Special Article

Choanal Atresia
Paraya Assanasen MD*,
Choakchai Metheetrairut MD*
* Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Choanal atresia is caused by failure of resorption of the bucco-pharyngeal membrane during embryonic development. The atresia can be membranous or bony in nature, but is usually mixed in most cases. When
the atresia is bilateral, newborns can have severe airway distress and cyanosis is alleviated by crying.
Bilateral choanal atresia is managed with an oropharyngeal airway. Flexible nasal endoscopy and computed
tomography can confirm the diagnosis. Surgery is the definitive treatment with two main approaches, namely
transnasal or transpalatal. The transnasal route is currently the preferred procedure and can be performed in
a minimally invasive fashion with endoscopic instrumentation. It is a safe and rapid procedure even in very
young children, with no complications and a high rate of success. The use of a navigation system for surgical
planning and intraoperative guidance and powered instrumentation can improve treatment outcome. The
transpalatal approach is more invasive and reserved for failed endoscopic cases.
Keywords: Choanal atresia
J Med Assoc Thai 2009; 92 (5): 699-706
Full text. e-Journal: http://www.mat.or.th/journal

Choanal atresia is the developmental

failure of the nasal cavity to communicate with the
nasopharynx. Choanal atresia is a relatively rare
congenital anomaly and occurs in approximately 1 in
5000 to 8000 live births, with a female to male ratio of
2:1(1). Choanal atresia can be associated with other
congenital anomalies up to 50%, whereas the rest
have isolated anomalies. The most common associated
congenital anomaly is CHARGE association (C =
coloboma, H = heart disease, A = atresia of choanae,
R = retarded growth and development, G = genital
hypoplasia, E = ear deformities or deafness)(2). Other
anomalies associated with choanal atresia include
polydactyly, nasal-auricular and palatal deformities,
Crouzons syndrome, Down syndrome, Treacher-Collins
syndrome, DiGeorge syndrome, craniosynostosis,
microencephaly, meningocele, meningoencephalocele,
facial asymmetry, hypoplasia of the orbit and midface,
cleft palate, and hypertelorism(3). Samadi et al(4) retrospectively reviewed medical comorbid conditions of
78 children with choanal atresia. They found that
common medical problems were otitis media with
Correspondence to: Assanasen P, Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok 10700, Thailand. Phone: 0-2419-8040,
Fax: 0-2419-8044. E-mail: paraya.assanasen@gmail.com

J Med Assoc Thai Vol. 92 No. 5 2009

effusion (32%), upper and lower airway diseases (32%

and 23%, respectively), cardiac anomalies (19%), and
gastrointestinal tract disorders (18%). Statistically
significant correlations were found for bilateral choanal
atresia and cardiac disorders, CHARGE syndrome,
obstructive sleep apnea, hematological problems, and
prematurity or failure to thrive.
Generally, 65% to 75% of patients with choanal
atresia are unilateral, whereas the rest are bilateral(5).
About 30% are pure bony, whereas 70% are mixed
bony-membranous(6). The atretic plate is usually sited
in front of the posterior end of the nasal septum. The
anatomic deformities include a narrow nasal cavity,
lateral bony obstruction by the lateral pterygoid
plate, medial obstruction caused by thickening of
the vomer, and membranous obstruction(7). Acquired
posterior choanal atresia rarely occurs. It is usually
caused by rhinopharyngeal injury e.g. after adenoidectomy; radiotherapy for nasopharyngeal carcinoma(8);
tuberculosis or syphilis of epipharynx(9), or sometimes
by unknown causes.
Embryogenesis
There have been several theories regarding
the embryogenesis of choanal atresia, but it is
generally thought to be secondary to persistence of

