The Journal of Laryngology & Otology (2010), 124, 387 392.

Main Article
# JLO (1984) Limited, 2009
doi:10.1017/S0022215109991861

Transnasal endoscopic repair of bilateral congenital

choanal atresia: controversies
H M ELADL

Abstract
Objective: To evaluate current concerns about transnasal endoscopic repair of bilateral congenital choanal
atresia, regarding technical difficulties, prognostic factors and important controversies.
Patients and methods: Ten infants with bilateral congenital choanal atresia, aged from 3 to 27 days
(mean, 11.2 days) were included. All cases underwent transnasal endoscopic repair and were clinically
and endoscopically monitored.
Results: Of the seven patients treated with stenting, five remained patent and two required minor
debridement (with complete patency thereafter). Of the three patients treated without stenting, one
remained patent and two required minor debridement (with patency thereafter).
Conclusions: Transnasal endoscopic repair of bilateral congenital choanal atresia is a safe and successful
technique. The use of powered instrumentation in neonatal patients requires experience and a correctly
sized drill. Stenting with an appropriate nasal tube for a suitable period is favoured, especially in
hospitalised patients.
Key words: Choanal Atresia; Endoscopy; Child; Otorhinolaryngologic Surgical Procedures

Introduction ossification of the posterior portion of the lateral

Congenital choanal atresia is a rare malformation
which causes airway obstruction in neonates and
infants; it has an incidence of one in 7000 to 8000
births. It seems to occur more commonly in girls than
boys, and to be more frequently unilateral and right-
sided than bilateral. The nature of the obstructing
atretic plate has been described as 90 per cent bony
and 10 per cent membranous. Modern imaging tech-
niques have revealed that 30 per cent of such malfor-
mations consist of a purely bony obstruction, and 70
per cent of a mixed bony-membranous obstruction.1
Most cases of congenital choanal atresia involve
isolated malformations, but association with other
congenital deformities is not exceptional (as in the
CHARGE anomaly syndrome, which includes
coloboma, heart disease, congenital choanal atresia,
retarded development, genital hypoplasia and ear
anomalies).2
There are currently four hypotheses regarding
the embryological origin of congenital choanal
atresia, but none has been proved. These include
the persistence of the nasobuccal membrane or of
the foregut buccopharyngeal membrane, abnormal
mesodermal adhesions in the nasal choanae, and
a misdirection of mesodermal flow due to local
factors.3
Congenital choanal atresia is characterised by
hypertrophy of the posterior vomer, together with
nasal wall at the level of the sphenopalatine region
adjacent to the pterygoid plates.4
Many approaches have been used to repair con-
genital choanal atresia. Four classical surgical
approaches have been described: transnasal, transpa-
latal, trans-septal and transantral.5 The transpalatal
technique is the method preferred by most surgeons,
due to its excellent surgical visibility and success
rates of approximately 80 to 90 per cent.2 The trans-
nasal approach has fallen from favour because of its
high failure rate, requiring revision.6
However, the development of rigid endoscopes
and powered instrumentation has led to reconsi-
deration of the transnasal approach.7 This technique,
performed endoscopically, is suitable for young
children (even neonates) with bilateral congenital
choanal atresia, and also for revision cases in which
previous transnasal or transpalatal approaches have
failed.2 This endoscopic approach allows a shorter
hospital stay and reduced blood loss, compared
with other, more traditional techniques.8
Patients and methods
This study included 10 neonates with bilateral con-
genital choanal atresia, aged between 3 and 27 days
(mean, 11.2 days), seen at the otorhinolaryngology
department of Mansoura University Hospital

From the ORL Department, Mansoura University Hospital, Mansoura University, Egypt.
Accepted for publication: 13 July 2009. First published online 25 November 2009.

