Transnasal Mucosal Flap Rotation Technique for Repair of Posterior Choanal Atresia

Abstract

PURPOSE: To describe improved surgical treatment for posterior choanal atresia (PCA) by creating mucosal flaps with the aid of operating microscope, CO2 laser, self-retaining nasal retractor, and stenting with a flat polytetrafluoroethylene (Teflon) keel. MATERIALS AND METHODS: Retrospective study of 19 patients with PCA, their ages ranging from 6 days to 4 years 4 months at the time of first repair, representing a total of 32 PCA repairs. Four patients had unilateral PCA, and one did not return for follow-up and could not be located. A transnasal microscopic approach uses a myringotomy knife or CO2 laser to create an anterior mucosal flap; the CO2 laser is also used to remove any bone plate and to create the posterior flap. The flaps then are rotated into position and are kept separated by a flat Teflon keel instead of a traditional round stent to avoid pressure necrosis. When a stable epithelialized opening (2 × 2 to 3 × 4 mm) is created, it is enlarged by subsequent staged transnasal CO2 laser submucosal scar excisions with preservation of the overlying mucosa. This creates rotation or sliding flaps to speed healing and prevents circumferential scar contraction. RESULTS: Eighteen patients were re-examined after periods of 3 months to more than 5 years from when their first epithelialized orifice was created with nasal endoscopy to measure the final orifice size. All 18 patients had clinically adequate-to-good bilateral nasal airways at the latest follow-up with an average orifice size of 3 × 5 mm and a range of 2 × 2 to 4 × 10 mm. This “same day surgery” technique with staged procedures provides similar or better patency rates than a single transpalatal approach but with less surgical morbidity. It has a much lower restenosis rate than the transnasal puncture or PCA excision with prolonged round tube stenting and multiple dilation technique.