© Borgis - New Medicine 4/2007, s. 83-86
Eliza Brożek-Mądry, *Lidia Zawadzka-Głos, Mieczysław Chmielik
Long-term experience in the management of choanal atresia
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Prof. Mieczysław Chmielik, MD, PhD
Choanal atresia occurs as an isolated congenital malformation or it is associated with other malformations. In Pediatric Otolaryngology Department in Warsaw children with choanal atresia have been operated for many years.
Material and method. Authors present a large material with a group of patients operated due to choanal atresia in Otolaryngology Department, Medical Academy of Warsaw in years 1959-2007. The operations were conducted in these children either by transpalatal or transnasal approach. The patients´ characteristics was presented in children with unilateral and bilateral changes. The operated children were evaluated in terms of reoperation necessity.
Results. between 1959 and 2007 a group of 136 patients was operated due to choanal atresia with a total number of 183 operations including 47 reoperations.
Conclusions. (1) Choice of operating method depends on anatomic conditions and experience of particular operating centre (2). Stent removal – when they achieve good mobility in posterior choanae and can be easily moved to nasopharynx (3). Method gaining much attention in the management of chonal atresia resently is transnasal approach due to the development of endoscopic techniques (4). Children with bilateral choanal atresia require re-dilation more frequently (5). Bilateral choanal atresia is more common in children with co-existing anomalies and with perinatal burden.
Choanal atresia (CA) is a congenital malformation leading up to nasal patency disorders, depending on its unilateral or bilateral character. First descriptions of the disorder in literature date the middle of XVIII century (Roederer) but it was 80 years later when the anatomy of choanal atresia was described (Otto) (1) . The disease prevalence is estimated between 1:5000 and 1:8000 live births, more frequently occurs in females, usually unilateraly and on the right side (2). In 70% patients the atretic plate in choanae is bony-membraneous, while the rest patients (30%) have a bony plate (3). There are four hypotheses leading to choanal atresia formation in embryogenesis: (1) persistence of the naso-buccal membrane of Hochstetter – disturbed perforation process in the 7th intrauterine week (2), persistence of bucco-pharyngeal membrane (3), abnormal adhesions formation in choanae, abnormal mesodermal flow secondary to local factors (4). CA co-exists with other congenital anomalies in CHARGE syndrome (5-6) and VATER syndrome (7). It is also sometimes observed in Down syndrome, Crouson syndrome, Apert syndrome and other. In bilateral CA the surgical treatment is advised as soon as the child´s general condition allows. In unilateral changes the operation is usually performed between 3rd and 5th year of life. Approaches described in surgical treatment include transpalatal, transnasal, transseptal in adults and transmaxillar approach which is no longer used. In recent years many surgeries are proceeded transnasaly due to spectacular development of endoscopic techniques (8,9). There are also introduced some modifications in surgical treatment such as using mitomycin C, KTP laser, or abandoning stent insertion, but no distinct answers on benefits were published (10).
MATERIAL AND METHOD
Documentation considering surgical treatment of CA in children was collected from January 1959 to May 2007 and analysed retrospectively. Patients since 2000 were searched in computer data base and the patients operated earlier were found in operation books of particular years. A group of children operated between 1995 and 2007 were analysed more precisely. The group of patients was divided depending on unilateral or bilateral changes. Sex, age, co-existing diagnosis, symptoms, perinatal history, examination results and radiological findings were discussed. Children were operated in general anesthesia through transnasal or transpalatal approach. Last stage in both methods was stent placement into the nasal cavities, with their proper fixation in front of columella and in choanae. The stents were made of sufficiently sized endotracheal tubes. In postoperative period parents were instructed how to take care of the stents properely. They had to learn to suck the excess discharge, moisurize the air in child´s surroundings, drop the saline into the stents and make inhalations of saline. After the scar stabilisation, the stents were removed. The complications and the necessity of reoperations were noted.
Between 1959 and 2007 there were 136 patients operated in Otolaryngolgy Department of Medical University in Warsaw (96 females and 40 males; F/M ratio ~ 5:2). Total number of operations in this period was 183 including 47 reoperations. Unilateral CA was diagnosed in 77 patients and bilateral CA – in 59 children. The effects in terms of reoperations were presented in table 1.
Table 1. The results of treatment with the respect of reoperations (1959-2007)
|Type of operation||No. of patients||Reoperations||% of reoperations|
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1. Friedman NR, et al.: Management and outcome of choanal atresia correction. Int. J. Pediatr. Otorhinolaryngol 2000; 52: 45-51.2. Chmielik M: Otorynolaryngologia dziecięca. PZWL, Warszawa 2001.3. Brown OE, et al.: Choanal atresia: a new anatomic classification and medical implications. Laryngoscope 1996; 106: 97-101.4. Hengerer AS, et al.: Choanal atresia: a new embryologic theory and its influence on surgical management. Laryngoscope 1982; 92: 913-921.5. Samadi DS, et al.: Choanal atresia: A twenty year review of medical comorbidities and surgical outcomes. Laryngoscope 2003; 113: 254-258.6. Schraff SA, et al.: Management of choanal atresia in CHARGE association patients: A retrospective review. Int. J. Pediatr. Otorhinolaryngol 2006; 70: 1291-1297.7. McLeod IK: Revision choanal atresia repair. Int. J. Pediatr. Otorhinolaryngol 2003; 67: 517-524.8. Khafagy YW: Endoscopic repair of bilateral congenital choanal atresia. Laryngoscope 2002; 112: 316-319.9. Schoem SR: Transnasal endoscopic repair of choanal atresia: why stent? Otolaryngol Head Neck Surg. 2004; 131: 362-366.10. Kubba H, et al.: An update on choanal atresia surgery at Great Ormond Street Hospital for Children: preliminary results with Mitomycin C and the KTP laser. Int. J. Pediatr. Otorhinolaryngol 2004; 68: 939-945.