The document discusses the case of a newborn male patient presenting with breathing difficulty and cyanotic spells since birth. Examination revealed bilateral choanal atresia, which was confirmed by CT scan. The patient underwent transnasal endoscopic surgery to repair the atresia. Post-operatively he was cared for in the neonatal ICU and recovered well. The document also provides background information on choanal atresia including epidemiology, etiology, pathogenesis, clinical presentation, diagnosis, management including surgical techniques, and post-operative care.

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2. DR TARIQUE AHMED MAKA
REGISTRAR ENT
MANAGEMENT OF BILATERAL
CHOANAL ATRESIA

3. MANAGEMENT OF BILATERAL
CHOANAL ATRESIA
 SEQUENCE OF CPC
 Case presentation
 Literature review
 Statistical data
 Conclusion
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4. 4
CASE PRESENTATION
MANAGEMENT OF BILATERAL
CHOANAL ATRESIA

5. PATIENT PROFILE
 Name XYZ
 Age Newborn
 Gender Male
 Residence Rawalpindi
 Date of admission 25.10.12
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6. PRESENTING COMPLAINTS
 Difficulty in breathing
 Cyanotic spells
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since birth

7. HISTORY OF PRESENT ILLNES
 Difficulty in breathing
 Cyanotic spells
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8. ANTENATAL HISTORY
 25yrs
 PG
 Planned pregnancy
 Regular antenatal visits
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9. NATAL HISTORY
 39 weeks pregnancy
 Spontaneous labour
 Vertex presentation
 Emergency LSCS
 Liquor clear
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10. POSTNATAL HISTORY
 Baby cried immediately
 APGAR score 8/10 ,9/10
 Admitted in NICU
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11. FAMILY HISTORY
 Non consanguinous
 No family history of any
 Neonatal death
 Congenital anomalies
 Chronic illness in family
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12.  Medical History
 Surgical History
 Drug History
 Socio economic history
Unremarkable
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13.  Heart rate 150 beats/min
 Respiratory rate 66/min
 Weight 2.1 kg
 OFC 31.4cm
PHYSICAL EXAMINATION
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14.  Cyanotic spells and breathing
difficulty with suprasternal,
intercostal,and subcostal recessions
 Relieved on crying and mouth
opening
 No misting of metallic tongue plate
 Inability to pass nasal catheter
PHYSICAL EXAMINATION
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15.  No mass/cyst
 No laryngeal air way obstruction
 Vocal cords equally mobile
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DIRECT LARYNGOSCOPY

16.  GIT system
 Central Nervous system
 Cardiovascular System
Unremarkable
16
SYSTEMIC EXAMINATION

17. Bilateral choanal atresia
Laryngomalacia
Vocal cord palsy
Haemangioma
DIFFERENTIAL DIAGNOSIS
17
Subglotic stenosis

18. Test Result Reference
range
Haemoglobin 17.4g/dL 16-20g/dL
Total Leucocyte Count 19.8x 10^9 /L 4.0-10.0x10^9 /L
HCT 0.528
MCV 101.3fl
MCH 33.4pg
MCHC 33.0g/l
Platelet Count 369 x 10 9 /L 150-400x10^9 /L
HAEMATOLOGICAL INVESTIGATION
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19. Test Result Reference
range
Blood Sugar Random 89mg/dl
Blood Group A+ve -
Anti HCV Antibody -ve By Elisa Method
Hepatitis B surface
antigen
-ve By Elisa Method
HAEMATOLOGICAL INVESTIGATIONS
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20. TEST PATIENT CONTROL
PT 14 14
PTTK 32 32
HAEMATOLOGICAL INVESTIGATIONS
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21. CT SCAN
 CT scan paranasal
sinus with contrast for
delineation of
Choanal atresia
confirmed the
diagnosis of bilateral
choanal atresia of
bony type
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22. CT SCAN
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23. CT SCAN
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24. Case Summary
 Newborn
 Breathing difficulty and cyanotic spells
 Relieved by crying
 Inability to pass nasal catheter
 Bilateral choanal atresia on CT scan
CASE SUMMARY
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25. DIAGNOSIS
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BILATERAL CHOANAL
ATRESIA

26. Case Summary
Guedel’s airway
placed in mouth and
secured to maintain
airway
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EMERGENCY MANAGEMENT