699

either the nasobuccal membrane of Hochstetter or the

buccopharyngeal membrane from the foregut. This
membrane normally ruptures between the fifth and
sixth weeks of gestation to produce choanae. Failure
of this membrane to rupture causes atresia of
choanae(10). Other theories are abnormal persistence of
mesoderm causing adhesions in the region of the
nasal-choana or misdirection of mesodermal cell
migration secondary to local factors(11). In addition, a
defect in the region of the nasal and palatal processes
surrounding the nasobuccal membrane probably
plays a role, leading to the associated findings of an
accentuated arch of the hard palate, a medial location
of the lateral and posterior nasal walls, and thickening
of the vomer.
Clinical manifestation
Since a newborn child is an obligate nasal
breather, respiratory distress occurs with patients
with bilateral choanal atresia at or shortly after
birth. They present with cyclic cyanosis relieved
by crying. Airway obstruction during feeding but
relieved by crying demonstrates that the oral airway
is intact while the nasal airway is obstructed. The
improved respiratory distress after crying may delay
the diagnosis. Respiratory collapse may occur, and
feeding difficulties may lead to failure to thrive. Most
patients with bilateral choanal atresia are detected
within the first month of life. However, it can be
diagnosed in adults with long-term bilateral nasal
obstruction and rhinorrhea(12).
Patients with unilateral choanal atresia rarely
present with immediate or severe airway obstruction.
They normally present within the first 18 months of life
with feeding difficulties and nasal discharge, but may
present with unilateral nasal obstruction and discharge
in later life (Fig. 1). Obstruction of the contralateral side
from infection or adenoid enlargement may precipitate
airway symptoms and prompt medical evaluation.
On anterior rhinoscopy, the occluded nasal cavity is
typically filled with thick, tenacious secretions.
Diagnosis
There are numerous ways to diagnose
choanal atresia. The simplest method is to pass a soft,
red-rubber catheter (no. 8 French catheter) or 2.6-mm
feeding tube through the nose into the nasopharynx. If
the catheter is visualized in the oral cavity or oropharynx,
a nasal airway is present. Inability to pass that catheter
to the pharynx raises the possibility of choanal atresia;
however, the diagnosis can be missed because of

700

misdirection or coiling of the flexible catheter. The

effort to pass a catheter through a patent but narrow
airway may cause edema and/or bleeding, resulting in
complete obstruction. In addition, observing misting
on a metal spatula or a laryngeal mirror or detecting
movement of a cotton wisp placed beneath the
nose when the mouth is closed or during feeding
and auscultation of the nares may be helpful. This
documentation of the airflow rules out an atresia, but
does not preclude a stenosis. A drop of methylene blue
can be placed into the nasal cavity on the suspected
side. If the blue dye appears in the oral cavity or
oropharynx, atresia is excluded.
Patients may also be examined with a rigid or
flexible endoscope, operating microscope, mirror
examinations, or digital examination. The use of flexible
fiberoptic endoscope is the preferable method of
choice because nasal patency can be assessed, and
the anatomy (nasal vestibule, nasal septum and lateral
nasal wall) can be evaluated. Additionally, other
causes of airway obstruction such as congenital nasal
septal deviation, piriform aperture stenosis, nasal
cavity stenosis, nasolacrimal duct cysts, or other space
occupying lesion can be ruled out. A traditional method
of diagnosis is radiography using radiopaque contrast
material instilled into the nasal cavity with the patient
in a supine position. Acoustic rhinometry can be used
for the diagnosis, but is especially helpful in the postoperative period to follow patients for restenosis(13).

Fig. 1 A 31-year-old male with a unilateral nasal obstruction

and persistent mucoid discharge since childhood.
Nasal endoscopy (0 degree telescope) revealed right
choanal atresia on the nasal side (A, B) and normal
left nasal cavity (C) and choana (D). (IT-inferior
turbinate, S-septum, C-choana, CA-choanal atresia)

