|Year : 2015 | Volume
| Issue : 3 | Page : 259-261
Management of congenital choanal atresia: A pedodontist's role
Fathima Niloofar, Kumaran Parvathy, Balagopal R Varma, Xavier Arun Mamachan
Department of Pedodontics and Preventive Dentistry, Amrita School of Dentistry, Amrita Institute of Medical Sciences and Research Center, Ponnekara, Kochi, Kerala, India
|Date of Web Publication||9-Jul-2015|
Dr. Balagopal R Varma
Department of Pedodontics and Preventive Dentistry, Amrita School of Dentistry, Amrita Institute of Medical Sciences and Research Center, Ponnekara, Kochi - 682 041, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Choanal atresia is a rare cryptic congenital anomaly with developmental failure of the nasal cavity to communicate with the nasophaynx, resulting in a significant physiological and anatomical alteration of the dento-facial complex. It is considered as a life-threatening or lethal congenital malformation in an obligatory nasal breathing neonate. Elective transnasal endoscopic repair is the most preferred and minimally invasive procedure to correct this anomaly. This case report describes the multi-disciplinary team approach that included pedodontists to manage the case of a 6-month-old infant with choanal atresia suffering from breathlessness, feeding difficulty, and disturbed sleep.
Keywords: Choanal atresia, nasal conformer, splint
|How to cite this article:|
Niloofar F, Parvathy K, Varma BR, Mamachan XA. Management of congenital choanal atresia: A pedodontist's role. J Indian Soc Pedod Prev Dent 2015;33:259-61
|How to cite this URL:|
Niloofar F, Parvathy K, Varma BR, Mamachan XA. Management of congenital choanal atresia: A pedodontist's role. J Indian Soc Pedod Prev Dent [serial online] 2015 [cited 2022 Dec 2];33:259-61. Available from: http://www.jisppd.com/text.asp?2015/33/3/259/160407
| Introduction|| |
Choana (plural: Choanae) is derived from the Greek word 'XOÁVN' which means funnel. It is the space between the nasal cavity and the nasopharynx. Choanal atresia (CA) is a congenital anomaly that results in the obstruction of one or both posterior nares. It was first described by Roederer in 1755.  It has an incidence of 1 in 5,000-8,000 births. It occurs twice as often in females as in males, with a preponderance to occur on the right side. Surgery is the only and definitive treatment modality. 
| Case Report|| |
A 6-month-old baby boy had reported to Amrita Hospital with chief complaint of breathing difficulty while breast feeding, disturbed sleep and general irritability since 1-2 months.
Clinical examination revealed a malformed left external nare of the nose, orbital hypertelorism, and severe mouth breathing with constant digit suckling.
A size 6-8" french plastic catheter was inserted to check for any nasal obstruction. A typical solid feel for nasal obstruction was felt around 3-3.5 cm from the alar rim. The child was otherwise healthy and did not show the presence of any other features associated with CHARGE syndrome.
The patient was posted for a nasal endoscopy and computerized tomography (CT) to confirm the diagnosis. The endoscopy revealed that the patient had complete obstruction of both posterior nasal openings with no communication with the nasopharynx, while the CT of the nose and paranasal air sinuses revealed bilateral choanal atresia, of a mixed bony-membranous type [Figure 1].
Patient was taken up for transnasal endoscopic repair by the ENT specialists under general anesthesia. After attaining a patent connection between the nasal cavity and the nasopharynx, hemostasis was achieved. Mitomycin C soaked gauze was applied for 5 minutes. Portex endotracheal tubes were inserted in the right and left nares as stents. An impression of the nose and surrounding structures was then recorded by the pedodontists using an elastomeric impression material. The impression was then removed along with the endotracheal tubes [Figure 2]a-c. Another set of endotracheal tubes were placed temporarily and both tubes were secured at the columella with a 3.0 Ethilon until the splint with nasal conformer was ready to be placed. A cast die was poured to get a positive replica of the nose with the tubes in place at the correct position and angle. A wax spacer of 1-2 mm was placed all over the nose in the cast, except at the borders before fabrication of the splint to avoid undue irritation [Figure 2]d. The acrylic splint was finally fabricated and polished [Figure 2]e.
In the next visit, nasal endoscopy was done to ensure patency and proper healing at the choanae. The nasal endotracheal tubes were placed, then the conformer was placed and secured to the tubes with acrylic [Figure 2]f and it was stabilized using black silk and micropore [Figure 3]a.
