Posterior Choanae Research Articles

Correction of congenital choanal atresia in children and adults.

AbstractCongenital choanal atresia occurs once in 7,000 to 8,000 births. The atresia is bony in most cases, more common in females, and more often right‐sided in patients with unilateral atresia. The incidence of associated congenital anomalies is relatively high. During the 25‐year period 1951 to 1976, 36 patients with choanal atresia were treated at the Mayo Clinic; 19 were females and 17 were males. The ages at the time of surgical treatment ranged from 1 day to 58 years. Twenty‐four patients had unilateral obstruction, and 12 had bilateral obstruction. Six patients (17%) had other associated congenital anomalies. Intranasal perforation and transpalatal correction were most commonly employed in children who were less than 8 years old, and transseptal correction was most often carried out in older patients. The nature of the stenting material and the age of the patient have important bearing on the outcome of the operation.Congenital choanal atresia is a bony or membranous closure of the posterior choana. It may be complete or incomplete and unilateral or bilateral. We wish to report on a series of children and adults who were treated for congenital choanal atresia at the Mayo Clinic during a 25‐year period and to describe a transseptal method of correction that may be performed concurrently with septal reconstruction and external nasal surgery in older children and adults.

Treatment of acquired choanal atresia.

A method of correcting cicatricial obliteration of the posterior choanae and upper part of nasopharynx utilizing the sphenoid sinus cavity for (1) enlargement of the vertical diameter of choanae, (2) formation of a new roof of the nasopharynx, or even, (3) creation of a bypass of the posterior nares has been clinically helpful and has produced satisfactory results.

Choanal Atresia and/or Cardiac Disease

There are few catastrophies in the neonatal period which present so dramatically and uniquely, yet are remedied so quickly and simply, as congenital atresia of the posterior choanae. The lesion, once thought to be rare, is being detected more frequently and probably accounts for 0.5% per thousand major congenital anomalies. Unfortunately, even with early accurate diagnosis, many of these infants do not survive associated organic defets.1-4 Over 50% of the patients with bilateral choanal atresia studied at the Children's Hospital of Philadelphia between January 1960 and January 1967 had associated life-threatening congenital anomalies, especially cardiac disorders. One might speculate that maldevelopment in both organ systems occurs during the sixth to eighth week of fetal development, although no chromosomal aberration, chemical agent, or physical agent has been correlated.

Congenital atresia of the posterior choanae

A review of the literature of congenital atresia of the posterior choanae is made and a case report of unilateral type in a boy of 18 years is presented. Operative technique best suited for such a case is described.

Posterior choanae and choanal polyps.

Posterior choanae and choanal polyps.

Nasopharyngeal Carcinoma: A Simplified Technic of Individualized Intracavitary Therapy for Superficially Recurrent or Persistent Disease in the Conscious Patient

Various methods for individualizing intracavitary radiotherapy by casting a mold of the nasopharynx have been discussed in the literature. Suit et al. (4) discuss a technic requiring rather prolonged general anesthesia. That article also furnishes an excellent historical review covering the evolution of methods of intracavitary nasopharyngeal radiotherapy. Boyer (1) presents a method which utilizes a much shorter general anesthesia time and is particularly well suited to a patient in the pediatric age group (i.e. sarcoma) or to one who will first undergo biopsy of a suspicious recurrent lesion, employing the same general anesthesia. Not all centers rely on frozen sections, however, especially when there has been prior radiotherapy, to establish a group of patients in whom the construction of a nasopharyngeal mold is indicated. We prefer to await the permanent sections and to construct the individualized nasopharyngeal mold at another sitting. One is also occasionally faced with the patient who comes to the radiotherapy clinic with an adequate biopsy recently performed elsewhere. We wish to report an extension of the method described by Boyer, that makes his method applicable to the fully conscious patient. Actually, by varying the loading distribution, one can effectively treat a relatively local area of the nasopharynx or the entire surface, as the clinical problem dictates. Description of Method With the use of topical anesthesia with viscous Xylocaine instilled transnasally via medium-bore catheters, preceded by topical aerosol Xylocaine (2 per cent) anesthesia, the Silastic alginate paste (Coe Laboratories, Inc.) is quickly packed into the nasopharynx to fill the posterior choanae and extend into the posterior nares. The packing material is inserted to a level just above the reflection of the soft palate. The technic of preparing and manipulating the alginate during the procedure is simple, as one need only add water to the dry powder and allow the resultant thick paste to assume a soft rubbery consistency (which takes place in a few minutes). We would stress the importance of speed of insertion and keeping the mold moist during manipulation. When one employs alginate, great care must be taken to dislodge the mold quickly and deftly to maintain it intact. Transnasal catheters and flat spatulas are helpful. With adequate topical anesthesia any problems associated with removal would exist, of course, whether or not the patient was asleep. Following removal, the mold is inspected, and usually an accurate surface imprint of the recurrent (persistent) tumor can be discerned. The use of Silastic materials to evaluate the regression or response of nasopharyngeal neoplasms to external beam therapy has been described by Cook and Mercado (2), and the findings with this method are quite similar. A clear acrylic mold (tissue-equivalent material) is then constructed from our in vivo model, and anchoring sutures are placed in holes drilled through the plastic.

