Endoscopic Laser Surgery of Choanal Atresia – The New Retropalatine Approach

Abstract

Summary Posterior choanal atresia (PCA) is an uncommon congenital anomaly which consists of an anatomical malformation and a bony and/or membraneous diaphragm that separates the nasal cavity from the nasopharynx. Therefore nasal breathing as well as mucus discharge are impeded. If present bilaterally it has life threatening consequences. The goal of treatment in neonates and infants is to safely open and maintain the patency of the nasal choana without damaging surrounding normal anatomical structures or affecting future growth patterns of the palate and the posterior nasal cavity – paranasal sinuses complex. In every case an unimpeded nasal breathing and mucus drainage towards the deeper aero-digestive tract must be achieved. The therapeutical strategy is strictly surgical. Traditional surgical approaches are the transnasal, the transseptal, the transpalatine and – but seldom – the transvestibular-transmaxillary route. All these surgical approaches have one in common: There is either a quite large and tissue compromising access with rather good exposition of PCA and a high risk for intra- and postoperative complications, or a bad access and visibility of the PCA due to a very limited tissue sparing route. Neither intraoperative microscopy nor endoscopy could completely help out of this dilemma. We present with this paper the new transoral retropalatine approach for endoscopic laser surgery of PCA . We report on our first five patients with an age of 0 to 9 years all treated from 1998 to 2001 by this approach with fiber guided diode laser surgery (wavelength: 940 nm) and an endoscopic laser application sheath which derives from our concept of Functional Endoscopic Endonasal Laser Surgery (FEELS). Stenting of the re-opened choana with an individually customized U-shaped nasopharyngeally open silicone tube, which was transseptally fixed and hidden in the nasal cavity, was performed for 6 weeks. The outcome and follow up showed excellent results concerning wound healing; no complications, no re-stenosis and no evidence for growth changes in the surrounding choanal and palatal anatomy were encoutered.