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ORIGINAL ARTICLE

Repair of Acquired Posterior Choanal Stenosisand Atresia by Temperature-ControlledRadio Frequency With the Aid of an Endoscope

Qin ying Wang, MD; Liang Chai, MD; Shen qing Wang, MM; Shui hong Zhou, MD; Yu yu Lu, MM

Objectives: To examine the clinical effects of tempera-ture-controlled radio frequency (TCRF) repair of ac-quired choanal stenosis and atresia with the aid of an en-doscope and to discuss the value of acquired choanalstenosis and atresia typing in clinical therapy.

Design: Retrospective study.

Setting: Academic otorhinolaryngologic referral center.

Patients: Thirty-two patients, aged 32 to 65 years, withacquired choanal stenosis and atresia (from trauma in 9cases and from radiotherapy after nasopharyngeal car-cinoma in 23 cases); 13 cases were bilateral, and 19 wereunilateral.

Interventions: Transnasal TCRF repair with the aid ofan endoscope. Acquired choanal stenosis and atresia canbe divided into 3 types:type 1, diagnosed within 3 monthsof the causative trauma or radiotherapy; type 2, diag-nosed between 3 and 6 months after the trauma or ra-diotherapy; and type 3, diagnosed more than 6 months

after the trauma or radiotherapy. All patients with types1 and 2 disease received nasal stents made from Silasticthat were fixed with transseptal sutures. However, pa-tients with type 3 disease received no stenting.

Main Outcome Measures: The thickness of the ste-nosis and atresia revealed by computed tomographic

scan and the surgical results were also analyzed. Therewas no significant correlation between them (P .05).

Results: Twenty-nine patients remained free of symp-toms for 12 to 42 months after surgery. Three patientsrequired revision surgery, including 2 cases of type 1 dis-ease (3 sides) and 1 case of type 2 (1 side). Two of the

patients who underwent revision recovered completely,with no restenosis at 12 months after the second sur-gery. However, 1 patient with type 1 bilateral atresia ex-perienced another restenosis and required another revi-sion, through a transpalatal approach. There were nopostoperative complications. There wasno significantcor-relation between thickness of the stenosis revealed by com-puted tomographic scan and the surgical results.

Conclusions: We describe a TCRF technique with theaid of an endoscope for choanal repair. In our experi-ence, it has been a highly successful, safe, and effectiveprocedure, with minimal blood loss, swift recovery, and

short time of hospitalization. It is important in postop-erative care to remove any granulation or polyps at thesite of the neochoana. Types 2 and 3 are the best typesof disease to treat with this procedure.

Arch Otolaryngol Head Neck Surg. 2009;135(5):462-466

T

HERE ARE CONGENITAL AND

acquired choanal atresias(CAs). Most acquired CAsare fibrous membranousatresias. Many approaches

have been used in the repair of CA, in-cluding transnasal,transpalatal, and trans-septal approaches. The transpalatal ap-proach offers excellent exposure and highsuccess rates. However, increased opera-tive time, bleeding, palatal fistula, palatalmuscle dysfunction, and maxillofacialdisturbances are possible sequelae of thisprocedure.1

Technical advances and experience inendoscopic nasal surgery have provided

the opportunity to use a transnasal endo-scopic approach. The transnasal endo-scopicapproach hasbeen successfully usedover the past decade in the treatment ofCA.2-12 The technique permits a direct ap-

proach to the atretic area, with the advan-tages of an angled view, good illumina-tion, and magnification of the CA.

We describe an endoscopic surgicaltechnique and the clinical types of ac-quired choanal stenosis and atresia thatmay decrease the rate of restenosis in sur-geryfor acquired choanalstenosis andatre-sia. We also discuss the value of acquiredchoanal stenosis and atresia typing forclinical therapy.

Author Affiliations:Department of Otolaryngology,The First Affiliated Hospital,College of Medicine, ZhejiangUniversity, Hangzhou,Zhejiang, China.

