Atresia bilateral de coanas en la adolescencia / Bilateral choanal atresia in adolescence / Atresia bilateral de choana na adolescência

Introducción: la atresia de coanas es una anomalía congénita nasal con una incidencia de 1/70.000 nacidos vivos en Argentina. Se presenta con dificultad respiratoria desde el nacimiento en el caso de las bilaterales. Presentaremos 2 casos de pacientes masculinos con atresia de coanas bilateral diagnosticados tardíamente. Para su tratamiento se utilizó técnica endoscópica transeptal con colgajos doblados sin tutores y azitromicina como antiinflamatorio de mucosa respiratoria en el postquirúrgico. Material y método: Se valoraron en forma descriptiva y retrospectiva 2 pacientes adolescentes diagnosticados e intervenidos quirúrgicamente en el Servicio de Otorrinolaringología del Hospital Posadas, mediante técnica endoscópica transeptal con colgajos doblados sin tutores. Se analizaron variables como tipo de placa atrésica, edad de diagnóstico, malformaciones asociadas y resultados quirúrgicos. Como tratamiento médico postquirúrgico, se utilizó azitromicina a dosis antiinflamatorias. Resultados: La técnica endoscópica transnasal con colgajos doblados sin tutor que hemos realizado en estos dos pacientes reduce el riesgo de reestenosis, no requiere reintervenciones posteriores para retirar el stent y genera una mejor tolerancia del paciente en el postoperatorio. El uso de azitromicina postoperatoria disminuyó el proceso inflamatorio favoreciendo la cicatrización, lográndose una correcta permeabilización de las coanas y una respiración nasal normal bilateral. Conclusiones: El diagnóstico temprano en este tipo de pacientes es fundamental, debido a la característica de respiradores nasales estrictos que presentan los neonatos. No se han encontrado reportes de pacientes diagnosticados en la adolescencia, por lo cual el diagnóstico y el tratamiento, en este caso, plantearon también un desafío.

Introduction: choanal atresia is a nasal congenital anomaly with an incidence of 1 / 70,000 live births in Argentina. It presents with respiratory difficulty from birth in bilateral cases. We will present 2 cases of male patients with bilateral choanal atresia of late diagnose. We used a trans-septal endoscopic technique with folded flap without tutors and azithromycin as an anti-inflammatory of the respiratory mucosa in the postoperative time. Material and method: A descriptive and retrospective study was carried out on 2 adolescent patients diagnosed and surgically treated in the Otorhinolaryngology Service of the Posadas Hospital, using transeptal endoscopy with a folded flap technique without tutors. Variables such as atresia plaque type, age of diagnosis, associated malformations, complications and surgical results were analyzed. Azithromycin was used at anti-inflammatory doses as a post-surgical medical treatment. Results: The transnasal endoscopic technique with folded flaps that we performed in these two patients reduces the risk of restenosis, does not require subsequent reinterventions to remove the stent and generates a better patient tolerance in the postoperative period. As for the use of postoperative azithromycin, the inflammatory process decreased, favoring cicatrization, being able to achieve a correct permeabilization of the choanas and a normal bilateral nasal breathing. Conclusions: We believe that early diagnosis in this type of patients is essential, due to the characteristic of strict nasal breathers presented by the neonates. There were no reports of patients diagnosed in adolescence, so the diagnosis and treatment, in this case, also posed a challenge.

Introdução: a atresia de choana é uma anomalia congênita nasal com incidência de 1 / 70.000 nascidos vivos na Argentina. Esse transtorno/a mesma apresenta dificuldade respiratória desde o nascimento no caso seja bilateral. (Em este estudo) apresentaremos dois casos de pacientes do sexo masculino com atresia de choana bilateral diagnosticada tardiamente. Uma técnica endoscópica trans-septal com aba curvada sem tutores e azitromicina como anti-inflamatório da mucosa respiratória foi utilizada como tratamento pós-cirurgico. Material e método: Foram avaliados de forma descritiva e retrospetiva dois pacientes adolescentes diagnosticados e tratados cirúrgicamente no serviço de Otorrinolaringologia do Hospital Posadas pela técnica transeptal endoscopica sem tutores aba dobrada. São analisados valores como tipo de placa de atresia, idade do diagnóstico, malformações associadas, complicações e resultados cirúrgicos. Como tratamento médico pós-cirúrgico, a azitromicina foi utilizada em dosagens anti-inflamatórias. Resultados: A técnica endoscópica trans-nasal com abas dobradas sem tutor que foi realizada em estes dois pacientes, reduz o risco de re-estenose, não precisando de novas intervenções cirúrgicas para remover o stent e gerar uma melhor tolerância do paciente no pós-operatório. Quanto ao uso de azitromicina pós-operatória, o processo inflamatório diminuiu, favorecendo a cicatrização, conseguindo uma permeabilização correta da choana e uma respiração nasal bilateral normal. Conclusões: Acreditamos que o diagnóstico precoce neste tipo de pacientes é fundamental, devido à característica de respiradores nasais estritos apresentada pelos neonatos. Não houve relatos de pacientes diagnosticados na adolescência, pelo que o diagnóstico e o tratamento, neste caso, também representaram um desafio.

