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Choanal atresia
- 1. Choanal Atresia Dr. Khalid Mahmoud Sayed MBBS (Juba) – DOHNS – MRCSEd (ENT) ENT Registrar( R3) - SMSB Tuesday 04/08/2020 Omdurman Military Hospital ENT Department
- 2. You have received a call from NICU , there is a neonate who has developed respiratory distress and cyanosis immediately after delivery and the paediatric on-call doctor couldn’t pass the NG tube through the nostrils
- 3. 1. What is your advice? Andwhat to preparefor you? 2. What are the bedside clinical tests you will do? 3. What arethe investigations you will request? 4. What do you want the paediatric department to exclude? 5. When to operate ?What are the options?
- 4. NEONATAL NASAL OBSTRUCTION The aetiology of neonatal nasal obstruction is diverse. Congenital Acquired
- 5. NEONATAL NASAL OBSTRUCTION The aetiology of neonatal nasal obstruction is diverse. Congenital causes of nasal obstruction in neonates
- 6. Acquired causes of nasal obstruction in neonates NEONATAL NASAL OBSTRUCTION
- 7. NEONATAL NASAL OBSTRUCTION Generally, neonates are innately obligate nasal breathers for the first few months of life. Therefore Whenever there is nasal obstruction , They will suffer from acute respiratory distress classically with cyclical cyanosis, relieved by crying
- 8. Blue / Pink baby
- 9. NEONATAL NASAL OBSTRUCTION The extent of the respiratory distress will alter related to the neonate’s ability to breathe orally which is dependent on their maturity & neurological development. Thus, an oral airway is often sufficient to relieve the respiratory distress until definitive treatment can be undertaken.
- 10. Flexible nasendoscopy is particularly useful and imaging via CT and MRI is of great value in delineating both nasal and post-nasal lesions. NEONATAL NASAL OBSTRUCTION
- 11. Choanal Atresia This is a rare condition (incidence 1 in 7000 live births) in which there is complete obstruction of the posterior choanae on one or both sides .
- 12. Choanal Atresia
- 16. The four parts of the anatomic deformity include : 1. Narrow nasal cavity. 2. Medialization of the pterygoid plates. 3. Widening of the vomer into a diamond shape. 4. Thining of the atretic plate inferomedially . Choanal Atresia Ref: Rhinology : Diseases of the Nose , Sinuses and Skull base (David W. Kennedy , MD
- 17. Choanal Atresia The blockage is thought to be either bony or membranous in origin BUT in reality a mixed picture is usually seen (70% of cases), with the remainder being purely bony.
- 18. Choanal Atresia The nasobuccal membrane Or The buccopharyngeal membrane. It is believed to be secondary to persistence of
- 19. • Bilateral choanal atresia in neonates presents as acute respiratory distress as neonates are obligate nasal breathers. Classically the neonate will have cyclical cyanosis relieved by crying, and placement of an appropriate sized oral airway resolves the distress. Clinical presentation
- 21. McGovren nipple
- 22. • Unilateral choanal atresia It may present later in life, and can be picked up in neonates when there is an inability to pass a nasogastric tube through one nasal passageway. Clinical presentation
- 23. Neonates with choanal atresia will have difficulty with feeding. Orogastric tube is to be inserted. Clinical presentation
- 24. Diagnosis How would you assess nasal patency at the bedside? 1. Cold spatula test. 2. Airflow detection with a stethoscope. 3. Ability to pass the NG tube (size 8F) 4. Flexible nasoendoscopy.
- 25. Diagnosis
- 26. CT scanning should then be performed to determine the extent and nature of the choanal atresia (with suction clearance of the nose and application of 0.5% ephedrine drops 30 minutes prior to scanning) Diagnosis
- 27. CT scan (axial view) to illustrate the expansion of the posterior vomer and medial side of perpendicular plate of the palatine bone Diagnosis
- 28. Unilateral C.A.
- 29. Unilateral C.A.
- 30. Bilateral C.A.
- 31. What to do immediately after suspicion ? Choanal Atresia In neonates, often a simple oral airway is well tolerated, in which case endotracheal intubation can be avoided.
- 32. Why not to take the neonate immediately to the OT? Choanal Atresia Other associated anomalies should be excluded CHARGE (coloboma, heart defects, atresia choanae, retardation of growth, genital anomalies, ear abnormalities) Apert $ DiGeorge $ Treasure Collin $
- 33. When to operarte? Hengerer and Wein (2003) state that some surgeons advocate “a rule of tens” to guide the timing of surgical intervention. 1. The child must reach 10 weeks of age 2. Weigh 10 pounds. 3. Hb level of 10 g/dl.
- 34. When to operarte? Other surgeons have demonstrated routine success in newborns 48 to 72 hours old and weighing as little as 1900 g Werkhaven J 2003
- 35. The two most common techniques Transnasal Transpalatal Sublabial Transantral Transseptal not as common now, but it can be useful in those neonates with significant craniofacial anomalies where the dimensions of the nose and postnasal space are limited. Definitive treatment
- 36. Transnasal approach Transnasal puncture technigue Transnasal endoscopic technigue Definitive treatment
- 37. Choanal Atresia Transnasal approach • It is a blind classical technique. • It may require repeated revision and dilataion. • Lempert curettes or urethral sounds are used to puncture the atretic bony or membranous layer. • Stent is inserted to prevent restenosis. The Transnasal puncture technique:
- 41. The Transnasal endoscopic approaches Endoscopic technique
- 42. The initial puncture should be directed through the thinnest point of the atretic plate which is usually at the junction of the floor of the nose and posterior part of the nasal septum.
