Abstract
Choanal atresia surgery is still a challenge, particularly due to the small dimensions of the surgical field and the possibility of restenosis. The authors present an easy and effective endoscopic surgical technique based on the removal of the posterior third of the bony/cartilaginous nasal septum and the atretic plate, keeping their covering mucosa. At the end of the procedure, the neochoana is covered with the mucosal flaps previously kept from the removed septum. This technique has been used by the authors in over 25 children with 2–16 years follow-up, and no complications or cases of restenosis have been observed. The authors concluded that the cross-over flap surgical technique for choanal atresia repair is a safe, easy, and effective procedure.
Keywords
choanal atresia, choanal stenosis, endoscope, nasal flaps, pediatric
Introduction
The opening of choanal atretic plates can be obtained by various techniques. Despite the substantial available published literature on the treatment modalities of choanal atresia, the optimum technique is not fully established. The choice many times depends on the surgeon’s preference. This chapter describes the cross-over flap technique, which can be employed in unilateral or bilateral choanal atresia.
Surgical endoscopic techniques incorporating mucosal flaps have been shown to minimize the healing reaction, reduce subsequent scarring, and may present less chance of restenosis. Knowledge of the anatomy, good visualization (0-degree endoscope), and utilization of very delicate surgical instruments facilitate an easier, faster, and safer procedure.
Preoperative Considerations
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Choana atresia patients are usually children, often newborns, who present with narrow and small nasal cavities. Every initial step should be directed to preventing unnecessary mucosal trauma and bleeding and to create more operating exposure. Preoperative mucosal topical decongestion is recommended. At least 5 minutes should elapse to allow the vasoconstrictive pledgets to decongest the mucosa.
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To create more space to address the posterior part of the nasal cavity, cover the inferior turbinate with a piece of cotton and, with a delicate Freer elevator, gently move and outfracture it against the nasal lateral wall.
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In order to facilitate tailoring while displacing the posterior septal mucosa and the mucosa of the posterior floor of the nasal cavity, infiltration elevation can be accomplished by using a saline solution.
Preoperative Considerations—Radiographic Considerations
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Review in detail the axial and coronal computed tomography (CT) scans.
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Identify the atretic plate verifying the presence or absence of bone. Not uncommonly, septal deviations coexist, further narrowing the operating field exposure ( Fig. 5.1 ).
Fig. 5.1
(A) Axial computed tomographic (CT) scan showing unilateral choanal atresia (white arrow). (B) Axial CT scan showing bilateral choanal atresia (white arrows).
Pearls
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Adequately delicate instruments are essential to shorten the surgical procedure. In some cases, particularly in newborns, otologic microinstruments may be employed.
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After infiltration, before proceeding to displacing and elevating the mucosa, one may take advantage of the support of the osteocartilaginous septum to make linear incisions on the mucosa, creating the desired shape for the flaps.
Surgical Steps
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The entire surgical procedure can be accomplished with a 0-degree endoscope. If bilateral, choose the side with more space, thus with more operating exposure. If unilateral, begin by making an L -shaped (left side; Fig. 5.2 ) or J -shaped (right side) incision at the posterior part of the nasal septum, vertically on the septum mucosa and obliquely toward the end of the inferior turbinate on the floor of the nasal cavity.