387
388 H M ELADL

between March 2005 to February 2008. Prior to
commencement, the relevant institutional review
board approved the research, and appropriate
consent was obtained from the parents of all
patients.
Clinical evaluation included a complete physical
examination, to assess for other congenital
anomalies, and a complete nasal and nasopharyngeal
examination, to assess the deformity. All patients
underwent computed tomography (CT) scanning of
the nose and paranasal sinuses to assess the location
and type of atresia. The atresias were either bony
(in six patients), or composed of mixed bony and
membranous elements ( four patients) (Figure 1).
All patients were treated by the transnasal
endoscopic surgical technique, using conventional
biting instruments. However, the transnasal endo-
scopic drill-out technique was added in four cases.
Table I shows the patients ages at the time of treat-
ment, sex, weight, type of stenosis (bony, membra-
nous or mixed), use of drilling and stenting,
follow-up results, and post-operative complications.
FIG. 1
Axial computed tomography scan showing bilateral congenital
choanal atresia.
Oxymetazoline hydrochloride spray was applied to
the nasal cavity 15 minutes before transporting the
patient to the operating theatre. On arrival, general
anaesthesia was induced.
Using 4.0 mm 08 and 308 telescopes (Karl Storz,
Tuttlingen, Germany), both sides of the nasal
cavity were inspected, and the atretic plate was care-
fully identified. Otoscopic suction tubes were used
to remove discharge and to palpate the atretic plate.
Under endoscopic visualisation, a vertical cross-
over incision was placed at the cartilaginous bony
junction, a few millimetres superior to the maxillary
crest, over the posterior bony septum in the widest
part of the nasal cavity. The vomer was then
removed piecemeal using a dissector and paediatric
endoscopic forceps with 2- and 4-mm blades
(straight, 458 and 908). The two nasal cavities could
be reached via this septal window, and this enabled
bilateral endoscopic visualisation, together with the
facility to place the telescope on one side and the
dissecting instrument on the other side in order to
facilitate bone removal. The posterior vomer and
the mucosa over the atretic plate were carefully
removed. Using the suction tube, the atretic plate
was punctured at its weakest point, to establish a
reference point into the nasopharynx. Using conven-
tional forceps, the atretic plates were then removed
bilaterally, working in a medial to lateral direction,
in order to open the choanae. Each choana was
then enlarged circumferentially, avoiding superior
manipulation, grasping, and blind, vigorous
manoeuvres (Figure 2). The inferior aspect of the
middle turbinate was used as a guide for the superior
limit of dissection.
In four cases, drilling of the atretic plates was
required in order to achieve sufficient choanal
opening. Drilling was employed only when required
by the thickness of the atretic plate, in order to
achieve complete resection. Drilling was commenced
inferiorly and medially and continued until the
choana opened; then conventional instrumentation
was used to widen the choana. Excess superior or
blind drilling was avoided; drilling stayed posterior,
inferior and medial in the nasal cavity, along the
posterior maxillary crest.

TABLE I
PATIENT VARIABLES

Pt no Age Sex Wt Stenosis type Drilling? Stenting? Op time Post-op stay Follow up Post-op complications
(days) (kg) (wks) (min) (days) (mths)
1 4 F 2.9 Mixed N Y (3) 80 3 35
2 15 M 3.2 Bony Y Y (2) 85 7 31
3 7 F 3.0 Bony Y Y (4) 90 8 28 L vestibular stenosis
4 9 F 3.2 Bony N N 85 6 24 Bleeding
5 5 M 2.9 Mixed N N 65 6 18
6 3 M 2.5 Bony Y Y (4) 75 7 15
7 22 F 3.0 Mixed N Y (3) 60 8 12
8 13 M 3.2 Mixed N Y (1) 66 7 9
9 27 F 3.5 Bony Y Y (2) 75 8 8
10 7 F 3.0 Bony N N 60 4 5
Mean 11.2 3.04 N 2.7 74.1 6.4 18.5

Pt no patient number; wt weight; wks weeks; op time operation duration; post-op post-operative; mths months;
F female; M male; Y yes; N no; L left
TRANSNASAL ENDOSCOPIC REPAIR OF BILATERAL CONGENITAL CHOANAL ATRESIA 389

The mean operating time was 74 minutes. When

surgery was completed, seven patients were fitted
with a custom-made, soft nasal stent created from a
size 3.5 polyethylene tracheal tube, placed in the neo-
choanae and secured anteriorly with a trans-septal
Vicryl 3-0 suture (Figure 3). The nasopharyngeal
position of the stent was ensured by oropharyngeal
examination, and stent patency was tested with a
saline injection.
Antibiotic medication and paediatric isotonic
sodium chloride nasal drops were administered post-
operatively. Stents remained in situ for a period
ranging from one to four weeks (mean, 2.7 weeks)
(Table I).