- 44. Avoid excessive bone removal superiorly on the basisphenoid and beware of damaging the greater palatine and sphenopalatine arteries laterally. Also aim to remove the posterior end of the septum over a distance of 7mm
- 45. Transpalatal approach A longer, more invasive procedure
- 47. Transpalatal repair is a technique that provides excellent exposure and has a high success rate but requires more operative time and experienced hands. Possible complications: 1. Palatal fistula. 2. Palatal dysfunction . 3. Maxillofacial growth disturbance. Transpalatal approach
- 48. Many surgeons recommend insertion of stents for 6 weeks Stenting
- 49. Regular suctioning to clear secretions and daily washing with sodium chloride solution results in successful outcomes. Stenting
- 50. Stenting
- 51. Stenting
- 52. Stenting
- 53. HOW TO PREVENT RESTENOSIS ? Prevention of restenosis
- 54. Authors who do not support using stents stress the need for: 1. resection of the posterior aspect of the vomer. 2. early (1 week post repair) re-examination for removal of granulations and dilatation as required. Prevention of restenosis
- 55. Mitomycin C It is thought to act to reduce granulation tissue and fibrosis by inhibiting fibroblasts and angiogenesis leading to its use during stent removal Prevention of restenosis
- 56. A promising new technique , reported for the first time in 2016 , involved the use of mometasone furoate drug – eluting stensts at the conclusion of CA repair. In an effort to reduce trips to the OT , group of surgeons from Cleveland clinic – USA came up with Mometasone furoate drug – eluting stents Prevention of restenosis
- 57. Overall complications: 1. Basisphenoid fracture. 2. Spinal cord injury. 3. Palatal fistula. 4. Alar/columnella necrosis secondary to stent use. Complications
- 58. 35 year old female
- 60. Eight Edition 2018 Scott-Brown’s Otorhinolaryngology Head and Neck Surgery Vol 2 , Chapter 23 , P 251-254 Reference
- 61. That is all the Folk
Editor's Notes
- Imagine yourself sitting in the on call room , kicking back and relaxing , enjoying your cup of coffee and watching or reading something on your lap top computer . And then suddenly out of no where you received a call from a worrying paedia registrar calling you from the NICU concerned about a neonate with respiratory distress and cyanosis with failure to pass suction tube through the nostrils.
- The endoscopic transnasal approaches: One involves using the zero degree endoscope transnasally, with serial dilatations using urethral sounds or using powered instruments such as microdrills. In cases where the nasal cavity is too small to accommodate both instruments a posterior septal window is created and expanded, thus allowing the endoscope through one nostril and the powered instrument through the other nostril, creating a “neo-unichoana” (2) The second transnasal approach involves a 120-degree endoscope being placed in the mouth and positioned in the nasopharynx behind the soft palate to give a view of the postnasal space. Instruments and the drill can then be introduced through the nose.
- Transpalatal approach Some feel that the transpalatal approach allows better visualization and is associated with a decreased risk of restenosis. It is a longer, more invasive procedure and often reserved for the older child. - The Boyle–Davis gag is inserted. - After infiltration, a curved incision is made starting level with the maxillary tuberosities, medial to the greater palatine foramen, coming anteriorly parallel to the alveolar ridge or gingivopalatal magin, if teeth are present. - The mucoperisoteum is elevated to expose the bony margins of the palate. - A diamond burr is then used to remove the bony atretic plate and posterior end of the septum. - The mucoperiosteal flap is then repositioned and sutured. - Transnasal stenting
- The drug is coating the stent and it is slowly released to help pevents the granulation tissue and scaring eventually prevents restenosis.
- 35 – year – old , female patient presenting bilateral nasal obstruction , rhinorhoea, anosmina , and nasal voice since childhood . She denies need for special care at birth. She reports breathing difficulty while being breastfed in childhood. There is no association with other malformations at the physical examinations. She presents nasal fossa full of hyaline secretion at rhinoscopy.
- This abnormality, first described in 1988, is a very rare condition leading to nasal obstruction in the neonate . - It arises due to bony overgrowth of the nasal process of the maxilla . - The piriform aperture is the narrowest part of the nasal airway and so even minimal reduction in diameter here can cause significant problems. -- Symptoms are similar to bilateral choanal atresia occur and epiphora is also often seen secondary to bony involvement of the nasolacrimal ducts. - Diagnosis is suggested by the inability to pass a narrow gauge nasogastric tube 2.2 mm endoscope through the anterior nasal vestibule due to the bony obstruction. - CT scan confirms the diagnosis with an aperture width of less than 11 mm measured on an axial CT at the level of the inferior meatus (in a term neonate). Conservative treatment with nasal steroid drops or decongestants (for up to 2 weeks) and saline irrigation generally recommended as first-line treatment. If there is severe obstruction, respiratory distress or failure to thrive, surgical treatment is warranted. It has also been found that an aperture of less than 5 mm on CT is almost always associated with the need for surgical intervention.