(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/VOL 135 (NO. 5), MAY 2009 WWW.ARCHOTO.COM462

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METHODS

Thirty-two patients withacquired choanal stenosis and atresiawere treated with transnasal temperature-controlled radio fre-

quency (TCRF) procedures with the aid of an endoscope be-tween January 2000 and December 2006. There were 21 menand 11 women,aged32 to65 years (mean age, 49.5years), withthe conditions arising from trauma in 9 cases and radio-therapy after nasopharyngeal carcinoma in 23 cases. Thirteencases were bilateral, and 19 were unilateral. All patients werediagnosed by endoscopic examination (Figure 1) and com-puted tomographic (CT) scan (Figure 2). The stenosis andatresia were located in the posterior part of the nasal cavity andthe edge of the choana. The thickness of the stenosis and atre-sia ranged from 0.2 to 3.0 cm.

Choanal stenosis and atresiaoccurred 2 to 24 months (mean,9.3 months) after trauma or radiotherapy. Based on the time ofinjury of the posterior choana as inferred from the inflamma-tion encountered during surgery, acquired choanal stenosisand

atresia can be divided into 3 types: type 1, diagnosed within 3months of the causative trauma or radiotherapy; type 2, diag-nosed between 3 and 6 months after the trauma or radio-therapy; and type 3, diagnosed more than 6 months after thetrauma or radiotherapy. Four of our cases were type 1 disease(6 sides), 19 were type 2 (26 sides), and 9 were type 3 (13sides).

SURGICAL TECHNIQUE

We conducted the transnasal TCRF procedure with the aid ofendoscopy using a System 2000 Atlas Coblator II (ArthroCareCorporation, Austin, Texas); an endoscopic and video system(Stryker Corporation, Kalamazoo, Michigan), which includeda 4-mm 0 and 30 telescope; Blakesley forceps; and a powersoft-tissue shaver (Linvatec Corporation, Largo, Florida). Gen-

eral anesthesia was used. Additional nasal decongestion wasachieved by applying a solution of 1% lidocaine hydrochlo-ride and 0.25% phenylephrine hydrochloride to neurosurgi-cal cotton pledgets that were carefully placed in the nasal cav-ity. A solution of 1% lidocaine hydrochloride with 1:100 000epinephrine was administered with a spinal needle to the ste-nosis, atretic plate, and posterior septum under direct visual-ization. In patients with bilateral stenosis and atresia, the an-esthetic was administered to both sides during the inspection.

Under endoscopic visualization, a radiofrequency knife wasused to trim the scarred mucosa in the posterior choana. Ad-ditional scar tissue on the posterior septum and posterior end

of the inferior or middle turbinate was excised with the powersoft-tissue shaver and Blakesley forceps. Partial resection of theposterior edge of the vomer was performed with backward-biting forceps, which were then also used to reduce a portionof the posterior bony septum, further enlarging the neo-choana. Care was taken not to damage normal adjacent nasalmucosa. The nasopharynx was carefully examined to rule out

tumor recurrence, and surgical specimens were sent for histo-logic examination.When the surgi cal procedure was compl ete, a custo m-

made soft Silastic (Dow Corning,Midland, Michigan) stent witha foam cuff (Bivona Corporation, Gary, Indiana) was placed inthe neochoana and secured with a transseptal 2-0 silk suture.In 4 patients with type 1 disease and 19 patients with type 2,stenting was performed using these Silastic stents. In the 9 pa-tients with type 3 disease, no stent was inserted. Antibiotic andlocal glucocorticoid (0.05% mometasone furoate aqueous na-sal spray; Schering Plough Labo NV, Brussels, Belgium) wereadministered postoperatively.

