Choanal atresia

Choanal atresia is the absence of communication between the posterior nasal cavity and the
nasopharynx.

The incidence ranges from 1 in 5000 to 1 in 8000 live births.

Up to two thirds of cases are unilateral, with atresia most commonly occurring on the right side.1

NEURAL CREST
CELLS

Fifty percent of all patients with choanal atresia and up to 75% of patients with bilateral disease have
other associated congenital anomalies.2
The anatomic features that characterize choanal atresia include

1) a narrow nasal cavity,

2) lateral bony obstruction by the pterygoid plates,

3) medial obstruction caused by thickening of the vomer, and

4) membranous obstruction.

The diagnosis of choanal atresia is made clinically by failure to pass a 6F catheter through the
nose into the nasopharynx (a distance of approximately 32 mm).

Endoscopy (Fig. 189-16) and CT should be performed to confirm the diagnosis. CT is also helpful to
reveal the nature and thickness of the atresia.

Suctioning and pharmacologic vasoconstriction before imaging will improve resolution

CT scanning also differentiates between complete atresia and stenosis. Choanal stenosis is defined
as a narrowed yet patent choana, measuring less than 6 mm across.

Clinical presentation
 unilateral
present later in life
with rhinorrhea and nasal obstruction
On anterior rhinoscopy, the occluded nasal
cavity is typically filled with thick, tenacious
secretions.
bilateral
presents in the neonatal period
increasing efforts to breathe, tight mouth
closure, and chest retractions, followed by
cyanosis
The cycle is broken by crying
Bilateral choanal stenosis presents later in life
with mouth breathing, recurrent sinusitis,
chronic rhinorrhea, otitis media, failure to
thrive, and defects of speech

Treatment

unilateral atresia may be delayed for several months, allowing for growth of the nose, which
enhances the ease of surgery and reduces the risk of postoperative complications and restenosis.

Bilateral atresia requires an

1. initial intervention to establish an oropharyngeal or orotracheal airway and gastric feeding

before definitive surgery.
2. The timing of surgery is variable, and it may be preferable to wait several months until
adequate facial growth has occurred (similar to the timing of cleft lip repair).
3. In patients with additional indications for tracheotomy, a surgical airway is obtained and
definitive atresia repair is often delayed.

Currently, transnasal surgery is preferred over transpalatal approaches (Fig. 189-19), given
advances in endoscopic instrumentation and the lower risk of dental and facial growth
abnormalities.

a) The repair begins with using a urethral sound or suction instrument to perforate the atretic
plate at its thinnest portion.
b) A 0-degree transnasal endoscope or a 120-degree nasopharyngoscope is used for
visualization.
c) Subsequently, a backbiting forceps, a microsurgical débrider, a laser, and a drill are used as
necessary to remove choanal soft tissue and bone. Performing posterior septectomy with
resection of the posterior portion of the vomer using a back biting endonasal instruments
results in a three dimensional aperture less likely to stenose.
d) The posterior tip of the middle turbinate is a useful anatomic landmark. Restricting surgical
maneuvers to remain inferior to this structure reduces the risk of intracranial injury.48
e) The use of stenting and/or fibroblast inhibitors (mitomycin C) as well as the importance of
preserving mucosal flaps remain controversial.
f) Topical nasal steroids may serve to reduce swelling and granulation following surgery;
however, signi ficant systemic uptake of nasal steroids can cause adrenal insufficiency.7
Thus, we advocate a shortterm postoperative nasal steroid course followed by saline alone

Complications
lower the risk of restenosis. The lowest recurrence rates are seen in older children (with presumed
unilateral atresia) and patients with nonsyndromic choanal atresia.