93

CASE REPORT
Choanal Atresia
A Case Report Illustrating the Use of
Computed Tomography1
Ali Shirkhoda, M.D.
W. Paul Biggers, M.D.
Bilateral choanal atresia is often associated
with severe asphyxia immediately after
birth and can be the cause of death from
suffocation. However, in the unilateral
type, the diagnosis is often delayed until
the second decade of life or even later. This
communication presents a case of bilateral
complete choanal atresia, reviews the
clinical features, and emphasizes the role
of computed tomography in making the
diagnosis.
Index terms: Infants, newborn, respiratory
system #{14N9}asopharynx, abnormalities
#{1N49as}opharynx, computed
tomography,
2(6)1211 #{14(9N} ose, choanal atresia,
2[6].1493)
Radiology 142: 93-94, January 1982
S INCE 1971, when Williams reported a
relatively large series of cases of
choanal atresia (1), there has been scant
reference to this congential anomaly in
radiologic literature. We report what we
believe to be the first case of bilateral
complete choanal atresia studied by
computed tomography (CT) and compared
with conventional radiography.
The role of CT is described, not only in
making the diagnosis, but in determining
the nature of the atretic segment, its
thickness, and location. CT is the fastest,
least invasive way to obtain the diagnosis
of choanal atresia.
CASE REPORT
A newborn girl was admitted one day
after birth because of noisy breathing with
nasal flaring and chest retraction. The child
was born via spontaneous vaginal delivery
to a healthy, white, 25-year-old mother,

1 From the Departments of Radiology (AS.)

and
Otolaryngology (W.P.B.), University of
North
Carolina, Chapel Hill, NC. Presented at the
Sixty-seventh Scientific Assembly and
Annual
Meeting of the Radiological Society of
North
America, Chicago, IL, Nov. 15-20, 1981.
Received
May 15, 1981, and accepted July 2. ht
after a term gestation of 39 weeks. She
weighed 3320 g at birth, and had an Apgar
score of 6 at one minute after birth and 8
after 5 minutes. Immediately after birth she
was noted to exhibit noisy breathing and to
be slightly dusky, but skin color improved
with crying. An attempt was made to pass
a 5-F catheter per naris without success. She
was then intubated using a 3.5 oral
endotracheal
tube, at which time her dusky cyanosis
cleared. Good air exchange was established
bilaterally without labored respiration.
The chest radiograph was normal.
Physical examination was otherwise normal.
With a presumptive diagnosis of bilateral
choanal atresia, she was transferred
to our institution.
Following the instillation of oily contrast
material into both nasal cavities, skull
radiographs
demonstrated the absence of flow
from the nares into the region of the
nasopharynx
(Fig. 1), confirming the diagnosis
of bilateral complete choanal atresia.
It was elected to use a McGovern nipple
to help keep the tongue from occluding the
posterior pharynx and also to help develop
mouth breathing. Surgery was postponed
until after a moderate amount of growth.
The effectiveness of the nipple airway was
confirmed by studies performed by the
Pediatric Pulmonary Service. It was found

that oxygen saturations ran around 90-92%;

this is equal to a Pao2 in the 60% range
while
breathing is unobstructed. However, when
obstructed, the saturations dropped to about
80-82%; this is equal to a Pao2 in the mid to
high 40% range.
The infant spent about 6 weeks at home,
during which time she had no apnea and
was doing well. However, she required
frequent suctioning to remove nasal
secretions.
She had to sleep on her side in order
to be able to breathe effectively. For this
reason, the decision was made to correct the
anomaly instead of waiting until she was
older.
At the age of 7 weeks, she was readmitted
for surgery. CT examination was performed,
using both axial and sagittal scans
to seek additional information. Only a
limited number of sagittal scans were
obtamed
while holding the infant inside the
gantry, with the scanning beam parallel to
each naris. CT demonstrated symmetry of
obstruction (Fig. 2a), location of the
obstructive
tissue, its thickness, height, and
bony nature (Figs. 2b and c).
At this time, the infant underwent surgery.
By using the CO2 laser (2), the atretic
plate was penetrated. A significant amount
of bone anteriorly and laterally was removed
with the House curette. An opening
into the nasopharynx was expanded without
difficulty by using a curette on both
sides. The laser was used to remove soft
tissue in the area of the atresia. The child
tolerated the surgery well without any
postoperative complication, and has done
well through the ensuing months.
DISCUSSION
Choanal atresia occurs in 1 of 5000 live
births (3) and has been reported to have
a two-fold predominence of females over