POSTOPERATIVE CARE

Oral amoxicillin with clavulanic acid was prescribed for 2 weeksto preventinfection.Endoscopic follow-up wasperformedweekly,andblood clots andcrusts were removed or suctioned. After re-moval of the nasal packs, all patients were trained and advisedto perform nasal douches with normal saline (isotonic sodiumchloride) solution at least 3 times a day. Mometasone furoate,0.05%, aqueous nasal spray was also administered twice per day.The patients were seen weekly for the first 2 postoperative weeksto change the nasal packing. They were then observed every 2weeks for 1 month, monthly for 2 months, and then once per 3months. Inthe 4 type1 cases,the stent was removed within 2 to4 weeks (mean, 3 weeks). In the 19 type 2 cases, the stent was

S

I

Figure 1. Rigid endoscopic findings. The choana was almost completelyclosed with just a fissure remaining. I indicates inferior turbinate; S, nasalseptum.

Figure 2. Computed tomographic findings of the face demonstrate amembranelike soft tissue density obliterating the bilateral choana (lowerarrow), but no osseous component is identified. The anterior nasal passageis quite patent (upper arrow).




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removed within 1 to 2 weeks (mean, 1.5 weeks). In the 9 type 3cases, no stentwas used.Stents were removed under topical an-esthesia, and a meticulous cleaning was performed. The fol-

low-up period was between 12 and 42 months (median, 27months). At thefollow-upvisits, an endoscopic examination wasperformed, andany granulationtissue or polyps at the site of theneochoana were removed at that time.

RESULTS

Histologic analysis of the resected tissue revealed respi-ratory stromaltissue lined withepithelial cells and chronicinflammation, edema,andfibrosis butno tumor cells.Theoverall follow-up period was 12 to 42 months. Twenty-nine patients (91%) remained free of symptoms, and thediameter of the neochoana was larger than 1 cm after theprocedure (Figure 3). However, at 2 months after sur-

gery, restenosis was observed in 3 patients, represent-ing 2 type 1 cases (3sides) and 1 type case (1side). Thisrestenosis was discovered during an endoscopic exami-nation. Two of the patients who required revision recov-ered completely, with no restenosis at 12 months afterthe second procedure. However, 1 patient with type 1bilateral atresia (caused by trauma) experienced an-other restenosis and required another revision througha transpalatal approach 3 months after a second repair.There were no further postoperative complications(Table 1). The thickness of the stenosis revealed by CTscan and thesurgical results were also analyzed (Table 2).The procedure was considered successful if the patientremained free of symptoms and the diameter of the neo-choana was no less than 1 cm at follow-up 12 monthsafter the procedure.

COMMENT

Choanal atresia can be either congenital or acquired, al-though most cases are congenital. Acquired choanal ste-nosis and atresia are often complications of chemical cau-terization, nasopharyngeal carcinoma and radiotherapy,surgical trauma, and infectious disease.13-15 Most ac-

quired cases are fibrous membranous stenoses and atre-sias. Most arerelated to radiotherapy; in thepresent study,23 of 32 cases (72%) were the result of radiotherapy.

Many surgical approaches have been suggested for thetreatment of choanal stenosis andatresia, including trans-nasal, transpalatal, transantral, sublabial-transnasal, andtransseptal approaches. The transpalatal approach of-fers excellent exposure and high success rates. How-ever, increased operative time, bleeding, palatal fistula,

palatal muscle dysfunction, and maxillofacial distur-bancesarepossible sequelae of this procedure.1 The trans-nasal approach has narrow exposure and limited possi-bility to develop mucosal flaps. It also has the risk ofpossible injury to the eustachian tube and skull base.16

