Surgical Technique

Bilateral Atresia

If the obstruction is due to soft tissue then it is possible to palpate it and see with an endoscope where it should be perforated and opened up. If there is a complete bony plate, it is important not to lose your way, and most surgeons initially find it safer to place their finger in the nasopharynx and aim the drill at it. It is now possible to visualize the posterior aspect of the septum and the back of the inferior turbinate and use these landmarks to drill through the atretic plate under endoscopic control. Having made an opening by whatever means, it can then be widened endoscopi-cally in a controlled way (Fig. 14.51 a, b). The primary goals of surgery are to provide a wide airway with as little collateral mucosal damage as possible (Fig. 14.52 a-c). Conventionally, a wide stent has been inserted, but this causes pressure necrosis of any viable mucosa and it appears to encourage fibrosis and stenosis once the stent is removed. A loose stent is better, and the strut joining the two cylindrical stents should not press on the columella. An endotracheal tube that has a section cut out of it to leave one flat connecting piece between the two tubes can lightly rest on the columella with a loose circumferential tie placed through the tubes and around the nasopharynx to retain it.

Unilateral Atresia

In unilateral choanal atresia a simple technique that allows aeration and restoration of mucociliary clearance of the blocked airway relies on removing the vomer. This can be done endoscopically by incising through all layers just behind the quadrilateral cartilage and then removing all layers of the vomer with through-cutting forceps (Cumberworth et al., 1995). The septal branch of the sphenopalatine artery usually needs to be cauterized. No stent is required (Fig. 14.53 a-c).

Choanal Atresia

Fig. 14.51 a Preoperative and b postoperative views of left choanal atresia in a neonate. The changes were the same on both sides.

Fig. 14.51 a Preoperative and b postoperative views of left choanal atresia in a neonate. The changes were the same on both sides.

Choanal Atresia Surgery

Fig. 14.52 a Axial CT scan showing bilateral choanal atresia. b The right nasal cavity showing that the back of the vomer has been removed as well as the floor of the sphenoid sinus. c Postoperative view into the sphenoid and into the oropharynx below.

Fig. 14.52 a Axial CT scan showing bilateral choanal atresia. b The right nasal cavity showing that the back of the vomer has been removed as well as the floor of the sphenoid sinus. c Postoperative view into the sphenoid and into the oropharynx below.

Choanal Atresia Endoscopic View

Fig. 14.53 a Mucus stagnation in unilateral choanal atresia. b Axial CT scan showing a left unilateral membranous choanal atresia. c Postoperative endoscopic view showing a patent posterior choana 8 years later.

Fig. 14.53 a Mucus stagnation in unilateral choanal atresia. b Axial CT scan showing a left unilateral membranous choanal atresia. c Postoperative endoscopic view showing a patent posterior choana 8 years later.

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