J Med Assoc Thai Vol. 92 No. 5 2009

Computed tomography (CT), especially axial plane, is

the radiographic procedure of choice since it can
demonstrate the nature (bony or membranous),
position, and thickness of the obstructing segment,
which helps the surgeon in designing a plan for
repair, and other abnormalities, such as dermoids,
encephalocele, gliomas, anterior skull base defect(10)
can be excluded. CT usually shows a widening of the
posterior septum and a dense bony thickening of the
lateral buttress. Adequate using vasoconstrictor drops
and nasal toilet, sedation or general anesthesia may be
essential in infants to obtain good-quality images.
With CT scans, normative data are now available for
neonates, up to 6 months of age, regarding the size of
the nasal cavity(14).
Management
Management of these patients varies and
depends on age, type of atresia, and general condition
of patients. Because infants are obligate nasal
breathers, bilateral choanal atresia is a life-threatening
situation since, if not promptly recognized, it can lead
to severe asphyxia and death immediately after birth.
Nasal airway obstruction from bilateral choanal atresia
is usually demonstrated immediately after delivery.
Suckling or a mouth-closed posture will precipitate a
crisis. Immediate management of bilateral choanal
atresia involves training the infant to breathe through
the mouth with the aid of an indwelling oral appliance
such as a McGovern nipple or an oropharyngeal
airway. A McGovern nipple is an ordinary nipple with
a single enlarged hole and can be used for gavage
feeding. It is secured with ties or tape around the ears.
The infant can be fed, and the airway is protected
while definitive management is delayed to allow time
for a complete workup to rule out other anomalies.
Endotracheal intubation is usually unnecessary
unless the infant requires mechanical ventilation.
If there is severe respiratory distress and airway
cannot be established by endotracheal intubation, an
emergency tracheotomy should be performed until
further evaluation and treatment can be established.
Nevertheless, surgical correction is usually necessary
early in life.
Unilateral atresia is rarely emergent. The
repair is generally delayed for at least 1 year, which
allows the operative site to enlarge and reduces the
risk of postoperative stenosis, unless there are feeding
difficulties. Repair of atresia can be performed anytime
after the airway has been secured, and other anomalies
have been evaluated. Surgical repair and anesthesia in

J Med Assoc Thai Vol. 92 No. 5 2009

very young infants is technically difficult; however,

they usually tolerate stenting better than older infants.
Transnasal and transpalatal approaches are common
surgical techniques used. Transnasal approach with
the use of a rod-lens telescope is the method of choice
and has been used successfully in newborns and
infants and is suitable for membranous or very thin
bony atresia, while transpalatal approach is normally
reserved for the older children, thick bone, or case
with restenosis. Better instrumentation in endoscopic
sinus surgery and advances in CT scans have made
the transnasal repair the most popular method.
Nasal endoscopy is beneficial in the management of
choanal atresia since it helps to confirm the diagnosis,
characterize the extent of lateral nasal wall contribution
to the stenosis or atresia, evaluate the composition of
the atresia (bony and/or membranous), guide surgery,
and provide postoperative surveillance.
The transpalatal procedure has a higher
success rate (ability to create larger initial opening),
enables better visualization (wider surgical exposure
and improved access to the posterior vomer) and
preservation of mucosal flaps along the newly formed
apertures (decreased incidence of postoperative
scarring and restenosis), and permits short-term stenting.
In addition, there is less chance of disorientation and
significant surgical complications intracranially(11).
However, it may lead to a growth disturbance to the
hard palate, alveolar arch, and midface, occlusive
abnormalities e.g. crossbite, palatal fistula, increased
operative time and blood loss, risk of damage to the
greater palatine neurovascular bundle, and injury
of the soft palate resulting in a future problem with
rhinophonia.
The main advantage of the transnasal
procedure is minimally invasive, quick (avoiding the
need for prolonged anesthetic agents), less traumatic
with minimal blood loss, and provides excellent
visualization and the ability to perform exact surgery
on patients of all ages(15). Its disadvantage is limited
field of vision (which risks injury to sphenopalatine
artery or skull base), even with a microscope, especially
in newborn infants or a case with deviated nasal septum,
large turbinates, or small size of the nasal cavity, and
the inability to adequately remove enough vomerine
septal bone to prevent restenosis. Practically, creation
and maintenance of the flaps can be very difficult.
Although any surgery on the nose or septum carries a
risk of inhibition of facial growth, it has not been
reported with transnasal approach. Richardson and
Osguthorpe(16) compared transnasal with transpalatal

