Download Endoscopic Repair of Bilateral Congenital Choanal Atresia: 15

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