The use of mitomycin C in pediatric airway surgery: does it work?

PURPOSE OF REVIEW: To describe the efficacy of mitomycin C in combating airway stenosis. RECENT FINDINGS: Recent publications discussing mitomycin C utility have not altered the mixed results previously established by prospective trials. SUMMARY: Mitomycin C has been used for the past 16 years to inhibit pediatric airway fibroblast proliferation. Its benefit remains more hypothetical than proven and its future role remains uncertain.

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.

Transnasal endoscopic repair of choanal atresia in a tertiary care centre: a review of outcomes.

INTRODUCTION/AIM: Choanal atresia (CA) is an obliteration, in newborns, of the airway at the level of posterior nasal aperture resulting in absence of connection between the nasal cavity and the aerodigestive tract. It is rare, with incidence of 1 in 7000 live births. This review is aimed at assessing the factors influencing the outcome of transnasal endoscopic repair of CA in a tertiary referral children's hospital. MATERIAL/METHOD: A retrospective study was carried out between 2002 and 2009. 31 children; 14 boys and 17 girls, age range 1 day to 15 years, mean 23.4 months were included. Unilateral presentation was 19 (11 right, 8 left) and bilateral was 12. All patients had transnasal endoscopic repair under direct vision. Nasal stents were placed for varying duration (range 4-12 weeks) or nasopharyngeal airways (removed within 24h) were inserted at time of surgery. Patients were monitored for re-stenosis and revisions carried out as necessary, with a mean follow-up of 11.9 months. RESULTS: 54.7% (n=17) of patients had re-stenosis requiring revision surgery. Of these, 41.1% (n=7) had success after the 1st revision, 20% had success after the 2nd revision while 12.3% had success after the 3rd revision. One patient required more than four revisions. 80% of re-stenosis requiring revisions occurred in children who had surgery under 10 months of age and of these, approx. 42% were 1-week-old or younger. 57% of those who had stents for 4-6 weeks (n=15) had re-stenosis requiring revision while only 33.3% of those who either had no stents or had NP airways removed within 24h (n=16) had re-stenosis (P=0.019). The re-stenosis rate was comparable for those who had mitomycin (53%) versus those who did not (60%). CONCLUSION: Transnasal endoscopic repair of CA is effective and safe and provides the benefit of surgery under direct vision. Age 1 week or less was a predictive factor for re-stenosis. Intranasal stents was also associated with increased incidence of re-stenosis and the use of mitomycin C does not seem to have any significant effect on re-stenosis.

Atresia coanal congénita unilateral en paciente adulto: presentación de un caso y revisión bibliográfica sobre vías de abordaje: complicaciones y tratamientos adicionales / Unilateral congenital choanal atresia in adult patient: case report and bibliographical review about surgical approaches, complications and additional treatments

La atresia de coanas, es una patología poco frecuente, que habitualmente se diagnostica en las edades tempranas. Representa un reto quirúrgico por su alta tendencia a la reestenosis, considerándose en la actualidad de elección el tratamiento endoscóplco. Tratamientos como stents posoperatorios o la aplicación de mitomicina C tópica para disminuir la reestenosis son todavía controvertidos, sin que exista consenso. Presentamos el caso de un adulto con atresia de coana unilateral que se reparó vía endoscópica transnasal y se realiza una revisión bibliográfica sobre el estado actual del tratamiento de esta patología.

Choanal atresia is a very rare condition, usually it's diagnosticated in early age. It represents a surgical challenge for the high tendency to restenosis, being actually the endoscopic treatment first option. Other treatments like postoperative stents or topical mitomycin-C in order to avoid restenosis are controversial, and there is a lack of consensus. We present an adult case with unilateral choanal atresia treated by transnasal endoscopic technique and It's carry out a bibliographical review about the current treatment state of this pathology.