27. Case Summary
 Inj vit K 1g i/m stat
 Inj clefron 100mg i.v BD
 inj amikin15 mg i.v BD
MANAGEMENT
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28.  Parents explained about the nature of condition
in detail
 Surgery planned through Transnasal approach
 Pre-anaesthesia assessment done
 Written informed consent obtained
29
SURGERY

29. 30
OPERATIVE STEPS

30. 31
SURGERY

31. 32
SURGERY

32. 33
SURGERY

33. 34
SURGERY

34. 35
SURGERY

35. 36
SURGERY

36. 37
SURGERY

37. 38
SURGERY

38. 39
SURGERY

39. 40
SURGERY

40. 41
SURGERY

41. 42
SURGERY

42. 43
SURGERY

43. 44
SURGERY

44. 45
SURGERY

45. 46
SURGERY

46.  Nursed at neonatal ICU for 2 days
 Administered
 Inj augmentin
 Inj dexamethasone
 I/V fluids as advised by Pediatrician
 Regular suction of tubes to prevent blockage
47
POST OP CARE

47. 48
POST OP CARE

48. 49
POST OP CARE

49. 50
FOLLOW UP

50. 51
PRESENT STATUS

51. LITERATURE
REVIEW
52
PART II
LITERATURE REVIEW

52. 1755,
Roederer
18th Century
First recorded
case
19th Century
First successful
surgery
HISTORY OF
CHOANAL ATRESIA
53
1854, Emmert

53. BRIEF ANATOMY OF CHOANAE
• Medially: Free posterior edge of vomer
• Laterally: Medial pterygoid lamina
• Roof : Body of sphenoid
• Floor : Free posterior edge of horizontal plate
54

54.  Choanal atresia is a rare life
threatening congenital anomaly.
 Persistence of nasobuccal
membrane.
 Unilateral or bilateral
CHOANAL ATRESIA
55
Haddad J Jr. Congenital disorders of the nose. In: Kliegman RM, Behrman RE, Jenson
HB, Stanton BF, eds.

55. EPIDEMIOLOGY
 1 in 5,000 to 7,000 live births
 Females > males
 Atresias are bony,membranous or mixed
 Unilateral to bilateral cases is 2:1
 Unilateral presentation predominantly affects the
right nasal aperture
56
Hengerer AS, Brickman TM, Jeyakumar A. Choanal atresia: embryologic analysis and evolution
of treatment, a 30-year experience. Laryngoscope. May 2008;118(5):862-866.

56. ETIOLOGY
 Cause is unknown
 Smoking
 Coffee consumption
 High zinc and B-12 intake
 Prenatal use of antithyroid
(methimazole, carbimazole) medications
57
Barbero P, Valdez R, Rodríguez H, et al. Choanal atresia associated with maternal
hyperthyroidism treated with methimazole: a case-control study. Am J Med Genet A. Sep 15
2008;146A(18):2390-5.

57. PATHOGENESIS
58
 Persistence of the buccopharyngeal membrane
 Failure of the bucconasal membrane to rupture
 Medial outgrowth of vertical and horizontal processes
of the palatine bone
 Abnormal mesodermal adhesions forming in the
choanal area
Assanasen P, Metheetrairut C. Choanal atresia. J Med Assoc Thai. May 2009;92(5):699-706.

58. ASSOCIATED CONDITIONS
59
 Coloboma
 Heart defects
 Atresia choanae
 Retardation of growth
 Genital anomalies
 Ear abnormalities
(CHARGE)
Asher BF et al. Airway Complications in CHARGE Association. Arch Otolaryngol Head Neck
Surg. May 1990;116:594-595.

59. CLINICAL PRESENTATION
60
Bilateral choanal atresia is a
life threatening condition:
 Complete nasal obstruction
 Respiratory obstruction and
cyanosis is cyclic
 Inability to feed and breath at the
same time.
Sadek SA (January 1998). "Congenital bilateral choanal atresia" Int. J. Pediatr.
Otorhinolaryngol. 42 (3): 247–56. doi:10.1016/S0165-5876(97)

60. CLINICAL EXAMINATION
Pashley NRT. Choanal Atresia,(Chapter33). Clinical Pediatric Otolaryngology. St. Louis,
MO: C.V. Mosby Company; 1986 . 61v
 Failure to pass a # 6 to 8 french plastic catheter
through the nares
 Placing wisps of cotton in front of the nares and
absence of nasal movement of air.
 Absence of fog on a mirror when placed under the
nostrils

