow-up. CONCLUSIONS: This is a novel use of high pressure, non-compliant balloons. We found success in dilating membranous stenoses, post-repair granulation, and scar tissue in revision cases. Balloon dilation is an effective adjuvant tool for use in the repair of choanal atresia and stenosis.

Atresia de coanas, tratamiento quirúrgico endoscópico, 5 años de experiencia / Choanal atresia, endoscopic surgical repair, a 5 year experience

Atresia de coanas es la obstrucción congénita de la región posterior de las fosas nasales. Múltiples técnicas quirúrgicas han sido empleadas para su reparación. En el presente estudio se recopiló la información de 5 años de trabajo en el Hospital Universitario del Valle en la ciudad Santiago de Cali - Colombia, entre los años 2003 y 2008. Se obtuvo un total de 16 casos.La información demográfica documentada incluyó datos como edad, sexo, síntomas iniciales, método diagnóstico, lateralidad, tipo de atresia de coanas, comorbilidades, tratamiento inicial, edad de intervención quirúrgica, técnica quirúrgica usada. La técnica quirúrgica consistió en el fresado y apertura de la placa atrésica vía endoscópica transnasal utilizando taladro, previa realización de colgajos mucosos en cruz y resecando parcialmente paredes del vómer.La experiencia observada en estos 5 años de trabajo demuestra que el abordaje endoscópico transnasal presenta grandes ventajas, entre ellas la baja tasa de reestenosis.

Choanal atresia is a congenital disorder where the back of the nasal passage is blocked. Many surgical techniques have been used to repair this disorder. In this study we collected information from 5 years of work at the Hospital Universitario del Valle in the city of Santiago de Cali - Colombia, between 2003 and 2008. A total of 16 cases were obtained. The documented data included demographic information like age, sex, initial symptoms, diagnostic methods, laterality, type of atresia, comorbilities, initial treatment and surgical technique used. The surgical technique consisted in endoscopic opening of the atretic plate using drill. Mucosal flaps and resection of partial plate of vomer were made previously.The experience observed in these 5 years of work shows that the endoscopic transnasal approach has major advantages, including low restenosis rate.

Successful airway management with use of a laryngeal mask airway in a patient with CHARGE syndrome.

CHARGE syndrome refers to an autosomal dominant disorder in patients with coloboma (C) of the eye, heart disease (H), atresia of choanae (A), retarded growth (R), genital hypoplasia (G), and ear anomalies (E). In addition to these typical features, airway abnormalities, including retrognathia, glossoptosis, and laryngeal paralysis, have been reported in patients with this syndrome. This report describes a case of CHARGE syndrome observed in a 6-year-old male patient with a difficult airway, in whom anesthesia was managed successfully using a laryngeal mask airway.

Repair of acquired posterior choanal stenosis and atresia by temperature-controlled radio frequency with the aid of an endoscope.