Advantages of a TCRF approach with the aid of a rigidendoscope in the repair of choanal stenosis and atresiaare clear vision of the operative field and accurate re-moval of the stenosis and atresia plate without damag-ing neighboring structures, thus significantly reducingthe rate of restenosis. The TCRF approach is a safe pro-cedure with minimal blood loss, swift recovery, anda shorttime of hospitalization. It is also convenient, in postop-erative care, to remove any granulation or polyps at the

site of the neochoana at follow-up visits.Congenital and acquired choanal stenoses and atre-sias differ in structure and in the areas blocked; in addi-tion, the structures in acquired choanal stenosis and atre-sia can change with development. These differences haveclinical value, so we divided acquired choanal stenosisand atresia into 3 types. Type 1 had patent inflamma-tion, abundant secretions, and scar tissue in the naso-pharynx and bled freely. The tissue of the nasopharynxand choanae were significantly edematous after sur-gery. As a result, the restenosis rate in type 1 cases washigher than in types 2 and 3. Two patients with type 1disease experienced restenosis within 2 months of sur-gery. The recurrence rate in type 1 cases was 50% (2/4).

This was clearly the worst type for the operation. Type2 is a better type to operate on. Type 2 cases showed alower restenosis rate; there was1 case of restenosis within2 months of surgery (recurrence rate, 1 of 19 [5%]). Type3 cases had almost no inflammation in the nasal cavityand dryer mucosa; there was no case of type 3 restenosisin this study. Thus, type 3 is the optimal type to un-dergo operation, but the procedure should be per-formed in patients with type 2 or type 3 disease.

The use of stents in the management of patients withCA is a subject of some controversy. Several authors ad-vocate postoperative stenting. Stents are generally left inplace for 6 to 8 weeks because this is considered to be thetime necessary for the reepithelialization of the neo-

choana.1

Many materials have been used for stenting, andsofter materials apparently give better results in terms ofpreventing restenosis.17 We believe that stents are usefulto stabilize the nasal airwayin the postoperative period andto prevent the development of stenosis by maintaining alumen. However, stents can also serve as a nidus for infec-tion, and there is a question whether such a foreign bodymaycontribute to choanal stenosis,as an endotrachealtubemay cause subglottic stenosis. We have empirically usedreadily available Silastic stents for 2 to 4 weeks in type 1cases and for 1 to 2 weeks in type 2 cases (stenting was not

S N

T

Figure 3. Endoscopic view of the choanal passage 15 monthspostoperatively. The choanae were quite patent. N indicates nasopharynx;S, nasal septum; T, torus.




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carried out in our patients with type 3 disease). We usu-ally maintain a regimen of oral antibiotics for our patientsfor the duration of stenting to lessen the risk of purulent

rhinorrhea. Mometasone furoate, 0.05%, aqueous nasalspray was also used to lessen mucosal edema in the naso-pharynx. Our study demonstrated that it is possible to findtreatments that allow a reductionor even avoidance of theperiod of postoperative stenting.

We followed the technique of mucosal preservationindicated by Andrieu et al18 in their description of thetransseptal approach for the repair of CA. The TCRF sys-tem and power soft-tissue shavers are believed to be lesstraumatic to nasal tissue than traditional endoscopic sur-gical techniques, allowing better tissue healing.19-21 Thus,TCRF and power soft-tissue shavers were used in ourstudy.Some patients whose disease wascaused by traumashowed significant proliferation of fibrosis in choanal ste-

noses and atresias. The TCRF system is easier and saferto use than power soft-tissue shavers in cases of fibrosis.We think that the TCRF technique helped to reduce thepostoperative recurrence rate and the period of postop-erative stenting. Furthermore, the shortened period ofstenting and the use of soft stents diminished the likeli-hood of granulation tissue formation and therisk of post-operative infection.

On removal of the stent, endoscopic examination ofthe neochoana was carried out to ensure patency. If nec-essary, reactionary polyps at or near the neochoana were

removed. Thecases of restenosis in this study related pri-marily to granulation tissue or polyps at the site of theneochoana that were not removed owing to the lack ofendoscopic examination.

