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Endoscopic Repair of Bilateral Congenital Choanal Atresia over 100 cases: Lessons learned Yasser W. Khafagy, MD Professor of Otolaryngology Mansoura University 11-14, March 2015 PAFOS 2015 Introduction • It is a condition that describes narrowing or obliteration of the posterior nasal aperature • It occurs in 1:7,000 to 8,000 births, of those 45% are bilateral • Much more commonly in females • Mostly bony or mixed, rarely purely membranous 11-14, March 2015 PAFOS 2015 Ideal Procedure • • • • • Restore normal nasal passage Avoid damage to any growing structures Be safe Short surgery time and hospitalization stay Minimal morbidity and mortality – Endoscopic repair is more commonly used than other approaches ( transnasal, transpalatal, transseptal) 11-14, March 2015 PAFOS 2015 Objective • Early experience with 9 cases was published in the Laryngoscope; (112:316-319, 2002) • This study aims to present 18 years experience with treatment of bilateral congenital choanal atresia, report technique, results, pitfalls, complications 11-14, March 2015 PAFOS 2015 Lessons Learned • Be safe, do a comprehensive preoperative work up • Get proper preoperative counselling • Use the proper instrumentation • Have incubator ready for the baby • Second look procedure is common • Avoid Injury of the cartilage, nasal columella and vestibule • 11-14, March 2015 PAFOS 2015 Membranous atresia Look at the size of choana 11-14, March 2015 PAFOS 2015 Be safe • Get preoperative pediatric complete report including echocardiography, bleeding profile just before surgery • The infant should not be on assisted ventilation • Axial non contrast CT, with thin cuts • Study the CT scan 11-14, March 2015 PAFOS 2015 Mixed Aresia 11-14, March 2015 PAFOS 2015 11-14, March 2015 PAFOS 2015 Axial CT scan 11-14, March 2015 PAFOS 2015 Lessons Learned Preoperative Counseling • Describe the disease, the necessity for surgery, discuss difficulties • Describe the procedure, the expected outcome • Talk about the second look and its justification 11-14, March 2015 PAFOS 2015 Lessons learned : Get Ready Surgical Technique • GA with endotracheal tube, moist cotton in the oropharynx, be careful not to put bulky gauze in the oral cavity • Supine position, Afrin nose drops, 4 mm, 0 degree nasal endoscope, few instruments are usually needed, Some otologic instruments will be helpful. 11-14, March 2015 PAFOS 2015 Surgical Technique • Although the technique remains the same, some modifications were made as directed by the follow up for cases through the years. • Incision is made in the posterior septum close to the atretic plate, using sickle knife radiofrequency needle, coblation needle 11-14, March 2015 PAFOS 2015 Incisions 11-14, March 2015 Right PAFOS 2015 Left Radiofrequency needle and coblation needle 11-14, March 2015 PAFOS 2015 Surgical Technique • The incision extended to the atretic plate • The mucosa over the atretic plate is removed, In cases with mixed atresia, the atretic plate is perforated with suction tip (preferably suction diathermy)inferiorly and medially, • Removal of the vomer is the most important step, Extralong burs, ear curettes, dissectors are used to create the neochoana 11-14, March 2015 PAFOS 2015 Surgical technique • Extreme care to keep the cartilagenous septum intact, also extreme caution not to injure the alar cartilage by drill heat. • Attention is then directed to the lateral boundary of the neochoana drilling may be required to obtain a good sized neochoana keeping in mind the continuous healing attempts of all tissues in the area of surgery! 11-14, March 2015 PAFOS 2015 Surgical Technique • No stenting were used in the last 20 cases and to date • Atresia prim.mpg 11-14, March 2015 PAFOS 2015 Post-operative care • Early feeding is helpful for the baby and the mother! • Patient discharge is determined after ped consult • Regular weekly examination • Dilatation with bougies may be helpful 11-14, March 2015 PAFOS 2015 11-14, March 2015 PAFOS 2015 Second Look procedure • Usually needed in most cases • Usually needed once, less commonly not needed or needed more than once • Usually done betwwen 6 to 8 weeks post operatively 11-14, March 2015 PAFOS 2015 Results • 82 cases were mixed atresia, 16 cases were bony atresia, only two cases were membranous. • In all cases atretic bone removal was done, the vomer was removed in all cases, lateral wall drilling was used in 55 cases. • Average follow up was 6 years (6 months to 13 years) 11-14, March 2015 PAFOS 2015 Complications and re-stenosis • The most common is Re-stenosis (soft, bony or both). • one cases had alar cartilage necrosis. • One case had collumelar necrosis by the stent • One case had septal perforation with depressed nose at age of 8. • One patient had pin point palate perforation that heals spontaneously. • Only one case died shortly after the procedure, she had profuse bleeding during removal od soft tissue over the atretic plate (hemorrhagic disease of the newborn was suspected). • All are among the first 15 cases. 11-14, March 2015 PAFOS 2015 Re stenosis revision choanoplasty 3.mpg 11-14, March 2015 PAFOS 2015 Closure 11-14, March 2015 PAFOS 2015 Unilateral Stenosis 11-14, March 2015 PAFOS 2015 11-14, March 2015 PAFOS 2015 Drilling of lateral wall 11-14, March 2015 PAFOS 2015 Columellar injury 11-14, March 2015 PAFOS 2015 11-14, March 2015 PAFOS 2015 Discussion • “Choanal Obliteration” is more descriptive term than choanal atresia because the abnormally thick vomer and the medial pterygoid plates are more contributing to the problem than the atretic plate itself. • In many cases, the closure of the choana is made by meeting of the medial and lateral walls with or without soft tissue or small bony plate 11-14, March 2015 PAFOS 2015 Discussion • Removal of the atretic plate only or perforation of the central part of the choana on both sides will result eventually in re-closure • Removal of the vomer or and drilling out of the medial pterygoid plates are crucial in management of these cases. 11-14, March 2015 PAFOS 2015 Discussion: Stent or not • Stenting was used empirically in the first 80 cases in our series, no stenting was used in the last 20 cases • The importance of stenting is debatable. • stenting would help to keep better breathing in the early postoperative period • Better postoperative period and parent satisfaction in cases when stenting were not used • No difference in the need for second look 11-14, March 2015 PAFOS 2015 Discussion • Second look procedure is important in bilateral atresia, because of the small size of choanal space at this age in addition to the good rapid healing as well as active rapid growth in this age also predisopse to re-narrowing. • Sometimes , polyps are formed at the edge of the choana, restenosis with bone is not also uncommon ( growth, healing) 11-14, March 2015 PAFOS 2015 Discussion • Parent counseling is essential for assurence, postoperative care, explanation for the problem of re-stenosis • Teissier et al. [2008] noted that gastroesophageal reflux disease (GERD), age younger than 10 days at the time of surgery (bilateral atresia) and insufficient postoperative endoscopic revision are predictive factors for restenosis. 11-14, March 2015 PAFOS 2015 Conclusions • Endoscopic repair of bilateral choanal atresia meet the goals for efficacy, safety, and minimal effects on growth • Second look procedure is recommended for better outcome • Working in the infant nose is not difficult in the majority of cases • Careful dealing with the septum, alar cartilages is important. 11-14, March 2015 PAFOS 2015 11-14, March 2015 PAFOS 2015