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Effect of use of mitomycin C on the outcome of Choanal atresia repair.

OBJECTIVE: To investigate the effectiveness of topical mitomycin C (MMC) on outcome of endoscopic repair of choanal atresia (CA) in cases that had never had this operation and when nasal stent was not used. METHODS: Endoscopic repair of CA was performed in 20 children at King Abdul-Aziz University Hospital, Riyadh, Kingdom of Saudi Arabia between January 1999 and October 2005. Intra-operative application of topical MMC (0.4 mg/mL for 4 minutes) was carried out in 13 children, and 7 children did not receive MMC. The follow-up period ranged between 9 months and 6 years. The association between the 2 categorical variables was investigated using Fisher's exact test. RESULTS: Sixty-nine percent of the cases receiving MMC had a successful outcome compared with 57% of non-MMC cases, however, the difference was not statistically significant (p=0.230). In unilateral CA, 70% of those who received MMC had a successful outcome compared with 60% of those who did not; again the difference was not statistically significant (p=0.566). Successful outcome was considered when the posterior choana was patent during the successive follow up, without the need for revision surgeries. CONCLUSION: We did not demonstrate a statistically significant difference between the percentages of children treated with MMC versus no-MMC who remained patent after surgery.

An update on choanal atresia surgery at Great Ormond Street Hospital for Children: preliminary results with Mitomycin C and the KTP laser.

We present the results of transnasal choanal atresia correction in 46 children, as an update to the published Great Ormond Street Hospital series. Females outnumbered males 2-1, and half the cases in our series were bilateral. Eight of the children with bilateral atresia had the CHARGE association. The median number of procedures required was three over a period of up to 3 years. Eighty-two percent of children with unilateral atresia and 78% of those with bilateral atresia were asymptomatic at the time of their last follow up. Four deaths occurred, all but one in children with CHARGE association. We were not able to demonstrate any benefit from the use of Mitomycin C, the KTP laser, betamethasone nasal drops or (in unilateral cases) stents.

Topical mitomycin as an adjunct to choanal atresia repair.

OBJECTIVE: To evaluate the use of topical mitomycin in choanal atresia repair to reduce the development of granulation tissue and cicatrix. DESIGN AND SETTING: Retrospective case series in 2 tertiary care centers. PATIENTS: Twenty patients with either unilateral or bilateral congenital choanal atresia underwent repair using the transnasal endoscopic approach, the transpalatal approach, or both. INTERVENTIONS: The surgeons favor the use of the endoscopic transnasal drillout technique for all unilateral cases of choanal atresia and for selected bilateral cases. We describe our experience and treatment paradigm for these 20 patients (15 with unilateral atresia, 5 with bilateral atresia). Topical application of mitomycin was used, and in some cases postoperative stenting, for a period of 1 to 2 weeks. In 8 cases, a second application of mitomycin was used. Follow-up ranged from 3 months to 2 years (mean, 9 months). OUTCOME MEASURE: The patency of the choanae without respiratory distress or nasal drainage, as assessed by endoscopic evaluation, determined a successful repair. RESULTS: Of the 20 patients, 17 retained patent airways. Three patients experienced improvement from a total atresia to a narrowed, stenotic choana. CONCLUSIONS: The use of mitomycin as an adjunct to the surgical repair of choanal atresia may offer improved patency with a decreased need for stenting, dilatations, and revision surgery. Newer endoscopic techniques with powered instrumentation further enhance the safety and efficacy in the repair of choanal atresia.

The role of mitomycin in the prevention and treatment of scar formation in the pediatric aerodigestive tract: friend or foe?

OBJECTIVE: To evaluate the role of mitomycin in the prevention and treatment of scar formation in the pediatric aerodigestive tract. DESIGN: Prospective study; institutional review board-approved clinical trial. SETTING: Tertiary care pediatric medical center. PATIENTS: Fifteen patients; choanal atresia in 5 patients, airway stenosis in 8 patients, hypopharyngeal stenosis in 1 patient, and esophageal stenosis in 1 patient. OUTCOME: The efficacy and safety of mitomycin in the prevention of scar formation. INTERVENTION: All patients underwent surgical repair of the stenotic area, followed by topical application of mitomycin (1 mL of 0.4 mg/mL) for 4 minutes. RESULTS: Ten patients (67%) showed major improvement, 4 patients (27%) showed minor improvement, and 1 patient (7%) showed no improvement. CONCLUSION: Topical application of mitomycin can play an effective role in the prevention and treatment of scar formation in the aerodigestive tract.