Preoperative assessment by means of a CT scan and

rigid endoscopic examination is very important for thesuccess of surgical treatment. Axial CT scanning andrigidendoscopy can confirm the clinical diagnosis. In fact, CTscans can accurately characterize the nature and thick-ness of the atresia, the narrowing of the posterior nasalcavity, and the thickening of the vomer.22 In our series,all patients received a preoperative CT scan and rigid en-doscopic examination to assess the thickness and na-ture of the atretic plate, the deformity of the posterolat-eral aspect of thenasal cavity, andthe presence andnatureof anatomic deformities at thelevel of thevomer and pos-

Table 1. Transnasal Endoscopic Repair of Choanal Atresia and Choanal Stenosis in 32 Patients

Disease Type Patient Laterality Follow-up, mo Stent Duration, wk Result

1 1 Bilateral 40.0 3.5 Repair

2 Unilateral 42.0 3.0 Repair

3 Unilateral 17.5 2.0 Revision

4 Bilateral 16.0 4.0 Revision

2 5 Unilateral 23.0 1.0 Repair


7 Bilateral 34.0 2.0 Repair8 Unilateral 31.0 1.5 Repair



11 Bilateral 21.0 2.0 Repair










21 Bilateral 16.5 1.0 Revision



3 24 Unilateral 21.0 0 Repair

25 Bilateral 34.0 0 Repair


27 Unilateral 38.0 0 Repair






Table 2. The Thickness of the Stenosis and/or Atresiaand Surgical Resultsa

Thi ckness, cm Pat ients, No. Repair s Revisi ons

0.0-1.0 12 11 1 (Type 1)

1.1-2.0 11 10 1 (Type 2)

2.0 9 8 1 (Type 1)

a Unless otherwise indicated, data are reported as number of patients. Forthe comparison of type 1 with type 2 revisions, 2=0.048 (P .05).




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terior nasal cavity to choose the most suitable surgicalapproach. However, our study findings suggest no sig-nificant correlation between thickness of the stenosis re-vealed by CT scan and the surgical results.

In conclusion, a transnasal TCRF approach with theaid of an endoscope is a useful procedure for the repairof acquired choanal stenosis and atresia. This techniquepermits an angled vision,excellent visualization, and mag-nification of the atretic plate; compared with traditional

techniques, thistechnique allowed a shorter hospital stayand less blood loss. To reduce the chance of restenosisand shorten or even avoid the period of postoperativestenting, thorough mucosal preservation of the neo-choana is of paramount importance. Postoperative careis also important for removing any granulation or pol-yps at the site of the neochoana. Type 2 and 3 are thebest types to consider for the operation.

Submitted for Publication: November 23, 2007; final re-vision received April 14, 2008; accepted May 12, 2008.Correspondence: Qin ying Wang, MD, Department ofOtolaryngology, The First Affiliated Hospital, College ofMedicine, Zhejiang University, 310003, Hangzhou,

Zhejiang, China ([email protected]).Author Contributions: Drs S. Wang and Lu had full ac-cess to all the data in the study and take responsibilityfor the integrity of the data and the accuracy of the dataanalysis. Study conceptanddesign: Q. Wang, Chai, S.Wang,andLu.Acquisition of data: Q. Wang, S. Wang, and Zhou.Analysis and interpretation of data: Q. Wang. Drafting ofthe manuscript: Q. Wang, Chai, S. Wang, Zhou, and Lu.Critical revision of the manuscript for important intellec-tual content: Q. Wang and S. Wang. Statistical analysis:Q. Wang, Chai, and Zhou. Administrative, technical, andmaterial support: Q. Wang. Study supervision: S. Wang andLu.Financial Disclosure: None reported.

REFERENCES

1. Brown OE, Pownell P, Manning SC. Choanal atresia: a new anatomic classifica-

tion and clinical management application. Laryngoscope. 1996;106(1, pt 1):

97-101.

2. Teissier N, Kaguelidou F, Couloigner V, Francois M, Van Den Abbeele T. Predic-

tive factors for success aftertransnasal endoscopic treatment of choanal atresia.

Arch Otolaryngol Head Neck Surg. 2008;134(1):57-61.

