743

Computed Tomographic
Demonstration of Choanal
Atresia

R. Tadmor 1
M. Ravid 1
D. Millee
G. Leventon 2

During a 3-year period, nine girls and two boys (age range, 2 days-13 years) with
congenital choanal atresia were evaluated by computed tomography (CT). Other associated congenital anomalies, primarily craniofacial anomalies, were present in six of the
11 patients. In six patients the atresia was bilateral and consisted of both bony and
membranous components. Of the five patients with unilateral atresia, the lesions were
on the right in three and on the left in two. CT demonstrated the atresia, choanal
stenosis, septal deviation, and thickening of the vomer and palatine bone. The ease of
CT examination and the high accuracy of the results make it the preferred imaging
method for evaluating choanal atresia.

Choanal atresia is a rare congenital anomaly characterized by narrowing of the

posterior nasal cavity due to an obstruction at its end by an atretic plate. This plate
may be bony, membranous , or both . The atresia may involve one or both nasal
cavities , and other congenital anomalies may be associated with it [1-10].
If bilateral choanal atresia is present at birth, it requires immediate diagnosis and
intervention to permit respiration. Unilateral choanal atresia is usually diagnosed at
a later stage. The clinical diagnosis of choanal atresia is made easily when a
catheter cannot be passed through the nose. However, for confirmation and further
evaluation, various radiologic and other techniques have been described [1-10].
Traditionally, the conventional radiologic evaluation of this anomaly has consisted
of skull radiography, tomography, and instillation of radioopaque media into the
nose during fluoroscopy and radiography. The contribution of computed tomography (CT) also has been mentioned [11-13]. We report our experience in using CT
studies as the sole radiologic method for evaluating congenital choanal atresia.

Materials and Methods

Received October 31, 1983; accepted after revision April 29, 1984.
Presented at the annual meeting of the American
Society of Head & Neck Radiology, Boston , May

1983.
1 Division of Neuroradiology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel-Aviv
University, Tel-Hashomer 52621 , Israel. Address
reprint requests to R. Tadmor.

2 Department of Otolaryngology, Chaim Sheba

Medical Center, Sackler School of Medicine, TelAviv University, Tel-Hashomer 52621, Israel.

November/December 1984
0195-6108/84/0506-0743

AJNR 5:743-745,

American Roentgen Ray Society

During a 3-year period 11 children (nine girls and two boys) with congenital choanal atresia
were evaluated by CT. Their ages ranged from 2 days to 13 years. Three of the 11 patients
had had corrective surgery at an early age , but since reocclusion occurred they were referred
for radiologic evaluation before further treatment. Skull films were obtained in all 11 patients;
instillation of contrast medium into the nasal cavities before radiography was performed in
only one patient. CT scanning in all patients was performed with the Elscint-Exel scanner.
Sequential axial sections of the entire nasal region were obtained using 5-mm slice thickness
with 2-mm overlap. CT in the coronal plane was performed in three patients. Before the CT
studies , a vasoconstricting decongestant such as ephedrine nose drops (0.5% or 1%,
depending on the child 's age) was administered. Particular attention was paid to suctioning
out the excessive secretions in order to obtain a more accurate delineation of the anatomy
and pathology.

Results
The earliest diagnosis was made in a 2-day-old infant with bilateral choanal

TADMOR ET AL.

744

AJNR :5, Nov/Dec 1984

Fig. 1.-Bilateral choanal atresia in 2-day-old infant. A, Before suctioning. Nasal cavity is filled bilaterally with secretions (arrows). B, After suctioning.
Bony atresia and soft-tissue component clearly
shown on both sides (arrows). Note sinistrad deviation of septum.

A
Fig. 2.-Bilateral choana I atresia in 13-year-old girl
with reocclusion despite two previous operations to correct it. Stenosis of left posterior nasal cavity with thick
bony plate (solid arrow); posterior narrowing and thin
bony septation (open arrow) on right. Note asymmetry of
face. with smaller maxillary bone on right.

