Endoscopic repair of bilateral choanal atresia in neonates: anesthetic and surgical implications

ABSTRACT

Bilateral Choanal Atresia patients are usually in respiratory distress at birth. Such patients [neonates] have unique anesthetic and surgical requirements regarding equipment, intravenous access, fluid and drug therapy, anesthetic dosage, and environmental control. An understanding of the basic differences in physiology, pharmacologic and pharmaco-dynamic responses, and the underlying pathology of the surgical problem is essential for the development of a safe anesthetic/surgical plane. To describe and evaluate the outcome of the anesthetic / endoscopic transeptal approach for the repair of bilateral choanal atresia in neonates. A prospective analysis of a case series of neonates with bilateral choanal atresia who were treated by the endoscopic transeptal approach between July 2003 and December 2005 was undertaken. Endotracheal intubation was performed under adequate plane of general [inhalational/narcotic] anesthesia. Adequate depth of general [inhalational/narcotic] anesthesia with spontaneous and gentelly assisted ventilation were appropriate till the end of surgery. The endoscopic approach was performed using 4-mm 0° telescope. A laterally based trapezoid shaped septal mucosal flap was created on each side using a radiofrequency needle. The flaps were elevated in a swinging door fashion to expose the atretic plate and the vomer. After removal of the posterior bony septum and widening of the choana, the flaps were trimmed and applied to the exposed lateral bony rim of the choana. All patients were stented bilaterally for three to four weeks postoperatively. Neonatal/infant Pain Scale [NIPS] was used to assess the wellbeing and pain status of neonates in the immediate postoperative period. The study group included 14 neonates aged 2 to 25 days at the time of surgery. Follow up ranged from 4 to 36 months with a mean of 17.3 +/- 9.3 months. All neonates had a smooth anesthesia course, with minimal blood loss. Postoperatively, all have 0 to 1 score in the NIPS. Recovery was uneventful in all cases except for one case that developed bleeding in the immediate postoperative period and was controlled under endoscopic guidance. One case died three months following stent removal from uncompensated heart failure due to concomitant ventricular septal defect. An adequate functional nasal breathing and appropriate feeding with sufficient weight gain were maintained during the entire follow-up period. The described anesthetic/endoscopic technique was very adequate. It offered excellent visualization of the choana and allowed maximal widening of the choana while preserving the mucosa along the entire circumference of the newly created choana and hence less risk of postoperative stenosis