Results
The success rate of the primary procedure was 70 per
cent, as seven of the 10 patients had patent choanae
after one transnasal endoscopic procedure. The
endoscopic aspect of the choanae looked almost
normal in five of these cases, and was slightly nar-
rowed with a small amount of granulation or
adhesions in two cases (Figure 4). All patients were
clinically and endoscopically monitored for nasal
obstruction and healing. The follow-up period
ranged from five to 35 months (mean, 18 months)
(Table I).
No major post-operative complications occurred;
however, one case showed post-operative unilateral
vestibular stenosis. In this case, drilling and stenting
had been used. Excessive post-operative bleeding
occurred in one case, which was managed by stent
removal and packing for two days. No other post-
operative complications (e.g. distress, infection,
bleeding or nasal deformity) were encountered.
Normal feeding was possible on the day after
FIG. 3
Customised soft nasal stent.
surgery. The mean post-operative hospital stay was
6.4 days (Table I).
Nasal stents ( fashioned from size 3.5 endotracheal
tubes) were used in seven patients, and were removed
between one to four weeks after surgery. Second
look endoscopic evaluation was performed under
general anaesthesia two to four weeks post-
operatively (Table I). Of the seven patients with
stenting, five remained patent, while two required
minor debridement of granulation tissue, with a
patent result after the second procedure. Of the
three patients without stenting, two remained
patent, while one required minor debridement of

