What is the treatment for choanal atresia?

Treatment of Choanal Atresia

The definitive treatment for choanal atresia is surgical correction using a micro-endoscopic endonasal approach without postoperative stenting, combined with intraoperative Mitomycin C application (0.4 mg/ml for 10 minutes) and regular postoperative transnasal dilations for up to one year. 1

Immediate Management

Bilateral Choanal Atresia (Neonatal Emergency)

• Immediate airway management with oropharyngeal airway intubation is required within the first hours of life because newborns are obligate nasal breathers and present with periodic respiratory distress, cyanosis relieved by crying, severe feeding problems, and aspiration 1
• Surgical correction should be performed within the first week of life after initial airway stabilization 1, 2

Unilateral Choanal Atresia

• Elective surgical correction should be performed before school age, preferably around 2 years of age 1, 2
• Symptoms are typically mild (mucoid nasal discharge, upper airway infections, headache, rhinolalia) and do not require emergency intervention 1

Preoperative Workup

Obtain high-resolution multiplanar CT scans with 3D reconstructions to analyze the individual anatomical topography, determine whether the atretic plate is purely bony (30%) or mixed bony-membranous (70%), and identify any concomitant malformations or skull base defects 1, 2

• Perform thorough endoscopic examination to assess the extent of obstruction 1, 2
• Screen for CHARGE syndrome (present in 20% of cases): requires 2 of the following—Coloboma, Heart defects, Choanal Atresia, Retardation, Genito-urinary abnormalities, Ear abnormalities 1
• Evaluate for other associated congenital abnormalities (present in 50% of cases, up to 75% in bilateral manifestations) 1

Surgical Approach

Preferred Technique: Micro-Endoscopic Endonasal Approach

The micro-endoscopic endonasal approach is the preferred method because it provides excellent visualization and magnification, allows for atraumatic and time-effective repair, increases safety, and reduces surgical time 1, 2

Key surgical steps:

• Complete removal of the atretic plate with all bony and membranous components based on preoperative CT analysis 1, 2
• Use powered miniaturized instrumentation, drills, cutting forceps, and punches as needed—the drill is most suitable for widening the medial aspect by removing the thickened vomer and posterior septum 1
• Apply topical Mitomycin C (0.4 mg/ml) intraoperatively for 10 minutes to reduce excessive granulation and scar formation 1, 2

Alternative: Transpalatine Approach

Reserve the transpalatine approach only for cases where the nasal passage is too stenosed for endonasal instrumentation, failed endoscopic revisions, or children older than 5 years 1, 3, 4

• This approach has significant drawbacks: 50% long-term complication rate including palatal muscle dysfunction, mandibular joint pathology, and orthodontic problems 1, 2

Critical Postoperative Management

Avoid Stenting

Do NOT use postoperative stents—they are associated with a 35% failure rate compared to only 11% without stents 1, 2

• Stents cause circumferential pressure leading to ischemia, osteoblastic and fibroblastic reactions, lack of reepithelization, granulation tissue formation, and pressure-related lesions of the columella, alar cartilages, and septal cartilage 1
• Granulation tissue from stents is associated with a 30% failure rate regardless of surgical technique 1

Implement Regular Dilations

Perform repeated endoscopic examinations combined with transnasal dilations using a soft rubber bougie 1

Dilation protocol:

• Initially daily by the surgeon
• After 3 weeks, reduce to once weekly
• Continue with parents or patients performing dilations themselves for up to one year 1

Treatment Outcomes

The combination of micro-endoscopic approach, Mitomycin C application, and postoperative dilations without stenting achieved 100% success in recent case series with no surgical revisions needed after >12 months follow-up 1, 2

• Overall, 63% of patients require only one procedure, 24% require two interventions, and 13% require three or more revisions 1, 2
• The most common complication is restenosis, particularly when stents are used 1, 2

Common Pitfalls to Avoid

• Do not use stents—they dramatically increase restenosis rates 1
• Do not delay bilateral repair—it is a life-threatening emergency requiring correction within the first week 1
• Do not perform inadequate vomer removal—insufficient removal of the thickened vomer is a common cause of failure 1, 4
• Do not skip long-term follow-up—regular endoscopic examinations for at least one year are essential to detect early restenosis 1, 2