CHOANAL ATRESIA IN CHILDREN

1. MRS. NIBI BENJAMIN
ASST. PROF
CHONAL ATRESIA

3. INTRODUCTION
• Choanal atresia is a congenital disorder where the
back of the nasal passage (choana) is blocked, usually
by abnormal bony or soft tissue (membranous) due
to failed recanalization of the nasal fossae during
fetal development. It was first described
by Roederer in 1755.

4. DEFINITION
• Choanal atresia is a congenital narrowing of the back
of the nasal cavity that causes difficulty breathing.
• Choanal atresia is a blockage in the back of a baby’s
nose that makes it hard to breathe. It’s often seen in
newborns with other birth defects, such as Treacher
Collins syndrome or CHARGE syndrome.

5. INCIDENCE
• It is rare, occurring in approximately 1 in 7,000 live
births,
• seen more often in females than in males

6. CAUSES
• Idiopathy.
• By the 38th day of development, the 2-layer membrane
consisting of nasal and oral epithelia ruptures and forms
the choanae (posterior nares).
• In 2008, Barbero et al suggested that prenatal use of
antithyroid (methimazole, carbimazole) medications was
linked to choanal atresia .
• Choanal atresia is a congenital disorder where the back
of the nasal passage (Choana) is blocked, usually by
abnormal bony or soft tissue (membranous) due to failed
recanalization of the nasal fossae during fetal
development.

7. Cont….
• Embryogenesis
 Persistence of the buccopharyngeal membrane.
 Failure of the bucconasal membrane of Hochstetler
to rupture
 Medial outgrowth of vertical and horizontal process
of the palatine bone
 Abnormal mesodermal forming in the choanal area.

8. cont….
• Prenatal/maternal
 Use of antithyroid medication eas linked to choanal
atresia
 Intake in the highest quartile : vitamin B-12, zinc
niacin
 Intake of the lowest quartile: methionine, vitamin D
 Smoking
 Coffee more than 3 cups a day

9. Types
Unilateral
choanal
atresia
• this is more common of the two & is also a
less threatening, atresia effects just one
side of the nasal passageways.
Bilateral
choanal
atresia
• this can be a life threatening as blockage
affects both passageways, causing extreme
respiratory difficulty. In some cases this
may present with cyanosis while the baby is
feeding, because the oral air passages are
blocked by tongue, further restricting the
airway. The cyanosis may improve when
the baby cries, as oral airway is used at this
time.

10. Sign and symptoms
• Bilateral Atresia: Presents as a newborn,
 Cyanosis,
 Increased respiratory effort,
 Chest retractions,
 Classically cyanosis/saturations improve with crying,
Inability to nurse and breathe at same time.

11. Unilateral:
Present later in life (non-emergent),
 Chronic nasal discharge,
 Nasal obstruction,
 Thick nasal secretions on examination

12. Diagnostic evaluation
• History taking
• Physical examination
• CT Scan
• Sinus x ray.

13. CHARGE SYNDROME
Coloboma( Essentially a hole in one of the structures
of the eye . Affects iris, retina (most common) •
Heart defects(Also PDA, ASD, and VSD)
Atresia of the Choana
Retardation of Growth
Genitourinary hypoplasia
 Ear anomalies

14. ASSESSING FOR CHOANAL ATRESIA
• Select an appropriate size catheter (10-12 French)
• Place the newborn in a supine position on the
examination table.
• Stand at the newborn’s side and use the non dominant
hand to hold the newborns head in the midline position.
• Use the dominant hand to insert the catheter to through
the nasal passage and into the nasopharynx.
• Remove the catheter.
• Perform the test through the opposite nare to evaluate
the patency.

15. Cont….
• Normally the catheter dose not meet resistance and
is able to pass freely to the nasopharynx . Inability to
pass freely to the nasopharynx coupled with
symptoms of snorting respiration feeding problems.

16. Treatment
• The immediate concern is to resuscitate the baby if
necessary.
• An airway may need to be placed so that the infant
can breathe. In some cases, intubation or tracheostomy
may be needed.

17. Cont…
• Treatment can be divided into emergent and elective definitive
categories.
• Bilateral choanal atresia in a neonate is an emergency that is best initially
treated by inserting an oral airway to break the seal formed by the tongue
against the palate.
• This oral airway can be well tolerated for several weeks.
• The method of repair is controversial, with no technique having gained
universal acceptance.
• Bilateral choanal atresia in the newborn requires prompt diagnosis and
airway stabilization.
• An oral airway, McGovern nipple, and intubation are viable options.
• The ideal procedure for choanal atresia restores the normal nasal passage,
prevents damage to growing structures important in facial development, is
technically safe, requires short operative time, and provides short
hospitalization and convalescence.

