Choanal Atresia

Choanal Atresia
Introduction: - Choana is the posterior nasal hole where air passes from nasal cavity into the
nasopharynx. Choanal atresia is a condition that obstructs nasal airways leading to breathing difficulties.
It is rare but more common in females than males.
Choanal atresia manifests when the back of nose does not open or is not able to communicate with the
rest of airway system. It is usually a congenital disorder.
Anatomy: -
Definition: -
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 the
fetal development.
Developmental failure of the nasal cavity to communicate with the nasopharynx.
Epidiomiology: - the incidence of this malformation is between 1:5000 and 1:8000 live births. It is more
often unilateral than bilateral (60%vs 40%) and occurs more frequently in females than in males (2:1).
Etiology: -
Choanal atresia is a developmental abnormality. There is no known specific cause of choanal atresia.
Most believe that choanal atresia occurs when the tissue that separates the nose and mouth area
during fetal development remains after birth.
It is not exactly known why this anomaly occurs but theories and studies suggest that there are multi-
factorial causes ranging from genetic to environmental factors responsible. Maternal use of a medicine
known as methimazole has also been associated with this disorder.
EMBRYOGENESIS THEORY: - buccopharyngeal membrane from foregut ruptures between 5-6 week
of gestation which forms choanae. Failure of rupture of this membrane can cause choanal atresia
Approximately 50-70% of affected infants have other congenital abnormalities. The CHARGE
syndrome is one of the most common anomalies associated with choanal atresia.
C : Coloboma (eye abnormality in which there are missing pieces of tissues in structure that
form the eye )
H : Heart disease
A : Atresia choanae
R : Retarded growth and development
G : Genital anomalies and hypogonadism or both
E : Ear anomalies or deafness or both
Coloboma
Pathophysiology:
Multifactor involvement (embryo genetic theory)
Failure of rupture of buccopharyngeal membrane
Abnormal mesodermal adhesion forming in the choanal area
Choanal atresia
Respiratory arrest
Aspiration
Death
Types: - Choanal atresia can be divided into two types:
Bilateral
This is where two of nasal airways are blocked causing difficulty in breathing. It happens immediately
after birth. Babies usually use their nose to breathe at a very young age, so when their two noses are
obstructed it results in severe breathing.
Unilateral
Only one nasal passage is obstructed and the child can breathe without major troubles. Unilateral Choanal
atresia signs and symptoms are less severe and occur later during infancy and childhood.
Neonatal airway obstruction that leads to respiratory distress may be regarded as a fairly common
problem seen in pediatric ICU setting. Therefore, it is important to speedily delineate the reasons why the
obstruction is occurring so that a timely treatment may be offered.
Bilateral choanal atresia is highly treatable. Even unilateral atresia could result in less severe symptoms
and at times, it could present sometimes later in a child or it may show up in adult’s life. It is paramount
to recognize that, there are other possible causes of obstruction of neonatal airways apart from choanal
atresia.
Others: bony, membranous

Symptoms: - the symptoms of choanal atresia include:
 Cyclic respiratory distress relieved with crying
 Noisy breathing
 Feeding difficulties
 Inability to pass a suction catheter into the nasopharynx
 Nasal drainage
 Symptoms of this condition include very small chin and jaw in some patients because of underdeveloped
facial bones. Poorly developed facial bones in infants will narrow their air passage leading to severe
breathing problems.
Symptoms of Choanal atresia depend on the type of Choanal atresia that patients have (bilateral and
unilateral).
Bilateral Choanal Atresia
Patients with bilateral Choanal atresia experience cyclic respiratory distress and observable chest
retractions. This can only be minimized when the babies start to cry because crying opens their air
passage to allow them breath.
Babies with bilateral Choanal atresia require intubation after delivery to help secure their air passage.
When this is done, the patient can assessed for other developmental anomalies
Unilateral Choanal Atresia
Patients with unilateral Choanal atresia manifest symptoms later during infancy and childhood. The
symptoms include nasal discharge and breathing from the mouth.
Diagnosis
Physical examination : - in which mainly insertion of catheter through one or both nares and any
inability to pass the catheter is noted as a sign of blockage in airways.
Endoscopy/rhinoscopy
The scope is inserted either through mouth or nose which help to view the airways for any abnormalities.
Computed tomography (CT) scan: This is a form of an imaging test that uses X-rays to produce
comprehensive pictures of sinuses.
Treatment
Treatment depends on the severity of the anomaly (unilateral or bilateral), how much it affects the child's
breathing and eating, and what other medical conditions the patient has.
Treatment for mild cases (unilateral)

