What are the treatment options for temporal atresia?

Treatment Options for Temporal Atresia

The preferred treatment for temporal atresia is micro-endoscopic endonasal surgical correction combined with postoperative dilations and intraoperative application of Mitomycin C, which provides the best long-term outcomes with the lowest restenosis rates. 1

Diagnostic Evaluation

• High-resolution CT scans with multiplanar reconstructions are essential before surgical planning to evaluate the individual anatomical characteristics of the atretic plate (bony vs. mixed bony/membranous) and identify any associated anomalies 1
• Endoscopic examination should be performed to assess the extent of the atresia and rule out associated airway abnormalities 1
• Inability to pass a catheter through the nostril into the pharynx is a simple diagnostic test for choanal atresia 1

Timing of Surgical Intervention

• For bilateral choanal atresia: Immediate airway management and surgical correction within the first week of life due to respiratory distress 1
• For unilateral atresia: Elective surgical correction before school age, preferably around 2 years of age 1

Surgical Approaches

1. Micro-endoscopic endonasal approach (preferred) 1

   • Offers excellent visualization and magnification
   • Results in increased safety and reduced surgical time
   • Allows for bimanual surgical manipulation
   • Appropriate when nasal airway is not severely compromised by concomitant malformations

2. Transpalatine approach 1

   • Reserved for cases with insufficient endonasal visualization
   • Used in revisions or children older than 5 years
   • Associated with long-term complications including palatal muscle dysfunction, mandibular joint pathology, and orthodontic problems in up to 50% of cases

3. Transantral approach (less commonly used) 1

4. Transseptal approach (less commonly used) 1

Surgical Technique Components

• Complete removal of the atretic plate with all components 1
• Use of various instruments including bougies, dissectors, cutting instruments, and powered drills 1
• Topical application of Mitomycin C (0.4 mg/ml for 10 minutes) intraoperatively to reduce excessive granulation and scar formation 1

Postoperative Management

• Regular endoscopic controls combined with transnasal dilations using a soft rubber bougie 1
• Initial dilations performed by the surgeon daily, gradually decreasing to weekly intervals 1
• Later dilations performed by parents or patients in outpatient follow-up for up to one year 1
• Stents are NOT recommended due to their association with higher restenosis rates (35% failure with stents vs. 11% without) 1

Special Considerations

• Patients with CHARGE association (12% of cases) or other syndromes require careful evaluation for associated anomalies 1
• The "delta deformity" of widened vomer is common and creates an hourglass-shaped configuration of the choanal region 1
• Careful assessment of the facial nerve position is essential to avoid injury during surgery 1

Complications and Their Management

• Restenosis is the most common complication, especially when stents are used 1
• Granulation tissue formation can lead to restenosis and may require additional interventions 1
• Mucosal flaps have been proposed by some surgeons to minimize raw surfaces, though evidence for their effectiveness is limited 1

Long-term Follow-up

• Follow-up for at least one year is necessary to ensure stable patency 1
• Regular endoscopic examinations to detect early signs of restenosis 1
• Prompt intervention for granulation tissue or early signs of stenosis 1

Treatment Outcomes

• Success rates are significantly higher with the micro-endoscopic approach combined with Mitomycin C application and postoperative dilations 1
• Multiple surgical revisions may be required in some cases, with 63% of patients requiring only one procedure, 24% requiring two, and 7% requiring three interventions 1