701

repair in 37 with congenital atresia or severe stenosis

of both posterior nasal choanae. They found that
transnasal repair allowed correction with minimal
blood loss and without facial growth or occlusal
abnormalities.
Transnasal procedure
All surgical procedures are performed under
general anesthesia, and the airway is prior controlled
by endotracheal intubation or rarely tracheostomy. For
transnasal approach, the most precise techniques can
be done under an operating microscope or telescope(15).
Soft palate retraction enables the visualization of
posterior choanae. Gauze packs should be placed in
the nasopharynx to protect the nasal surface of the
soft palate, confirm the anatomy when the atresia plate
is penetrated, and prevent blood from being swallowed
or aspirated. The use of vasoconstrictor drops and
nasal suction provide a good view of anterior nares.
The mucosa over the anterior face of the atretic area,
posterior portion of the septum, and lateral nasal
wall are injected with a solution of lidocaine with
diluted epinephrine under direct visualization, and
cooperation with pediatric anesthesiologist is required.
The nose is then packed with cottonoid pledgets
soaked in a solution of 0.025% oxymetazoline. These
packs are left in place for 10 minutes. Excellent
vasoconstriction is achieved using this method. The
anterior mucosa overlying the atretic plate is incised
vertically, and the mucosal flap is elevated medially
and laterally by the use of a flap or sickle knife (Fig. 2C).
If the atresia is only membranous, the incision may
open the choanae. If the bone is present, the atretic
plate is perforated using a curved urethral sound
starting at the junction of the atretic plate, hard palate,
and vomer (inferomedial part of atretic bone), since
this junction is usually the thinnest portion of the
atresia. It is important to remember that the atretic plate
in the newborn is close to the basisphenoid, which
separates the nasal cavity from intracranial contents.
Care should be taken not to damage the postnasal space
since it may result in basisphenoid fracture. Therefore,
the nasopharynx should be approached inferiorly. The
membrane or bone from the atretic plate, lateral nasal
wall (medial aspect of pterygoid plate), and lateral
portion of the posterior septum is then removed by
curette or burr, exposing the nasopharyngeal region
and the previously placed gauze packs, until a size of
18 French-gauge dilator can be introduced with ease.
It is essential to adequately resect the abnormal
posterior vomer to create a common cavity posteriorly,

702

which provides a larger nasal airway, a lower stenosis

rate, and a favorable outcome of the procedure. This
can be accomplished using the drill and tissue shaver
or a back-biting forceps. After bone removal, the
mucosal flaps should be folded posteriorly (medial
and lateral flaps) before a stent is placed.
Nevertheless, it is difficult to preserve
mucosal flap and completely remove the thick bony
plate, which may lead to restenosis. Stamm and
Pignatari(17) performed transnasal micro-endoscopic
surgical approach in 33 patients with choanal atresia
utilizing nasal septal crossover flap technique to
diminish the incidence of restenosis. Their success
rate for unilateral cases was 86%, while for bilateral
cases was lower, 72%. Newer endoscopic techniques
with powered instrumentation(18,19) or laser(20) and
the computer-assisted navigation system(21,22) can
enhance the safety and efficacy in the repair of choanal
atresia especially in refractory cases.
Recent reports using transnasal endoscopic
repair have shown excellent results. Khafagy (18)
performed transnasal endoscopic repair in nine
infants with bilateral choanal atresia and stented
neochoana for 5 to 8 weeks. Five cases remained
patent after removal of stenting. Two patients required
revision surgery. Pasquini et al(23) also reported the

Fig. 2 The same patient from Fig. 1. The right choana was
completely closed as seen by 70 degree telescope on
the nasopharyngeal side (A). CT scan showed
membranous atresia on the right side (yellow arrow)
(B). Transnasal repair was performed using crescent
knife to make a curvilinear incision at the inferior
border of choana (C). Atretic area was removed
until the chaoana was large enough (D). (S-septum,
C-choana, CA-choanal atresia)

J Med Assoc Thai Vol. 92 No. 5 2009

effectiveness of the transnasal endoscopic approach

for the treatment of 14 patients with congenital
choanal atresia (three cases were bilateral, while 11 were
unilateral). The overall follow-up period ranged from
2 to 64 months (mean 31 months). Only one restenosis
was observed.
Possible complications of the transnasal
approach include pressure necrosis of anterior nares
or columella, plugging and displacement of the
indwelling stents, cerebrospinal fluid leaks, meningitis,
and granulation tissues around the stents.
Transpalatal procedure
For transpalatal approach, the palate is
exposed with a mouth gag and injected with lidocaine
with epinephrine for hemostasis, which requires
cooperation with a pediatric anesthesiologist. Then, a
curved or vertical incision is made in the soft and hard
palatal mucosa to expose hard palatal bone and the
soft palatine muscle. The curved incision starts behind
the maxillary tuberosity on one side and is carried
medially to the alveolar ridge to the canine region, and
the same incision is performed on the other side to
create U-shaped palatal flap. The mucoperiosteal
flaps are elevated posteriorly to the edge of the hard
palate, and care should be taken to preserve the
neurovascular bundle from the greater palatine
foramen. The soft palate is retracted posteriorly and
superiorly to expose the posterior edge of the hard
palate and the nasopharynx. Then, the posterior hard
palate is removed using a cutting bur or a Kerrison
punch to expose the nasal cavity basal mucosa, and
the mucosa is reflected as a flap and lifted until it
reaches the choana. The posterior part of the septum
and lateral superior nasal wall should be removed. A
stent is placed, and the nasal mucosal flaps are placed
on the inferior aspect of each tube before the palatal
flap is replaced and sutured.
Possible complications of the transpalatal
approach include pressure necrosis of anterior
nares or columella, plugging and displacement of the
indwelling stents, palatal flap dehiscence, development
of maxillary hypoplasia resulting in midface retrusion
and malocclusion, and granulation tissues around the
stents.
Stents
Stenting is needed to maintain the patency of
the new lumen and hold the mucosal flaps in place. A
No. 3.5 or 4 endotracheal tube cut to the appropriate
length and shape is commonly used as a stent since it