FIG. 2
(a) Endoscopic view of the septal window, showing two posterior choanae (arrows) and septum (star). (b) Endoscopic view of right
choana (arrow) after removal of atretic plate. (c) Endoscopic view of the septal window, showing two posterior choanae (arrows) and
posterior vomer bone (star).
390
FIG. 4
Endoscopic view taken during second look endoscopy,
showing nasal adhesions in the left posterior choana.
granulation tissue, with a patent result after the
second procedure.
Discussion
Newborn children are obligate nasal breathers. Bilat-
eral congenital choanal atresia is characterised by
respiratory distress at birth, although Wiatrack
observed that respiratory distress can also be
present in cases of unilateral choanal atresia within
the first week of life.4 Pre-operative radiological
assessment, by means of a CT scan, is very important
for the success of surgical treatment; CT scans accu-
rately characterise the nature and thickness of the
atresia, the narrowing of the posterior nasal cavity,
and the thickening of the vomer.1
Surgical management of choanal atresia is contro-
versial. The evolution of optical telescopes and other
instrumentation, and the development of powered
microdebriders with drill attachments, have revolu-
tionised the transnasal approach.4 The transnasal
endoscopic approach has been successfully used for
the treatment of congenital choanal atresia.7,9,10
This technique enables a direct approach to the
atretic area, with the advantage of an angled vision,
good illumination and magnification of the operative
site. The current study modified this technique some-
what by using a transnasal approach under endo-
scopic guidance with a 1208 Hopkins rod telescope,
in order to visualise the posterior choanae from the
nasopharynx.11 In the current series, the operative
technique was similar to that of Stankiewicz, who
reported that resection of the vomer by means of
backbiting forceps, together with drilling out of the
lateral bone, helped to create a large opening,
which was crucial to the success of the procedure.12
Kamel reported using a cruciate incision for exposure
of the mucoperiosteum covering the atretic plate,
H M ELADL
then a diamond burr to create a hole at the level
of the inferomedial portion of the plate (considered
the thinnest and safest area); the neochoana was
then widened laterally at the level of the pterygoid
plate and palatine bone, medially at the septum,
and superiorly at the sphenoid sinus.7
The technique of mucosal preservation and neo-
choana resurfacing, used in the trans-septal approach
to congenital choanal atresia repair, is useful in redu-
cing the post-operative recurrence rate and also the
period of post-operative stenting.13 However, in this
study flap preservation and elevation was technically
inapplicable in this patients age group. Furthermore,
the shortened stenting period and the use of soft
stents diminished the risk of granulation tissue
formation and post-operative infection.8
The benefits and risks of stenting after congenital
choanal atresia repair have been hotly debated.
Stents cause discomfort, localised infection and
ulceration, circumferential scar tissue, and injury to
surrounding tissue.14 Once removed, circumferential
restenosis is common. Indwelling nasal stents are
difficult to manage, easily crust and clog (causing a
functional stenosis or blockage during the period
of stenting), and may migrate or break. However,
regardless of the risks, some authors believe that
stenting is necessary in all cases, while others
believe that stenting is only needed in bilateral
cases. One case series used long-term stenting for
at least three to four weeks, while another used short-
term stenting for less than one week.8,15 Another
study used no stents at all.16 The use of stents is advo-
cated by some and avoided by others.2,17 19 In this
study seven patients with stenting, five remained
patent and two (28.5 per cent) required minor debri-
dement of granulation tissue, with a patent result.
Of three patients without stenting, two remained
patent and one (33.3 per cent) required minor debri-
dement of granulation tissue, with a patent result.
However, one patient with transnasal endoscopic
choanoplasty, who received stenting and drilling,
developed vestibular stenosis and adhesions. In this
series, stenting was preferred in hospitalised cases
treated in humidicribs, and in cases in which exten-
sive mucosal laceration and/or drilling had been
required. The duration of stenting varied from one
to four weeks (mean, 2.7 weeks).
In the new era of miniaturised telescopes, high-
speed protected drill bits and microdebriders,
lateral drilling is eliminated or minimised. Focusing
on careful removal of the posterior septal vomer
segment reduces the need to protect denuded tissue
in order to prevent the development of obstructive
synechiae and exuberant granulation tissue. Schoem
supports the notion that stenting may not be neces-
sary in the transnasal endoscopic repair of both uni-
lateral and bilateral choanal atresia.20 All patients in
this authors study were treated without stents, and
patency results compared favourably with those of
studies using stents.
Transnasal endoscopic repair of congenital
choanal atresia is a safe and effective procedure.
This technique is suitable for neonates with bilateral
congenital choanal atresia.2 The endoscopic
TRANSNASAL ENDOSCOPIC REPAIR OF BILATERAL CONGENITAL CHOANAL ATRESIA
approach allows a shorter hospital stay and fewer
complications, compared with other, more tra-
ditional techniques.8,21,22 In the current series, early
experience with transnasal endoscopic choanal
atresia repair showed a primary success rate of 70
per cent; after second look endoscopic debridement,
the success rate was 100 per cent, without any
major complications. Post-operative failure of the
endoscopic approach may be a result of prolonged
mucosal trauma from stenting, rather than any
deficiency inherent in the surgical technique.20
Factors which appear to favourably affect the
outcome of bilateral congenital choanal atresia
surgery include the absence of associated facial
anomalies, weight at the time of surgery (i.e.
greater than 2.3 kg), stent size (i.e. greater than
3.5 mm) and duration of stenting.14 In the current
study, the most important operative and post-
operative prognostic factors were: avoidance of
excessive mucosal injury; early stent removal; avoid-
ance of unnecessary drilling; second look endoscopic
debridement; and close follow up.
. Transnasal endoscopic repair of bilateral
congenital choanal atresia is a safe and
successful technique in neonates
. The use of powered instrumentation in the
neonatal age group requires appropriate
experience and a sizable drill
. Stenting with a nasal tube for a suitable period
is favourable, especially in hospitalised
patients
New interventions are being introduced to
improve the outcome of endoscopic repair of conge-
nital choanal atresia, including the use of mitomycin
C, potassium-titanyl-phosphate laser and diode laser
(which also manages recurrences effectively).23,24
The use of an optical, CT data based navigation
system has been described for surgical planning and
intra-operative guidance, in order to improve treat-
ment outcome.25 However, in the current series the
use of conventional endoscopic instruments, with a
4-mm endoscope, was effective in completing the
procedure. When indicated, drilling was performed
as precisely as possible using suitably sized burrs,
which were covered completely except for the
cutting head in order to avoid mechanical and
thermal injury to the important surrounding nasal
and cranial structures.
Conclusion
The endoscopic, transnasal, trans-septal approach for
the treatment of bilateral congenital choanal atresia
is a safe, effective, easily applicable procedure for
which extensive prior experience is unnecessary.
In the current study, drilling was employed only in
cases in which the thickness of the atretic plate
required its use in order to achieve complete
391
resection of the atretic plate and formation of ade-
quate neochoanae bilaterally. Flap preservation and
elevation were technically inapplicable in our
patient age group.
Stenting is preferred in the neonatal age group,
especially in cases with extensive mucosal lacerations
and/or drilling, and in hospitalised patients, to avoid
restenosis and reoperation. In this study of seven
patients with stenting, five remained patent, while
two required minor debridement of granulation
tissue, with a patent result thereafter. Of three
patients without stenting, two remained patent,
while one required minor debridement of granulation
tissue, with a patent result thereafter. However,
prolonged stenting should be avoided, in order to
prevent adhesions, vestibular stenosis and infection.
An adequate post-operative follow-up period and
second look endoscopy are crucial to the success of
this type of surgery. Despite the controversies and
debates regarding transnasal endoscopic repair of
bilateral congenital choanal atresia, this technique
is still target-specific, easily applicable and widely
accepted.
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939 45
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