3. Pardo Romero G, Mogollon Cano-Cortes T, Pando Pinto JM, et al. Endoscopic

treatment for choanal atresia. Acta Otorrinolaringol Esp. 2007;58(1):34-36.

4. James FM, Parente EJ, Palmer JE. Management of bilateral choanal atresia in a

foal. J Am Vet Med Assoc. 2006;229(11):1784-1789.

5. Anderhuber W, Stammberger HR.Endoscopic surgery of uniand bilateral choa-

nal atresia. Auris Nasus Larynx. 1997;24(1):13-19.

6. Lazar RH, Younis RT. Transnasal repair of choanal atresia usingtelescopes. Arch

Otolaryngol Head Neck Surg. 1995;121(5):517-520.

7. Josephson GD, Vickery CL, Giles WC, Gross CW. Transnasal endoscopic repairof congenital choanalatresia: long-termresults. ArchOtolaryngolHeadNeck Surg.

1998;124(5):537-540.

8. Deutsch E, Kaufman M, Eilon A. Transnasal endoscopic management of choa-

nal atresia. Int J Pediatr Otorhinolaryngol. 1997;40(1):19-26.

9. Uri N, Greenberg E. Endoscopic repair of choanal atresia: practical operative

technique. Am J Otolaryngol. 2001;22(5):321-323.

10. WiatrakBJ. Unilateral choanal atresia: initialpresentationand endoscopicrepair.

Int J Pediatr Otorhinolaryngol. 1998;46(1-2):27-35.

11. VickeryCL, Gross CW.Advanced drilltechnologyin treatmentof congenital choa-

nal atresia. Otolaryngol Clin North Am. 1997;30(3):457-465.

12. Yaniv E, Hadar T, Shvero J, Stern Y, Raveh E. Endoscopic transnasal repair of

choanal atresia. Int J Pediatr Otorhinolaryngol. 2007;71(3):457-462.

13. Ku PK, Tong MC, Tsang SS, van Hasselt A. Acquired posterior choanal stenosis

and atresia: management of this unusual complicationafter radiotherapyfor na-

sopharyngeal carcinoma. Am J Otolaryngol. 2001;22(4):225-229.

14. Bonfils P, de Preobrajenski N, Florent A, Bensimon JL. Choanal stenosis: a rare

complication of radiotherapy for nasopharyngeal carcinoma. Cancer Radiother.2007;11(3):143-145.

15. Miho H, Kato I, IwatakeH, Akao I, Takeyama I. A case reportof acquired choanal

atresia. Acta Otolaryngol Suppl. 1996;522:111-115.

16. Morgan DW, Bailey CM. Current management of choanal atresia. Int J Pediatr

Otorhinolaryngol. 1990;19(1):1-13.

17. Carpenter RJ, Neel HB III. Correction of congenital choanal atresia in children

and adults. Laryngoscope. 1977;87(8):1304-1311.

18. Andrieu J, Guitrancourt P, Stipon M. Chirurgiede limperforation choanale. Paris,

France: EMC Editions Techniques; 1994.

19. Krouse JH, Christmas DA Jr. Powered instrumentation in functional endo-

scopic sinus surgery, II: a comparative study. Ear Nose Throat J. 1996;75

(1):42-44.

20. Powell NB, Riley RW, Guilleminault C. Radiofrequency tongue base reduction in

sleep-disordered breathing: a pilot study. Otolaryngol Head Neck Surg. 1999;

120(5):656-664.

21. Thiagalingam A, DAvila A, McPherson C, Malchano Z, Ruskin J, Reddy VY.

Impedance and temperature monitoring improve the safety of closed-loop

irrigated-tip radiofrequency ablation. J Cardiovasc Electrophysiol. 2007;18

(3):318-325.

22. Brown OE, Smith T, Armstrong E, Grundfast K. The evaluation of choanal atre-

sia by computed tomography. Int J Pediatr Otorhinolaryngol. 1986;12(1):

85-98.



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