J Med Assoc Thai Vol. 92 No. 5 2009

is available in the operating room, easily shaped and

trimmed. A 3 to 4 mm section of the middle part of the
tube is removed to allow non-traumatic positioning
across the columella. The opening should be large
enough to allow easy passage of suction catheters
through the endotracheal tube anteriorly into the
nasopharynx. The posterior end of the stent should
pass through the posterior choana, but it should not
touch the nasopharyngeal wall. Its length should be
adequate to support the newly formed choana, but
short enough to avoid discomfort or regurgitation of
food through the nose. The stent is fixed in place using
2-0 silk transseptal sutures. It should be hidden about
3 to 4 mm behind the alar rim, and should not protrude
from the nose to prevent being grasped by the infant
or child, and should not be visible externally to prevent
social and psychologic trauma in an older child.
Uncommonly, a single stent may be used in
case of unilateral atresia. After the operation, the child
can breathe through the stent, and meticulous care is
needed to prevent plugging of secretion, infection,
stent displacement, and columella ulceration. Regular
suction should be carried out after instillation of 0.9%
normal saline drops, and parents are trained to use
suction apparatus and saline irrigation. Care should be
taken to the area of fixation of the stents to prevent
erosion and permanent scarring. The broad-spectrum
oral antibiotics should be prescribed for the whole
period of stenting to reduce the risk of purulent
rhinorrhea. Complications of stents include granulation
tissue formation, nasoseptal perforations, and erosion
of the naris of the nose or columella.
A stent should be kept for 2 to 3 months until
the choanal operative site is mucosalized since the
incidence of restenosis is high. Since maintenance of
stents is difficult, educating parents and close followup are very essential. Occasionally, nasal dilatation and
revision surgery may be indicated after stent removal.
They may require multiple procedures to achieve the
desirable patency. Samadi et al (4) retrospectively
reviewed surgical outcomes of 78 children treated for
choanal atresia transnasally with an average follow-up
of 35 months. Main outcome measures were type and
number of procedures and airway patency. Surgery was
effective in establishing a patent airway in all cases.
Unilateral choanal atresia required, on average, 2.7
total procedures, including dilation and removal of
stents, compared with bilateral choanal atresia,
which required 4.9 procedures. They concluded that
meticulous postoperative care particularly stent
management and routine postoperative revision