An adenoid-biting forceps.

A routine close examination of the adenoid during a tonsillectomy and adenoidectomy has impressed upon me the need for an instrument to remove more adequately remnants of adenoid tissue in this area. The presence of pieces of adenoid tissue in the higher area of the nasopharynx, and even into the posterior choanae, following an adenoidectomy has been nearly a routine finding, confirmed by the constant use of a large laryngeal mirror to recheck the adenoid area during surgery. The instruments available did not give me ease of access to this area. The adenoid-biting forceps has been devised for this purpose. It presents a right-angled biting surface, allowing an additional ½ in. (1 cm.) and more of bite into the region of the choanae and fossae of Rosenmuller. Use of this instrument has given a cleaner adenoid bed at the termination of the adenoidectomy. The adenoid-biting forceps is also

UNILATERAL CONGENITAL INCOMPLETE BONY ATRESIA OF THE POSTERIOR NARES (CHOANAE) Technique for Its Correction

ATRESIA of the posterior nares is a congenital obstruction in the nose, situated at the junction of the hard and soft palate. This atresia completely closes off the posterior choana, preventing on that side the passage of air from the nose into the nasopharynx. There are two definite types, complete bony atresia and incomplete bony atresia. It is possible that a third type exists, which I call partial atresia. A complete bony atresia is one in which the atresia is completely bony. An incomplete bony atresia is one in which the atresia, although complete in form, is partly bony and partly membranous in structure. I consider a partial atresia one which has one or more openings in it and which may be completely or incompletely bony. The experience gained in developing the technique for the correction of an atresia of the posterior nares is based on two cases. One case

Paradoxical expiratory ballooning of the hypopharynx in siblings with bilateral choanal atresia.

Atresia of the posterior choanae is a relatively rare congenital anomaly, cases of which may be classified as unilateral or bilateral, complete or incomplete, and membranous, osseous, or mixed. The majority of patients with this disorder are said to have osseous obstruction, with thickness of bone varying from a few millimeters to more than 12 millimeters. The central portion of the obstruction is usually thinner and may be membranous. To explain the abnormality on a developmental basis, persistence of the bucconasal membrane is postulated. This structure usually ruptures in the thirty-five-day to thirty-eight-day embryo, forming the primitive choanae. Persistence of the portion of the buccopharyngeal membrane above the palate is suggested as a secondary cause, while a third possibility offered is overgrowth of the vertical and horizontal palatal processes. A familial incidence has been reported (1–s6). Roentgen studies of choanal atresia usually emphasize demonstration of the obstruction by a contrast medium in the nasal cavity (7) and the finding of abnormal bony structures (Fig. 1). The authors, however, recently had an opportunity of making some interesting fluoroscopic observations on two brothers with complete bilateral choanal atresia, in whom the paradoxical distention of the hypopharynx during expiration was so striking that it was deemed worthy of report. The embryological aspects of these cases are to be discussed elsewhere by our colleagues in otolaryngology (8). In the normal infant and in early childhood, as pointed out by Pancoast (9), “during the inspiratory phase the pharynx is often filled with air and the post-pharyngeal space is comparatively narrow. During expiration the space may be much wider, when the pharyngeal space is completely or partially collapsed.” Hay (10) also emphasized the presence of air in the pharynx in the inspiratory phase, and his excellent illustrations demonstrate the relative distention of the hypopharynx during inspiration, in contrast to its collapse during expiration. The disturbance of the mechanics of respiration in our cases of complete bilateral atresia was productive of a striking reversal of these normal findings. Case I: The patient was a male infant born at term Aug. 28, 1950, with normal vaginal delivery after a short labor. He cried soon after birth, but in a few minutes stopped breathing and an airway was introduced. His hands and feet were cyanotic at that time. He experienced considerable difficulty in eating and was kept in an oxygen tent most of the time. A diagnosis of posterior choanal atresia was made, and the possibility of an associated congenital anomaly of the heart was also considered.

