Shivnani, Raman, and Amle: Trans-nasal endoscopic repair without stenting in bilateral congenital bony choanal atresia: Our technique


Background

Infants with bilateral Choanal Atresia (CA) can present as an airway emergency at birth. The goal of initial treatment is to maintain an adequate airway.1 Incidence of choanal atresia is around 1 in 7,000 live births2 It is a potential life threatening condition in neonates because this condition is predominantly in first 6 weeks of births3. 65–75 % of patients with choanal atresia are unilateral, and the rest are bilateral4 There are five different approaches described for surgical treatment of CA: (1) trans-nasal, (2) trans-palatal, (3) trans-antral, (4) trans-septal and (5) sublabial– transnasal.5, 6 Our objective is to report our experience in Trans-nasal Endoscopic Minimal Invasive Technique without stenting for the surgical management of CA.

Technique

1. This case series includes 6 children who presented or referred to our Hospital with congenital bilateral CA between October 2015 to July 2017. Institutional Review Board approval was taken. We used a Trans-nasal Endoscopic Minimal Invasive Technique without stent placement. It is based on the following steps

2. Stents and nasal packs were not placed in any case. No topical mitomycin or corticosteroids were applied. Postop care: Antibiotic Therapy, Nasal Saline Spray at least twice a day for several weeks were recommended. Patients underwent a regular follow-up to wash away crusts and secretions and verify choanal patency. All patients were followed up at-least for 18 months.

Figure 1

Step 1: CT scan images were evaluated to assess the thickness of atretic plate.

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Figure 2

Step 2: After the positioning and draping, the nose is topically decongested with vertically cut neuro-patty soaked in decongestant solution (1 ampoule adrenaline,30 cc saline with 10 drops of .025% oxymetazoline)

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Figure 3

Step 3: Nasal Endoscopy performed with 2.7mm karl storz endoscope.Bilateral CA was confirmed.

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Figure 4

Step 4: 2mm diamond drill with contra-angle hand piece used.Catheter sleeve placed over Drill bit to prevent alar thermal injuries.

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Figure 5

Step 5 : Both microdrill and endoscope used viaTransnasal route.

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Figure 6

Step 6: Inferomedial portion of atretic plate drilled out enough to let 4mm karl storz endoscope to pass through.

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Discussion

  1. Four patients were male and two were female. Only 1/6 patient needed revision surgery for restenosis. Mean Procedure time = 90 min (range = 60-120 min) Mean Hospital stay = 4.3days (range = 3 to 9 days) No intra- and/or early postoperative complications such as epistaxis, infection noticed.

  2. Erosion of the nares or intranasal synechiae occurred. All patients underwent postoperative follow-up with clinical evaluation. One patient developed naso palatine fistula due to drilling choanal part as this patient was having high arched palate. No significant regurgitation noticed through the fistula.

Table 1

Patient Name

Age

Sex

Investigation done

Other comorbidities

Hospitalisation

Follow up

Baby of A

6 Days

M

Endoscopy

None

4 Days

No Restenosis

Baby of R

6 Days

M

CT Scan

None

3 Days

No Restenosis

Baby Of Z

18 Days

F

CT Scan

Charge Syndrome

9 Days

Partial Stenosis

Baby of N

7 Days

F

CT Scan

None

3 Days

No Restenosis

Baby of Ar

4 Days

M

CT Scan

High Arched Palate

3 Days

No Restenosis, Naso palatine fistula developed due to high arched palate

Baby of S

5 Days

M

CT Scan

4 Days

No Restenosis

Conclusion

Repair without stenting avoids the potential for stent-related complications, such as discomfort, localized infection and ulceration, circumferential scar or granulation tissue formation. A combination of close post-operative follow-up, revision endoscopy to remove nasal crusting 1 week after the primary repair, and frequent nasal saline irrigation was the key to successful management of CA without stenting. However, due to the number of patients included, these findings cannot be generalized and a larger sample is necessary to obtain statistically significant conclusions.

Clinical significance

We suggest this Trans-nasal Endoscopic Surgery because it follows the basic requirements of a minimally-invasive corrective approach: the creation of patent posterior nasal choana sufficient for nasal breathing, minimization of endonasal scar tissue formation, absence of secretion accumulation, and prevention of abnormal craniofacial growth in children who have not reached their full growth yet.

Source of Funding

None.

Conflict of Interest

None.

References

1 

V Sinha Y More Choanal atresia: surgery by puncture, dilatation and stentingJ Rhinol20061321247

2 

M Gleeson G George M J Burton R Clarke H John S Nicholas Scott Brown’s otolaryngology head and neck surgeryAnn R Coll Surg Engl200893755910.1308/147870811X598605b

3 

N K Panda S Simhadri S Ghosh Bilateral choanal atresia in an adult: is it compatible with life?J Laryngology Otol20041183244510.1258/002221504322928099

4 

J M Dobrowski K M Grundfast K N Rosenbaum J T Zajtchuk Otorhinolaryngic Manifestations of CHARGE AssociationOtolaryngol Head Neck Surg198593679880310.1177/019459988509300619

5 

A Freng Growth in Width of the Dental Arches After Partial Extirpation of the Mid-Palatal Suture in ManScand J Plast Reconstr Surg19781232677210.3109/02844317809013003

6 

N R Friedman R B Mitchell C M Bailey D M Albert S E J Leighton Management and outcome of choanal atresia correctionInt J Pediatr Otorhinolaryngol2000521455110.1016/s0165-5876(99)00298-0



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Article History

Received : 18-05-2021

Accepted : 11-06-2021

Available online : 14-07-2021


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https://doi.org/10.18231/j.ijpns.2021.013


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