703

endoscopy were crucial for successful treatment of

choanal atresia.
Although it has been suggested that a stent
should be kept for a long period of time, in some cases,
success has been seen with minimal duration of
stenting or without stents. Van Den Abbeele et al(24)
report the favorable outcome of transnasal endoscopic
repair of choanal atresia using powered instrumentation
and routine postoperative revision endoscopy in 40
children (unilateral: n = 26, bilateral: n = 14). Nasal
tubes in neonates or infants and nasal packing in older
children were removed after 2 days. Postoperatively,
32 patients (80%) had normal nasal patency and a
satisfactory choanal diameter without prolonged
nasal stenting after surgery. In agreement with this
study, Rombaux et al(19) also performed the endoscopic
endonasal approach using the microdebrider to
correct seven children with unilateral choanal atresia.
At the end of the procedure, topical application of
mitomycin was performed without postoperative nasal
stenting. Of the seven patient procedures, six (85.7%)
remained patent (follow-up range 12 to 36 months).
Holzmann and Ruckstuhl (25) also supported the
technique without stenting due to requiring less
invasive post-operative care. They found favorable
results of the transnasal surgical repair in eight
patients with unilateral choanal atresia by which no
stents were used. The success of choanal patency
was followed by nasal endoscopy with a mean postoperative follow-up time of 1.9 years. In all patients,
both choanae remained patent. No further treatment
was required. Moreover, Tzifa and Skinner(20) described
the endoscopic repair of three patients with unilateral
choanal atresia with the KTP laser with no requirement
for stenting. Follow-up was between 12 months and
four years with all choanae remaining patent, and no
dilatation was needed. These data suggest that postoperative stents can be placed for a shorter duration
and may not be required in some selected cases.
Avoidance of stents has a great deal of
appeal, but may be associated with a higher rate of
restenosis. Rahbar et al(26) reported a good result
using mitomycin for prevention and treatment of scar
formation in five patients with choanal atresia. Prasad
et al(27) also found a favorable result (17 patients: 85%)
of the use of topical mitomycin as an adjunct to the
surgical repair of 20 patients with choanal atresia
in improving patency with a decreased need for
stenting, dilatations, and revision surgery. Holland
and McGuirt(28) evaluated the intraoperative use of
mitomycin in eight patients with bony choanal atresia

704

undergoing choanal atresia repair, which were

compared with 15 historical controls. All patients in
both groups were treated with post-operative stenting.
The success rate of the repair of the choanal atresia
as determined by the post-operative need for dilation
or revision surgical procedures was compared. The
post-operative dilations for soft tissue restenosis in
children with intra-operative use of mitomycin
were significantly less than those in the controls.
These results show that mitomycin is an effective and
reliable treatment for improving the surgical outcome
for choanal atresia repair by reducing post-operative
scarring, obviating the need for postoperative
dilations and potentially eliminating the need for
surgical stenting.
After surgery, patients should be closely
followed-up for a long time to check restenosis. If
re-stenosis occurs, transnasal revision surgery or
dilations can be safely and easily repeated. This will
help to break up the forming scar, and eventually
leads to better patency. Increasingly larger diameter
male urethral sounds are lubricated and gently passed
through the nose into the nasopharynx. The stenotic
part is enlarged using guarded drills(29,30). Resection of
granulation tissue can be done with the use of CO2
laser. With the use of best possible techniques of
surgical correction, medication, and stenting, the
authors may cut down on postoperative stenosis
formation and the need for dilatation and revision
surgery in the future.
References
1. Theogaraj SD, Hoehn JG, Hagan KF. Practical
management of congenital choanal atresia. Plast
Reconstr Surg 1983; 72: 634-42.
2. Bergstrom L, Owens O. Posterior choanal atresia:
a syndromal disorder. Laryngoscope 1984; 94:
1273-6.
3. Harris J, Robert E, Kallen B. Epidemiology of
choanal atresia with special reference to the
CHARGE association. Pediatrics 1997; 99: 363-7.
4. Samadi DS, Shah UK, Handler SD. Choanal atresia:
a twenty-year review of medical comorbidities and
surgical outcomes. Laryngoscope 2003; 113: 254-8.
5. Dobrowski JM, Grundfast KM, Rosenbaum KN,
Zajtchuk JT. Otorhinolaryngic manifestations of
CHARGE association. Otolaryngol Head Neck
Surg 1985; 93: 798-803.
6. Brown OE, Pownell P, Manning SC. Choanal
atresia: a new anatomic classification and clinical
management applications. Laryngoscope 1996;

