Transnasal mucosal flop rotation technique for repair of posterior choanalatresia

PURPOSE:To describe improved surgical treatment for posterior choanal atres ia (PCA) by creating mucosal flaps with the aid of operating microscope, CO 2 laser, serf-retaining nasal retractor, and stenting with a flat polytetra fluoroethylene (Teflon) keel. MATERIALS AND METHODS: Retrospective study of 19 patients with PCA, their a ges ranging from 6 days to 4 years 4 months at the time of first repair, re presenting 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 mi croscopic approach uses a myringotomy knife or CO2 laser to create an anter ior mucosal flap; the CO2 laser is also used to remove any bone plate and t o create the posterior flap. The flaps then are rotated into position and a re kept separated by a flat Teflon keel instead of a traditional round sten t to avoid pressure necrosis. When a stable epithelialized opening (2 x 2 t o 3 x 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 circum ferential scar contraction. RESULTS: Eighteen patients were re-examined after periods of 3 months to mo re than 5 years from when their first epithelialized orifice was created wi th nasal endoscopy to measure the final orifice size. All 18 patients bad c linically adequate-to-good bilateral nasal airways at the latest follow-up with an average orifice size of 3 x 5 mm and a range of 2 x 2 to 4 x 10 mm. This "same day surgery" technique with staged procedures provides similar or better patency rates than a single transpalatal approach but with less s urgical morbidity. It has a much lower restenosis rate than the transnasal puncture or PCA excision with prolonged round tube stenting and multiple di lation technique.