Fig. 3.-Bilateral choanal atresia in 5-year-old girl with reocclusion despite corrective surgery. A,
Thick bony atretic plates bilaterally (arrows) . B, Adjacent CT section. Narrowing of posterior nasal
cavities; thick mucosa and membranous component (open arrows).

atresia, in whom cyanosis was noted during breast feeding

(fig . 1). The oldest patient was a 13-year-old girl with partial
right and complete left atresia, in whom reocclusion occurred
despite two previous operations to correct it (fig . 2). There
were six patients with bilateral choanal atresia (figs. 3 and 4)
and five with unilateral atresia, three involving the right side
(fig. 5) and two the left. In all the cases of bilateral atresia, the
obstruction consisted of both bony and membranous tissue
(figs. 3 and 4). The septum deviated to the left in three patients
and to the right in two. Other associated congenital anomalies
were present in six of the 11 patients: Four had craniofacial
anomalies, one had a facial hemangioma, and one had cardiac
anomalies and a tracheoesophageal fistula.

geal membrane persists. Overgrowth of the bone at the

medial vertical and horizontal palatine plate has been postulated to explain the bony component of the atresia [1-10].
Some authors suggest occurrence of congenital adhesions at
the stenotic posterior choanal region as the most likely explanation for the condition [1 , 2].
Choanal atresia has been estimated to occur in one of
every 5000-8000 births [3, 7, 8]. There is a slight female
preponderance [3-10]; however, in two reports, the female:male ratio was found to be equal [1, 2] . In our series
there were nine girls and two boys. The condition is not
considered to be hereditary, although there are some reports
of more than one sibling of the same family being affected [3,

4].
Discussion
Congenital choanal atresia is an uncommon developmental
defect characterized by lack of communication between the
nasal cavity and the nasopharynx. This occurs embryologically around the seventh week of gestation, when either the
bucconasal membrane fails to perforate or the buccopharyn-

The anomaly may be bilateral or unilateral. Clinical diagnosis

of bilateral atresia is usually made when a newborn infant has
respiratory distress that is relieved by crying and aggravated
by nursing. The establishment of mouth breathing then becomes an emergency, while surgical correction can be
planned [1-10]. Unilateral choanal atresia becomes clinically
manifest at a later stage with complaints of unilateral nasal
obstruction, thick mucoid nasal secretions , impaired sense of

CT OF CHOANAL ATRESIA

AJNR:5, Nov/Dec 1984

745

Fig . 4.-Bilateral choanal atresia in 4-month-old infant. A, After suctioning. Thick bony atretic component
bilaterally (arrows). B, 5 mm lower. Membranous component (open arrows) .

smell, and repeated infections. Right-sided choanal atresia

has been reported as more common than left-sided or bilateral
atresia in some series [4, 7-10], whereas others claim that
the incidence of unilateral and bilateral atresia is equal [1, 2]
or that bilateral atresia is more frequent [5, 6] . In our series
of 11 patients, six cases were bilateral; of the five unilateral
cases, three were on the right.
CT in the axial plane was extremely valuable in demonstrating choanal atresia. The configuration of the nasal cavity is
displayed in its entire length and it is possible to visualize
stenosis and septal deviation and to differentiate between the
bony and membranous components. By altering window
width and center, complete and incomplete atresia can be
shown as well as variations in the thickness of the bony
atretic plate. CT in the coronal plane, performed in three
patients in our series, failed to contribute any valuable information. There has been one report of CT in the sagittal plane
to evaluate choanal atresia [13].
Septal deviation and stenosis are reported as concomitant
findings in this condition [2, 3, 6, 7]. These details were well
demonstrated by CT in our series. Variations in bone thickness and soft tissues also are extremely well displayed (figs.
2-5). The atresia has been reported as bony in 68%-90% of
cases [3, 7, 9] and as membranous in the rest. In our series,
the atresia was bony and membranous in all but one case, in
which it was purely membranous. Differentiation between
thickened mucosa and pure membranous occlusion may be
a problem. We believe that any soft tissues visualized posteriorly on the axial CT scans after adequate suctioning and
instillation of vasoconstricting nose drops should correspond
to the membranous components of the atresia.
Other congenital anomalies such as craniofacial cleft palate,
Treacher Collins syndrome, and cardiovascular and abdominal malformations have been reported in 20%-50% of cases
of choanal atresia [4, 10]. In the series of Evans and Mclachlan
[1], 28 (43%) of 65 patients had associated anomalies. Carpenter and Neel [8] reported other congenital anomalies in 6

Fig. 5.-Unilateral choanal atresia in 4-monthold infant. Thin bony plate with thick membranous
component on right (arrow) .

(17%) of 36 patients. In our series, six (55%) of 11 patients

had other congenital anomalies: Four had craniofacial anomalies, one had a facial hemangioma, and one had a ventricular
septal defect and a tracheoesophageal fistula.
Various approaches have been advocated for surgical repair of choanal atresia: transnasal, transpalatal, transantral,
or transseptal, all involving microsurgical techniques [1-9].
Currently, transnasal resection using the CO 2 laser seems
very promising, even in cases of reocclusion [9].

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