NASAL PACKING: The Rubber Pneumatic Pack

An improved model of the rubber pneumatic nasal pack previously described1has been developed after 15 yr. of experience with nasal packing methods. The earlier model of the nasal pack (Fig. 1) was unavailable during World War II owing to the rubber shortage, and the present change was felt advisable when production was resumed. The old model of the pack without the breathing tube was found to have several minor disadvantages. In the case of a very large nasal fossa, the flat pack assumed an ovoid cross section on adequate inflation which allowed the pack to slip through the posterior choana like an olive-tipped bougie. In one case of postoperative polypectomy with considerable turbinate atrophy the inflated pack, fastened to the cheek by adhesive tape, was swallowed by a senile patient, causing considerable apprehension until the pack appeared in the patient's stools within 24 hr. (still inflated). The small

CONGENITAL ATRESIA OF THE POSTERIOR NARES: DESCRIPTIONS OF TECHNICS USED IN MEETING THE OPERATIVE DIFFICULTIES AND REPORT OF A CASE

Atresia of the posterior nares is a condition characterized by closure of one or both posterior choanae. The obstructing partition may be either complete or incomplete and may be membranous, membrano-osseous or osseous. It is not atresia in the true sense of the word in that it probably occurs because of the failure of normally occurring embryonic structures to disappear. Choanal atresia, although a rare anomaly, has been described in the literature for over a hundred years. It was first portrayed in 1829 by Otto,¹who observed it at autopsy. In 1853, Emmert²diagnosed and successfully operated on it in a 7 year old boy. In 1859, Luschka³found it in a newborn dead child. In 1876, Betts⁴reported a case in which it was discovered shortly after birth. Hubbel,⁵in 1886, reviewed the literature and listed 17 recorded cases of congenital choanal atresia to which he added I. Clarke,⁶

Spheno-Occipital Chordoma of Unusual Radiosensitivity

Spheno-occipital chordoma is itself an unusual tumor, and one which is radiosensitive is a rarity. As a tumor of the notochord which itself is a derivative of the entoderm, the chordoma would not be expected to be radiosensitive. On the other hand, since the notochord becomes, in its development, more closely identified with derivatives of the mesoderm and may take on some of the features of these supportive elements, it is not strange that an occasional chordoma may be radiosensitive, for most of the radiosensitive cells and tissues are mesodermal in origin. Case Report A 71-year-old white male presented himself in January 1941 with persistent severe headache, total blindness of one eye, and failing vision in the other. Because of the poor visual acuity in the eye in which sight remained (20/200) the extent of the visual field could not be determined accurately although it was thought on gross perimetric estimation to be constricted. The nerve head in this eye was swollen and pale. X-ray examination of the skull (Fig. 1) showed complete, symmetrical destruction of the pituitary fossa, the roof of the sphenoid sinus, and the adjacent portions of the sphenoid bone. A tentative diagnosis of pituitary tumor was made, based on the clinical findings and to a considerable degree upon the anatomic character of the growth as demonstrated by the x-ray examination. The patient was considered a poor surgical risk and x-ray irradiation was undertaken on the presumption that the tumor might be a chromophobe adenoma or an adenocarcinoma of radiosensitive type. A total tumor dose of 1,300 roentgens (0.9 mm. copper half-value layer) was given in twenty-nine days. One month after the completion of this treatment the headaches had ceased entirely and visual acuity in the one eye had been restored to 20/40; the other remained blind. In January 1942, one year later, the patient returned with complete nasal obstruction and headache of lesser severity. Vision in the eye in which sight remained had not failed. Examination showed that the nasopharynx was filled with tumor, and roentgenograms revealed the presence of a large mass continuous with that in the middle cranial fossa through an extensive bony defect in the central part of the floor of the fossa. The tumor completely occluded the posterior choanae of the nares and rested on and depressed the uvula. The occlu- sion of the nasopharyngeal airway was well shown on the roentgenogram (Fig. 2). The presence of accessible tumor in the nasopharynx made biopsy possible and histologic study-showed typical chordoma (Fig. 4). The initial radiosensitivity of the tumor having been very impressive, further radiation of the same quality was administered. A total tumor dose of 1,750 roentgens was given in fourteen days. This larger dose was given only for the reason that the patient tolerated this series of radiation treatments better than he had tolerated the first.

OSSEOUS ATRESIA OF THE POSTERIOR CHOANAE

A simple and yet comprehensive classification of atresia of the posterior choanae may be made on the basis of the histology and embryology of the atresia, as follows: 1. Membranous: (a) Lack of rupture of the primitive bucconasal membrane. (b) Secondary epithelial overgrowths, or epithelial plugs. 2. Osseous: (a) Bone formation in membranous atresia. (b) Anomalies of the internal pterygoid plate of the sphenoid bone. Although it is conceivable that osseous atresia likewise may be due to anomalies of the vomer or posterior septum, I have not encountered or found described such a condition and therefore have not included it in the classification. Membranous atresia, according to Schaeffer, 1 occurs as follows: In the formation of the primitive choanae the dorsal growth or extension of the blind pouch-like primitive nasal fossae meets the ectoderm of the oral fossae. One now finds in these positions the bucconasal membrane composed of two