38.1 Introduction

Choanal atresia is the most common congenital nasal abnormality that occurs at a frequency of 1 per 8,000 to 10,000 live births and is more common in females. ^{1 , 2} Bilateral choanal atresia is suspected in a neonate who has cyanotic spells and respiratory distress with temporary resolution during crying. Inability to pass a 6 French suction catheter and visualization of the atretic plates confirm the diagnosis. ³ Cyanosis and desaturations occur which necessitate early intervention. The obliteration of the choanae by the atretic plates may be bony, membranous, or a combination of the two. The most common presentation is a combination of the two which is confirmed with computed tomography (CT). CT scans can also serve as a guide for endoscopic intervention. ⁴ Restenosis after repair and development of granulation tissue requiring subsequent interventions are dreaded sequelae. Various mucosal flaps have been described to aid in coverage of the exposed bone that is present after the choanae are opened. ⁵ A disadvantage of some of these techniques is that the flap is not large enough to withstand manipulation and may fall short in full coverage of the bone. We present our novel endoscopic approach to bilateral choanal atresia repair utilizing nasoseptal flaps as an option to provide well-vascularized, robust tissue around the neo-choanae.

38.2 Surgical Technique

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  The patient is intubated under general anesthesia and turned 130 degrees. The endoscopic instruments and towers are set up across from the surgeon. Oxymetazoline-soaked cottonoids are inserted into the nasal passages. Image guidance is not routinely used. 2.7-mm nasal endoscopes are used during the case.

  
  
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  1% lidocaine with epinephrine is injected sparingly along the septum and atretic plate mucosa. The sphenopalatine artery is also injected at the base of the middle turbinate (▶ Fig. 38.1).

  
  
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  Using a sickle knife, a nasoseptal flap is raised from the mid-septum back posteriorly to be pedicled off of the sphenopalatine artery. The flap is elevated posteriorly until the bony plate is visualized and the membranous portion is entered. The same flap is raised on the contralateral side. If a completely bony atresia is encountered, the flap is elevated to the sphenopalatine foramen and a diamond drill is used to penetrate through the atretic plate at the medial and inferior portion (▶ Fig. 38.2).

  
  
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  The vomer is visualized and the cartilaginous septum is fractured off of the vomer (▶ Fig. 38.3). Cutting instruments are used to remove 1 cm of the posterior cartilaginous septum.

  
  
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  Using a high-speed diamond drill, the vomer is drilled off in order to connect both choanal openings (▶ Fig. 38.4).

  
  
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  Once a large enough choana is created, the left nasoseptal flap is rotated to cover the superior aspect of the nasopharyngeal opening and the right nasoseptal flap is rotated to cover the inferior aspect of the nasopharyngeal opening (▶ Fig. 38.5).

  
  
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  Once the flaps are in the optimal position, a fibrin sealant is applied along the edges of the flap to help prevent collapse (▶ Fig. 38.6).

  
  
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  Stents are not routinely used; however, if there is concern of collapse of the flap or edematous flaps that could create an obstruction, a 2.5 or 3.0 endotracheal tube is fashioned to be placed along one side of the nose through the nasopharynx and is secured to the septum. This is left in place for one week and then removed.

Postoperative care includes saline drops to the bilateral nares twice daily for 3 weeks. Follow-up in clinic is 2 to 3 weeks after surgery when an endoscopic examination is performed. The patient is followed every 3 months for 1 year.