OBJECTIVES: To examine the clinical effects of temperature-controlled radio frequency (TCRF) repair of acquired choanal stenosis and atresia with the aid of an endoscope and to discuss the value of acquired choanal stenosis and atresia typing in clinical therapy. DESIGN: Retrospective study. SETTING: Academic otorhinolaryngologic referral center. PATIENTS: Thirty-two patients, aged 32 to 65 years, with acquired choanal stenosis and atresia (from trauma in 9 cases and from radiotherapy after nasopharyngeal carcinoma in 23 cases); 13 cases were bilateral, and 19 were unilateral. INTERVENTIONS: Transnasal TCRF repair with the aid of an endoscope. Acquired choanal stenosis and atresia can be divided into 3 types: type 1, diagnosed within 3 months of the causative trauma or radiotherapy; type 2, diagnosed between 3 and 6 months after the trauma or radiotherapy; and type 3, diagnosed more than 6 months after the trauma or radiotherapy. All patients with types 1 and 2 disease received nasal stents made from Silastic that were fixed with transseptal sutures. However, patients with type 3 disease received no stenting. MAIN OUTCOME MEASURES: The thickness of the stenosis and atresia revealed by computed tomographic scan and the surgical results were also analyzed. There was no significant correlation between them (P > .05). RESULTS: Twenty-nine patients remained free of symptoms for 12 to 42 months after surgery. Three patients required revision surgery, including 2 cases of type 1 disease (3 sides) and 1 case of type 2 (1 side). Two of the patients who underwent revision recovered completely, with no restenosis at 12 months after the second surgery. However, 1 patient with type 1 bilateral atresia experienced another restenosis and required another revision, through a transpalatal approach. There were no postoperative complications. There was no significant correlation between thickness of the stenosis revealed by computed tomographic scan and the surgical results. CONCLUSIONS: We describe a TCRF technique with the aid of an endoscope for choanal repair. In our experience, it has been a highly successful, safe, and effective procedure, with minimal blood loss, swift recovery, and short time of hospitalization. It is important in postoperative care to remove any granulation or polyps at the site of the neochoana. Types 2 and 3 are the best types of disease to treat with this procedure.

Velopharyngeal stenosis, a late complication of radiotherapy.

Choanal stenosis has recently been recognized as a late complication of radiation therapy for nasopharyngeal carcinoma. The management of velopharyngeal stenosis is challenging with high risk of restenosis. We report a case of velopharyngeal stenosis post-radiotherapy and illustrated the use of mitomycin-C to prevent restenosis. Mitomycin-C application has being shown useful adjunct to surgical technique in managing nasopharyngeal stenosis for surgeons.

Atresia coanal congênita bilateral: paciente de 35 anos bilateral / Congenital choanal atresia: 35 years old patient

Introdução: Atresia coanal congênita é a falha no desenvolvimento da comunicação entre a cavidade nasal posterior e a nasofaringe. A incidência é de 1:5.000 a 1:8.000 nascidos vivos, sendo mais comumente unilateral e no sexo feminino. Objetivo: descrever a epidemiologia, a sintomatologia e os principais acessos cirúrgicos para correção da atresia coanal, a partir do relato de um caso. Relato do Caso: Sexo feminino, 35 anos, apresentando atresia coanal bilateral óssea. O diagnóstico foi realizado por tomografia computadorizada de seios paranasais e endoscopia nasal. Foi realizada correção cirúrgica com acesso transeptal associado ao acesso transnasal via endoscópica, com confecção de retalho mucoperiosteal cobrindo a parede lateral da neocoana. Realizada aplicação tópica de mitomicina. Não foi colocado stent. Conclusão: Em nossa experiência, o acesso transnasal via endoscópica constitui via de escolha para correção cirúrgica da atresia coanal congênita. Nos casos em que houver espessamento importante da porção posterior do vômer, o acesso transeptal pode ser associado ao transnasal. Não há necessidade da colocação de stents no pós-operatório, caso seja confeccionado um flap mucoso recobrindo a área cruenta da neocoana.

Introduction: Congenital choanal atresia is an imperfection on the development of communication between the posterior nasal cavity and the nasopharynx. The incidence is 1:5,000 to 1:8,000 live births. It is usually unilateral and in females. Objective: To describe the epidemiology, the clinical symptoms and the main surgical accesses for correction of choanal atresia from the case report. Case Report: 35-year-old female patient, presenting bone bilateral choanal atresia. The diagnosis was performed through CT and nasal endoscopic. Patient was treated by transnasal endoscopic surgical technique associated with transeptal access. It was performed a mucoperiosteal flap rotation covering the sidewall of the new choana. Topic use of mytomicin was performed, but there was no use of stents. Conclusion: In our experience, the transnasal access endoscopic is the choice for surgical correction of the congenital choanal atresia. In the cases where there is important thickness of the posterior portion of the vomer, the transeptal access can be associated with the transnasal. There is no need of stents use after surgery, if a mucous flap re-covering the new choana is made.