HO NURSING TRAINING COLLEGE
GROUP SIX PRESENTORS
1. AFELETEY DERRICK
2. AFUN ELMA
3. AFFUL ESI JANET
TOPIC:
CHOANAL ATRESIA
CHOANAl ATRESIA
Choanal Atresia in Paediatric Nursing is a congenital condition where the back of the nasal passage is blocked,
usually by abnormal bony or soft tissue. It can be unilateral (affecting one side) or bilateral (affecting both sides).
This blockage can severely affect breathing in newborns, as they are obligate nasal breathers in their early months
of life.
TYPES OF CHOANAL ATRESIA
1. Unilateral Choanal Atresia:
Affects one nasal passage, often the right side.
Often goes undiagnosed for years as infants can compensate by breathing through the open nostril.
2. Bilateral Choanal Atresia:
Both nasal passages are blocked, leading to immediate respiratory distress at birth.
Infants may exhibit cyanosis and require a breathing tube until surgical correction is performed.
INCIDENCE.
The incidence of choanal atresia is relatively rare, occurring in approximately 1 in 5,000 to 8,000 live births. It is
more common in females than in males, with a female-to-male ratio of about 2:1.
Unilateral choanal atresia is more common and may not be diagnosed until later in life, as it causes less immediate
respiratory distress. Bilateral choanal atresia, though less common, presents as a neonatal emergency because
newborns primarily breathe through their noses.
PATHOPHYSIOLOGY
Pathophysiology of Choanal atresia results from a developmental abnormality in the formation of the posterior
nasal cavity. Normally, the nasal passages form during the 4th to 11th weeks of gestation. In choanal atresia, the
oronasal membrane fails to break down during embryonic development properly. This leads to a blockage of the
nasal choanae, which are the passages that connect the nasal cavity to the nasopharynx. The atresia can be Bony
(90% of cases) and caused by the persistence of the bony plate that separates the nasal cavity from the nasopharynx.
Membranous (10% of cases): Caused by soft tissue thickening. In unilateral choanal atresia, only one side of the
nasal passage is blocked, and patients may present later with nasal obstruction or chronic discharge on one side. In
bilateral choanal atresia, both nasal passages are blocked, leading to immediate respiratory distress in newborns, as
they are obligate nasal breathers for the first few months of life. Choanal atresia is often associated with other
craniofacial abnormalities and syndromes, most notably CHARGE syndrome. The combination of choanal atresia
with other anomalies points to a disruption in early embryologic development affecting multiple structures.
CAUSES OF CHOANAL ATRESIA
1. Developmental Abnormalities: The nasal cavity and palate develop from neural crest cells, and disruptions in this
process can lead to choanal atresia.
2. Genetic and Environmental Factors: Genetic predispositions, along with environmental triggers such as exposure
to certain chemicals (e.g., herbicides) and medications (e.g., methimazole), may increase risk13.
CLINICAL MANIFESTATION
A. Bilateral Choanal Atresia (more severe):
1. Neonatal respiratory distress: Newborns with bilateral atresia exhibit respiratory difficulty immediately after
birth because they are obligate nasal breathers. They often present with cyanosis that improves when they cry (as
crying forces the baby to breathe through the mouth).
2. Feeding difficulties: Infants may struggle with feeding due to the need to breathe through their mouth, leading to
poor feeding, choking, and regurgitation. Cyanosis at rest: The cyanosis can worsen when the infant is calm or
quiet, as they attempt to breathe through the obstructed nasal passages.
3. Nasal obstruction: There will be an apparent lack of air passage through the nose, which may be observed by the
absence of fogging on a cold mirror held under the nostrils.
B. Unilateral Choanal Atresia:
1. Chronic nasal discharge: Affected infants may have a unilateral, persistent nasal discharge (usually
mucopurulent).
2. Unilateral nasal obstruction: There may be a noticeable difference in nasal airflow on one side, often leading to
delayed diagnosis in later childhood or even adulthood.
3. Snoring or noisy breathing: Mild snoring or noisy breathing may be noted during infancy but is not usually as
severe as in bilateral cases.
DIAGNOSIS INVESTIGATION
1. Physical Examination:
Failure of nasal airflow test: A cold mirror or cotton wisp placed near the nostrils will show no condensation
or movement if the air is not passing through the nasal passages.
Passage of a nasal catheter: The inability to pass a catheter (size 6 or 8 French) through the nostril into the
nasopharynx suggests obstruction. This is often the first clue in suspected cases.