The child was monitored on a weekly basis for a month following which the patency of the choanae was re-checked. The correction of the nostril deformity was then performed by the plastic surgeon and the nasal stent was modified well-confined to the nostrils. On an 8-month follow-up, the child was breathing normally and had no postoperative complications [Figure 3]b.
| Discussion|| |
Development of the face and cranial structures occurs during the first 12 weeks of gestation. The development of choanae takes place between the 4 th and 11 th weeks of gestation.  The choana is not a structure, but a space between the nasal cavity and the nasopharynx. Borders of the choana are: Medially, the vomer; laterally, medial pterygoid plate of the sphenoid; inferiorly, horizontal process of the palatine bone; and superiorly, ala of the vomer articulating with the vaginal process of pterygoid plate. 
CA may be due to the persistence of the buccopharyngeal membrane from the fetal foregut, abnormal persistence of mesoderm forming adhesions in the nasochoanal region, abnormal persistence of the nasobuccal membrane of Hochstetter or misdirection during neural crest cell migration. 
Most cases are isolated malformations but association with other congenital deformities can also be present as seen in CHARGE association, a malformative syndrome that includes coloboma, heart disease, CA, retarded development, genital hypoplasia and ear anomalies.  Other anomalies associated with choanal atresia include polydactyly, nasal-auricular and palatal deformities, Crouzon's syndrome, Down syndrome, Treacher-Collins syndrome, DiGeorge syndrome, craniosynostosis, microcephaly, meningocele, meningoencephalocele, facial asymmetry, hypoplasia of the orbit and midface, cleft palate, and hypertelorism. 
CA, particularly a bilateral case, is a life-threatening condition and there should be no delay in the treatment. The only definitive treatment is surgical correction. To ensure maximum efficacy of the correction, placement of stent is just as important. However, the use of mitomycin as an adjunct to the surgical repair of CA as used in this case may offer improved patency with a decreased need for re-stenting, dilatations, and revision surgery in the future. 
The maintenance of patency of the choanae is of concern because of recurrent obstruction due to re-stenosis. This is where pedodontists can extend their expertise beyond the scope of dentistry and be instrumental in saving lives. Most authors agree with the use of a stent, although exact duration is still controversial, ranging from 2 days to 4 months. However, we placed the stents for 5 months post-surgical correction and plastic surgery.
Silicone elastomeric impression materials are known for their easy handling, flowable properties, and ability to reproduce fine details.  Once the endotracheal tubes (stents) were in position at the prepared choanae, a light body putty impression material was introduced by the pedodontist into the nasal cavity that easily flowed and recorded the anatomic details surrounding the tube within the nose. Subsequently, a heavy body silicone impression material was used to record the external anatomy of the nose and surrounding structures. A suitable splint was then fabricated that secured the stent in place and covered the nasal deformity accurately.
Children with craniofacial birth defects are among those children with special health care needs. The health and well-being of these children are dependent upon the clinical expertise of those who serve them. In addition, society as a whole is affected by the quality of their care because the potential of the affected individual for a positive contribution to the community is inevitably influenced by the adequacy of treatment.  Treatment of such children do not end with surgical correction. It requires periodic follow-up with timely intervention and sometimes growth modification so as to achieve the best possible growth pattern. A thorough knowledge of the underlying condition, the growth and development of the child, and appropriate treatment or referral is of paramount importance.
| Acknowledgement|| |
I would like to extend special thanks to the department of ENT surgery, Department of Oral and Maxillofacial Surgery and Plastic surgery for working with us on a unique case such as the management of congenital choanal atresia.
| References|| |
Chandrashekharayya SH, Shandi P, Riyas M. Bilateral choanal atresia in a 11-year-old girl: An unusual presentation. Clin Rhinol An Int J 2012;5:132-4.
Sinha V, Sinha S, Gupta D, More Y, Prajapati B, Bhat V, et al
. Choanal atresia: Surgery by puncture, dilation and stenting. J Rhinol 2006;13:124-7.
Thiagarajan B. Choanal atresia. ENT Scholar 2013;2:1-8.
Blasberg B, Stool S, Oka S. Choanal atresia - A cryptic congenital anomaly. Cleft Palate J 1975;12:409-16.
Kaprana A, Karatzanis A, Velegrakis S, Chatzakis N, Papadakis I, Velegrakis G. Endonasal management of choanal atresia with the use of a surgical microscope. Otorhinolaryngol Head Neck Surg 2010;42:20-4.
Saleem AF, Ariff S, Aslam N, Ikram M. Congenital bilateral choanal atresia. J Pak Med Assoc 2010;60:869-72.
Bhandary SK, Bhat V, Shenoy SM. Choanal atresia- A clinical study and review of literature. Nitte Univ J Health Sci 2012;2:37-42.
Marković D, Puškar1 T, Hadžistević MM, Blažić PL, Hodolič J. The dimensional stability of elastomeric dental impression materials. Contemp Mater 2012;3:105-10.
Parameters for the evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. American Cleft Palate-Craniofacial Association. March, 1993. Cleft Palate-Craniofacial J 1993;30:S1-16.
[Figure 1], [Figure 2], [Figure 3]