During the first few weeks of life the larynx (voice box) is high up in the neck and the new born is an obligate nose breather. Choanal atresia is a rare congenital condition. Sometimes the nasal passages are blocked by bone or tissue and can affect either one or both nasal passages.
In majority of cases, a unilateral condition may not be diagnosed. At birth, the doctor passes a small catheter to clean the nasal passages of secretions that pass into the nostrils during delivery. It is during this time, that a suspicion of choanal atresia is evoked, if the catheter does not pass through either of the passages. When both sides are affected, the condition is likely to be diagnosed immediately at birth. Bilateral affection is an emergency and needs urgent management.
There could be other congenital anomalies associated with the condition and your child will be carefully evaluated by the doctors to see if there is such an association. The new born is evaluated by a neonatologist, an ENT doctor and a genetist.
A bilateral condition is repaired as soon as the baby is ready to undergo general anesthesia. The duration of the operation is about 45-50 minutes. The new born will have a tube passed into the mouth to aid ventilation. The operation can be done via the nose or mouth.
Unilateral (one nostril involved) atresia is repaired at 6-12 months, unless there are severe respiratory and feeding difficulties.
Immediately from the delivery room, the baby will be transferred to the intensive care unit of the Service of neonatology. You will be given a brief introduction of the intensive care unit by a nursing staff. You will meet the surgical team which will discuss the surgery and possible complications that can be anticipated during this procedure. You will be given a consent form which needs to be duly signed giving permission for your child to have the operation. You will then see the anaesthetists who explain you about the anaesthesia.
The principle of management is to open up the nasal passages. This will include making a hole through the bone or tissue blocking the nasal passages. It is done using highly advanced endoscopes allowing an excellent view into small nasal passages. This allows the surgery to be extremely precise and with no risks. In select cases, the CO2 laser is used. To make sure these holes stay open, the surgeon will put a small plastic / silicone tubes (nose stents) in each nostril which are fixed in place by stitches.
No, in majority of cases we avoid putting nose stents. We feel that they cause more trauma and collateral damage in small nasal passages which then cicatrise to narrow down the nose. However rarely, we use them in select cases of the CHARGE syndrome.
Operations in very small nasal passages could have some risks. The surgery carries a small risk of bleeding during or after the operation and there is a small risk of the general anesthesia. The CHUV surgical and anesthesia teams have plenty of experience in treating this condition.
The baby returns to the intensive care unit to recover and is very closely monitored for oxygen saturation. The front of the nose and the back of the throat will be monitored for bleeding. There would be a small feeding tube passed through the mouth, just in case if the baby has any feeding problems in the first few days after which it will be removed. A few hours after the operation, your baby will be able to feed. There has been a change in the breathing habit of the baby who will take some time to get used to the new nose anatomy. During this period he may be ventilated by a mask.
We usually avoid inserting nose stents, though in select cases they may be used. The stents can get blocked due to secretions and blood. They will need to be suctioned regularly and kept clear for your baby to breathe easily. The nursing staff will teach you how to suction the nostrils (or directly into the stents, if inserted) using normal saline and catheters. While at the hospital, you will maintain a chart keeping a record of your baby’s respiration, feeding habits and weight gain.
You will be given a prescription of pain killers and the material you will need to keep the stents clean. You will receive the next appointment date with the operating team and a date for the stent removal. The stents are usually removed after three to six weeks, or sometimes a little longer. Your baby will need to be hospitalised for 1-2 days after the stent removal.
Post surgery, the baby will be seen first after an interval of 3-6 weeks. This will be under general anesthesia during which the surgeon cleans the nasal passages and may lightly dilate (calibrate) the nasal passages. The baby needs to be then reseen at 3, 6 and 12 months.
The first year is important to have the nasal passages completely open and avoid troublesome adhesions within small air passages. Optimally repaired choanal atresia babies with no other congenital anomalies can expect normal growth.
The parents are advised to monitor their child for: nose bleeding, increased nasal secretions and repeat nasal blockages.
For patients staying outside Switzerland, a systematic plan of follow up is prepared taking into consideration the long distance of travel and individual country insurance policies.