61. RECOMMENDED TESTS
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 CT scan
 Endoscopy of the nose
 Cardiac echo
 Renal ultrasound
 Rhinogram

62. DIAGNOSTIC TEST
CT with intranasal
contrast that shows
narrowing of the
posterior nasal cavity
at the level of the
pterygoid plate is the
confirmatory test
Benjamin B. Evaluation of Choanal Atresia. Ann Otol Rhinol Laryngol. 94:429-432.63

63. 64
MANAGEMENT OF
CHOANAL ATRESIA

64. MANAGEMENT
65
MANAGEMENT OF
CHOANAL
ATRESIA
EMERGENCY/
INITIAL
MANAGEMENT
SURGICAL
MANAGEMENT

65. A. Airway
 oral airway of some sort must be
implemented very early
B. Feeding
 Delayed surgical correction;
orogastric tube
INITIAL MANAGEMENT
Hengerer AS et al. Choanal Atresia: A New Embryologic Theory and Its Influence on Surgical
Management. Laryngoscope. August 1982;92:913-921.

66. A. Transnasal blind puncture
B. Transnasal endoscopic Approach
C. Transpalatal Approach
SURGICAL MANAGEMENT
67
Richardson MA and Osguthorpe JD. Choanal Atresia. Current Therapy in
Otolaryngology-Head and Neck Surgery. St. Louis, MO: B.C. Decker Inc.; 1990

67. TECHNIQUE
 120 degree endoscope placed in mouth and positioned
in nasopharynx
 Atretic plate perforated
 Bilateral nasal stents placed
 Philtrum is protected
 Stents left in situ for 6 weeks
TRANSNASAL ENDOSCOPIC APPROACH
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68.  Advantages:
a. This approach is faster, easier, and less problematic.
b. Blood loss is minimal.
c. Excellent for children of all ages.
d. Allows for earlier repair in properly selected patients
and may avoid restenosis.
e. The child can breast feed immediately post op.
f. If no additional problems then the child can be
discharged on the 3rd or 4th post op day.
TRANSNASAL ENDOSCOPIC APPROACH
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69. DISADVANTAGES AND COMPLICATIONS:
a. Longer stenting time post op.
b. Can not be done on patients with multiple nasal and
nasopharyngeal anomalies.
TRANSNASAL ENDOSCOPIC APPROACH
Josephson GD, Vickery CL, Giles WC, Gross CW. Transnasal endoscopic repair of
congenital choanal atresia: long-term results. Arch Otolaryngol Head Neck Surg. May
1998;124(5):537-40.

70. TRANSPALATAL APPROACH
 In rare circumstances where the
skull base is abnormally developed
(other craniofacial anomalies are
present), the surgeon may need to
use a transpalatal approach to
access the area of choanal atresia
through the roof of the mouth.
SURGICAL MANAGEMENT
Zeitouni AG, Shapiro RS. Congenital anomalies of the nose and anterior skull base. In: Tewfik TL,
Der Kaloustian VM, eds. Congenital Anomalies of the Ear, Nose, and Throat. New York, NY: Oxford
University Press; 1997:189-200

71. A. STENTING:
1. Secure them in place for a approximate
period of 4-8 weeks
B. WOUND CARE:
1. The parents must be taught to maintain the
stents with frequent suction and a saline-
moistened pipe cleaner or cotton applicator 3
to 6 times per day.
2. Antibiotics and decongestant 72
POST OPERATIVE CARE

72. C. FOLLOW UP:
1. Every 2 weeks or more frequently if needed while
the stents are in place.
2. Once the stents are removed, the patients are seen
weekly for the first 2-3 weeks.
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POST OPERATIVE CARE

73. RELEVANT
STATISTICAL DATA
74

74. RELEVANT DATA
 Total Cases of CHOANAL ATRESIA = 4
 Duration 1st JANUARY, 2011 to 1st JANUARY, 2013
 Unilateral = 3
 Bilateral = 1 75
Bilateral
Unilateral

75. RELEVANT DATA
The male female ratio was 1 : 3
76
0
0.5
1
1.5
2
2.5
3
3.5
male female

76.  Bilateral choanal atresia is a rare life
threatening condition which presents with
stridor and acute respiratory distress at
birth
 Only immediate clinical evaluation and
efficient management is life saving
CONCLUSION
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77. Thank You
78