J Med Assoc Thai Vol. 92 No. 5 2009

106: 97-101.
7. Harner SG, McDonald TJ, Reese DF. The anatomy
of congenital choanal atresia. Otolaryngol Head
Neck Surg 1981; 89: 7-9.
8. Ku PK, Tong MC, Tsang SS, van Hasselt A.
Acquired posterior choanal stenosis and atresia:
management of this unusual complication after
radiotherapy for nasopharyngeal carcinoma. Am J
Otolaryngol 2001; 22: 225-9.
9. Imoto T, Hashimoto K. A case report of nasopharyngeal tuberculosis resulted in nasopharyngeal
obstruction. Otol Fukuoka 1981; 27: 592-4.
10. Dunham ME, Miller RP. Bilateral choanal atresia
associated with malformation of the anterior skull
base: embryogenesis and clinical implications.
Ann Otol Rhinol Laryngol 1992; 101: 916-9.
11. Hengerer AS, Strome M. Choanal atresia: a new
embryologic theory and its influence on surgical
management. Laryngoscope 1982; 92: 913-21.
12. Voegels RL, Chung D, Lessa MM, Lorenzetti FT,
Goto EY, Butugan O. Bilateral congenital choanal
atresia in a 13-year-old patient. Int J Pediatr
Otorhinolaryngol 2002; 65: 53-7.
13. Djupesland P, Kaastad E, Franzen G. Acoustic
rhinometry in the evaluation of congenital choanal
malformations. Int J Pediatr Otorhinolaryngol 1997;
41: 319-37.
14. Contencin P, Gumpert L, Sleiman J, Possel L,
De Gaudemar I, Adamsbaum C. Nasal fossae
dimensions in the neonate and young infant: a
computed tomographic scan study. Arch
Otolaryngol Head Neck Surg 1999; 125: 777-81.
15. Stankiewicz JA. The endoscopic repair of choanal
atresia. Otolaryngol Head Neck Surg 1990; 103:
931-7.
16. Richardson MA, Osguthorpe JD. Surgical
management of choanal atresia. Laryngoscope
1988; 98: 915-8.
17. Stamm AC, Pignatari SS. Nasal septal cross-over
flap technique: a choanal atresia micro-endoscopic
surgical repair. Am J Rhinol 2001; 15: 143-8.
18. Khafagy YW. Endoscopic repair of bilateral
congenital choanal atresia. Laryngoscope 2002;
112: 316-9.
19. Rombaux P, de Toeuf C, Hamoir M, Eloy P, Bertrand

J Med Assoc Thai Vol. 92 No. 5 2009

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

B, Veykemans F. Transnasal repair of unilateral

choanal atresia. Rhinology 2003; 41: 31-6.
Tzifa KT, Skinner DW. Endoscopic repair of
unilateral choanal atresia with the KTP laser: a one
stage procedure. J Laryngol Otol 2001; 115: 286-8.
Postec F, Bossard D, Disant F, Froehlich P.
Computer-assisted navigation system in pediatric
intranasal surgery. Arch Otolaryngol Head Neck
Surg 2002; 128: 797-800.
Caversaccio M, Hausler R. Unilateral choanal
atresia. A possible indication for computer aided
surgery? A report of two cases. Rhinology
2000; 38: 93-5.
Pasquini E, Sciarretta V, Saggese D, Cantaroni C,
Macri G, Farneti G. Endoscopic treatment of
congenital choanal atresia. Int J Pediatr
Otorhinolaryngol 2003; 67: 271-6.
Van Den AT, Francois M, Narcy P. Transnasal
endoscopic treatment of choanal atresia without
prolonged stenting. Arch Otolaryngol Head Neck
Surg 2002; 128: 936-40.
Holzmann D, Ruckstuhl M. Unilateral choanal
atresia: surgical technique and long-term results. J
Laryngol Otol 2002; 116: 601-4.
Rahbar R, Jones DT, Nuss RC, Roberson DW,
Kenna MA, McGill TJ, et al. The role of mitomycin
in the prevention and treatment of scar formation
in the pediatric aerodigestive tract: friend or
foe? Arch Otolaryngol Head Neck Surg 2002; 128:
401-6.
Prasad M, Ward RF, April MM, Bent JP, Froehlich
P. Topical mitomycin as an adjunct to choanal
atresia repair. Arch Otolaryngol Head Neck Surg
2002; 128: 398-400.
Holland BW, McGuirt WF Jr. Surgical management
of choanal atresia: improved outcome using
mitomycin. Arch Otolaryngol Head Neck Surg
2001; 127: 1375-80.
Randall DA, Kang DR, Mohs DC. Use of the
miniarthroscopic drill in choanal atresia repair:
how we do it. Otolaryngol Head Neck Surg 1997;
116: 696-7.
Vickery CL, Gross CW. Advanced drill technology
in treatment of congenital choanal atresia.
Otolaryngol Clin North Am 1997; 30: 457-65.

705


,
bucco-pharyngeal



oropharyngeal airway
2

706

J Med Assoc Thai Vol. 92 No. 5 2009