Sometimes, a child with unilateral choanal atresia has no respiratory distress or significant feeding issues.
These patients may initially be managed with close observation and occasionally supplemental oxygen.
Nasal saline can help to keep the nasal linings healthy and free of discharge. Parents with children
diagnosed with unilateral choanal atresia may wait until the child grows older before deciding to repair
the condition.
Treatment for severe cases (bilateral )

If child is diagnosed with bilateral choanal atresia the condition must be treated as soon as possible.
Surgery should be performed as soon as the patient is stable and has been evaluated for other anomalies.
The major goal of the surgical repair is to open the nasal airway sufficiently, allowing the infant to
breathe on his own . There are several approaches available to accomplish this goal, all of which are
performed in the operating room under general anesthesia.
Transnasal endoscopic approach

Currently, surgeons prefer to treat children with choanal atresia using the transnasal endoscopic
approach. It can be done safely on infants just a few days old. The posterior nasal airway is opened using
a combination of dilators, sinus instruments, ear curettes and drills. In some cases, a piece of endotracheal
tube is placed inside the nasal passage as a stent to maintain the opening while the area heals. The stent
will be removed a few weeks after the surgery at the bedside. Sometimes stenting is not required.
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 reach the area of choanal atresia through
the roof of the mouth.
Aero-digestive evaluation
If infant has choanal atresia, he should be evaluated for both airway and feeding issues. Management of
the airway often requires a combination of supportive, medical and surgical care. Feeding and swallowing
issues are very common in children with these conditions and often need to be addressed by speech
pathologists and GI specialists. Children born with syndromes often need other subspecialty evaluations
(cardiology, ophthalmology, etc.) and benefit greatly from the coordinated care provided in the
multidisciplinary setting of the Center for Pediatric Airway Disorders.
Remedies (Use of Nasal saline)
Patients with Unilateral Choanal atresia show nasal discharge symptoms, which can be relieved by taking
nasal saline.
Saline solution can help to moisturize dry nasal airways, reduce nasal congestions, and keep nasal lining
of the child healthy by controlling inflammation to mucous membrane.
Nursing management: -
 There is high association of choanal atresia with other congenital defects, so nurse must look for
other defects also.
 Nursing care of infant having choanal atresia is directed at keeping the nostrils clean and
preventing upper respiratory infections, if possible.
 Infants, who have bilateral choanal atresia, may need to be gavaged until the defect is corrected.
 Oxygen therapy is given for respiratory distress (by use of special nipple called Mc Govern
nipple, which has a large hole in its center for air passage or a plastic oral airway piece).
 Input and output should be maintained before and after surgery.
 Intravenous drip is used to hydrate the patient.
 Provide oxygen in case of dyspnea and cyanosis.
 Suction the nasal stents so that they don’t get blocked.
 Make sure nasal passage is patent before starting feed.
Prognosis : - when these defects are corrected and adequate nutrition is maintained, the outlook for these
infants is good.

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Choanal Atresia

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Choanal Atresia

Failure of rupture of buccopharyngeal membrane

Abnormal mesodermal adhesion forming in the choanal area

Others: bony, membranous

Treatment for mild cases (unilateral)

Treatment for severe cases (bilateral )

Transnasal endoscopic approach

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