18. • https://youtu.be/RxBMWHJtEDU
• Surgery video…..

19. Cont…
• The transseptal technique consists of
making a window in the septum
anterior to the atretic plate.
• Transpalatal repair, as seen in the
image below, is a technique that
provides excellent exposure and has a
high success rate but requires more
operative time. The increased blood
loss and the possible occurrence of
palatal fistula, palatal dysfunction, and
maxillofacial growth disturbance are
complications of this procedure.

20. Initial Management
• Oropharyngeal airway.
• Oral intubation in severe cases.
• ENT consultation.
• CT scan.
• Investigate for CHARGE syndrome: genetic consult and
examination for, colaboma of the eyes, ear anomalies,
hearing screening, genital hypoplasia, karyotype and
CDH7 mutation studies, genetic consult, renal ultrasound.
• Surgery, either transnasal or transpalatal to remove the
bone and soft tissue.

21. Pre-Operative
• Nurse prone.
• Secure Guedel airway using brown tape with central
hole cut to diameter of airway.
• Suction airway 2 to 4 hourly as required.
• Remove Guedel airway once per shift and replace
with new airway (disposable, single use).
• Orogastric tube feed only if on enteral feeds, usually
NBM pre op with full intravenous fluids.

22. Post-Operative Care
• Stents require 1 to 2 hourly suction for the first 48 hours to
maintain patency, then pre feed and prn. The size of the
suction catheter used will depend on the size of the stent. It is
very important to check the post op orders carefully for
instructions regarding stent care and suction. Each surgeon
will have their own preference for stent care & management.
• Normal saline is instilled into each stent prior to suction
using a blunt cannula in 0.2 mL increments. The suction
catheter should then be inserted as stated by the ENT surgeon
(usually 6cm), check the post op notes.
• A tape measure cut to the correct length should be taped to
the warmer or cot for visible confirmation of catheter length.

23. • Gentle suction with size 6 suction catheter around the
stents should also be applied.
• Stent patency is checked by
• auscultation with stethoscope and or
• by placing a mirror near the nose and observe misting
on expiration through the stents.
• During hospitalization the infant requires continuous
saturation monitoring.
• Stents are normally left in situ for 6 weeks then
removed by the surgeon and patency observed via
endoscope.

24. Discharge Planning
• Home management is often difficult due to stent blockage.
• Discharge home at ENT discretion. Early discharge encouraged
with home support.
• Parent education including signs of obstruction and
suctioning of stents and
• infant CPR.
• Home suction unit (hired through the PCH ECS).
• Supply of suction catheters, saline and syringes and referral
to PCH ECS for
• ongoing supplies.
• Home monitor.
• Home visiting follow up (HiTH or GP and community nurse).

25. Follow Up
• ENT follow-up to be arranged.

26. • The endoscopic technique (nasal or retropalatal),
with or without powered instrumentation, offers
excellent visualization with great ease in removing
the bony choanae.
• The potential of certain instruments for the
management of choanal atresia was published, such
as the retrograde 110° Sekunda endoscope and
silicone horseshoe-shaped protectors.

27. • Outlook (Prognosis) • Full recovery is expected.
• Complications:
Possible complications include:
• Aspiration while feeding and attempting to breathe
through the mouth
• Respiratory arrest
• Re narrowing of the area after surgery

28. • Nurse should Consider CA in newborn/child with
symptoms of nasal obstruction, so proper physical
examination should be done.
• There is high association of choanal atresia with
other congenital defects, nurse must look for other
defects also.

29. Cont …
• The most crucial initial interventions in a child with
bilateral atresia should focus on stabilizing the
patient. In achieving this, the goal should be finding a
way to oxygenate the patient despite the crippling
upper airway obstruction. For this purpose one may
use a special nipple called a McGovern nipple which
has a large hole in its center for air passage or a
plastic oral airway piece.
• Tracheostomy care must be provided to the child
with tracheostomy.

30. • Input output should be maintained before and after
surgery
• Keep the client warm.
• An intravenous drip is used to hydrate the patient.
• Monitor patients vital signs
• Provide oxygen in case of dyspnea and cyanosis
• All drugs to be administered keeping in mind five
steps of drug administration
• Suction the nasal stents so that they don’t get
blocked up.

31. • Teach parents also how to suction to keep stent
patent for period of three months after surgery till
stent will be removed.
• Nurse must teach how to keep nose clean & how to
give your baby nose drops.
• Make sure clients nasal passage is patent before
starting feed.

32. Assignment
• 10 nursing diagnosis .