males. (4). It may be complete or

incomplete,
and can be unilateral or bilateral.
The obstructing membrane is a vestigial
structure, which usually begins to disappear
at the end of the fifth week of intrautenine
life. In over 90% of the cases,
the obstruction is bony, while in the
memainder
it is membranous (5). The atresia
is bilateral in about / of the cases, and it
can be associated with anomalies such as
high-arched hard palate, thick vomer,
nasal septum, and other congenital
anomalies. In unilateral cases there may
be a narrow nasal cavity on the affected
side (6).
Bilateral choanal atresia is often associated
with severe asphyxia immediately
after birth. Since the neonate is an obligate
nasal breather and will most often
not attempt to breathe through the
mouth, there may be death from suffocation.
Those infants who do survive
birth usually continue to lose weight
because of inability to suckle. On anterior
rhinoscopy, the occluded nasal cavity is
found to be filled with thick, tenacious,
glaring, translucent secretion. The child
usually has the classic signs of mouth
breathing, with a typical open mouth,
pinched nostrils, and smooth expressionless
face. The voice is nasal and there
the occluding septum may be perforated
Figure 1
carefully with a straight trocar or urethral
sound, and the opening then enlarged
with sidebiting rongeurs.
.j
. . . ,
Department of Radiology
Division of Imaging
University of North Carolina
Chapel Hill, NC 27514
Figure2
a.b.c.

94 January 1982 Volume 142, Number 1

Shirkhoda and Biggers
is anosmia, dry mouth, and often a
conjunctivitis.
In unilateral cases, the diagnosis is
often not made until the second decade
of life when the patient seeks relief from
longstanding, unilateral nasal obstnuction
with excessive nasal discharge. This
may be misdiagnosed as a nasal foreign
body. A suspected diagnosis of choanal
atresia can be confirmed by attempting to
pass a small catheter through the nostril
into the oropharynx. If this is impossible,
the nose can be directly examined using
a zero-degree endoscope and/or an operating
microscope. One may also determine
the patency of the nostril by blowing
air through a nostril gently with a
Politzer bag. Anterior rhinoscopy will
reveal the presence of a glaring mucus.
On posterior rhmnoscopy, one can observe
a membrane occluding the choanae.
Radiologic study after instillation of a
radiopaque liquid while the patient is in
the supine position is the classic method
of diagnosis. However, CT has the
advantage
of being faster and less invasive;
also by not using any contrast material,
the diagnosis, including the nature of the
obstructing segment, can be obtained.
Bilateral choanal atresia usually requires
immediate surgical intervention,
but this is not always the case. Many
children resuscitated after delivery will
learn mouth breathing by using the
McGovern nipple (7). In an emergency,
References
1 . Williams HJ. Posterior choanal atresia.
AJR
1971; 112:1-11.
2. Healy GB, McGill T, Jako GJ, Strong MS.

Vaughan CW. Management of choanal

atresia with the carbon dioxide laser. Ann
Otol Rhinol Laryngol 1978; 87:658-662.
3. Maniglia AJ, Goodwin WJ Jr. Congenital
choanal atresia. Otolaryngol Clin North Am
1981;14:167173.
4. Flake CC, Ferguson CF. Congenital
choanal
atresia in infants and children. Ann Otol
Rhin Laryngol 1964; 73:458-473.
5. Roopenian A, Stermer AL. Congenital
postenor
choanal atresia. Am J Surg 1958; 96:
802-807.
6. Harner SC, McDonald TJ, Reese DF. The
anatomy of congenital choanal atresia.
Otolaryngol
Head Neck Surg 1981; 89:7-9.
7. McGovern, FH. Association of congenital
choanal atresia and congenital heart disease.
Report of two cases. Ann Otol Rhin and
Laryng 1953; 62:894-895.
;j
Basal view of the facial bones demonstrates
nasal passages outlined by contrast material
(arrows). There is no evidence for flow into
the
nasopharynx. Arrowheads point to the tube
in
the hypopharynx, which is held by a safety
pin.
a. Axial CT scan shows symmetrical
obstruction (arrows) slightly anterior to the
region of the choanae (c).
b. Sagittal CT scan demonstrates nasal
cavity (nc), nasopharynx (np), and the
obstructive segment in between.
C. By electronic manipulation of the image
using the appropriate window and center, all
the bony structures, including the bony
nature of
the atretic segment (arrowheads), are
displayed.