2. Endoscopy:
Nasal endoscopy is the gold standard for visualizing the posterior nasal cavity and detecting obstruction. A
flexible or rigid endoscope allows direct visualization of the atretic plate and can differentiate between
bony and membranous choanal atresia.
3. Imaging Studies:
CT scan of the head and neck: A high-resolution computed tomography (CT) scan with thin sections (1-2
mm) in the axial and coronal planes is the most definitive diagnostic tool. It provides detailed images of the
nasal cavity, showing the nature (bony or membranous) and extent of the obstruction.
MRI (Magnetic Resonance Imaging): Although not routinely used, MRI can be helpful in complex cases or
in evaluating associated craniofacial anomalies, especially in syndromic cases like CHARGE syndrome.
4. Other Tests:
Chest X-ray or ABG (Arterial Blood Gas): May be indicated in neonates with severe respiratory distress to
assess lung function and oxygenation status, but these are supportive rather than diagnostic for choanal
atresia.
Genetic Testing (if syndromic association is suspected): For infants with choanal atresia associated with
other congenital abnormalities (such as CHARGE syndrome), genetic testing may be recommended to
identify specific gene mutations, such as in the CHD7 gene.
SURGICAL TREATMENT
Surgical treatment for choanal atresia primarily involves endoscopic techniques aimed at restoring airway patency.
Key approaches include:
Trans-nasal Endoscopic Repair: This is the most commonly used method. Surgeons utilize endoscopes and
specialized instruments to create an opening in the blocked nasal passage, often employing dilators and
stents to maintain the airway during healing.
Trans-palatal Approach: In cases where craniofacial anomalies are present, surgeons may access the
choanae through the roof of the mouth.
Stenting: Post-surgery, stents (often modified endotracheal tubes) may be placed to prevent restenosis,
although their necessity is debated.
MEDICAL TREATMENT
Medical treatment for choanal atresia is generally limited, as the condition primarily requires surgical intervention.
However, some supportive measures can be employed, especially in less severe cases:
Observation: For unilateral choanal atresia without significant symptoms, close monitoring may be
sufficient. Parents are advised to watch for any respiratory distress or feeding difficulties.
Nasal Saline: Saline sprays can help maintain moisture in the nasal passages, preventing blockages from
mucus buildup.
Airway Management: In cases of bilateral choanal atresia, immediate airway management is critical. This
may involve intubation or using a McGovern nipple to maintain an adequate oral airway until surgery can
be performed.
Supportive Care: Infants may require supplemental oxygen or other supportive measures to manage
breathing difficulties until surgical correction is achieved.
NURSING DIAGNOSIS
1) Impaired Gas Exchange: Due to airway obstruction, particularly in bilateral cases, leading to respiratory distress.
NURSING MANAGEMENT
Maintain Airway Patency: Regularly assess and clear the airway using suctioning techniques as needed to
prevent obstruction.
Positioning: Elevate the head of the bed to enhance lung expansion and facilitate easier breathing.
Oxygen Therapy: Administer supplemental oxygen to maintain adequate oxygen saturation levels,
particularly in cases of respiratory distress.
Monitor Respiratory Status: Continuously assess respiratory rate, effort, and oxygen saturation to detect any
changes in gas exchange.
Nasal Saline Irrigation: Use saline drops or sprays to keep nasal passages moist and clear, reducing
secretions that may obstruct airflow.
Prepare for Surgical Intervention: Coordinate with the surgical team for timely intervention, especially in
cases of bilateral choanal atresia requiring immediate surgery.
Educate Parents: Provide information on recognizing signs of respiratory distress and the importance of
follow-up care post-surgery.
Emotional Support: Offer reassurance and support to parents, addressing their concerns about their child's
condition and treatment plan.
2. Ineffective Breathing Pattern: Resulting from the inability to breathe through the nose.
NURSING MANAGEMENT
Assess Respiratory Status: Monitor respiratory rate, depth, and pattern regularly to identify any changes or
distress.
Positioning: Position the patient in an upright or semi-Fowler's position to facilitate easier breathing.
Oxygen Therapy: Administer supplemental oxygen as prescribed to maintain adequate oxygen saturation
levels.
Suctioning: Perform gentle suctioning of secretions to maintain airway patency and reduce respiratory
distress.
Hydration: Encourage fluid intake to keep secretions thin and easier to manage.
Nasal Care: Implement nasal saline drops or sprays to moisten the nasal passages and alleviate congestion.
Teach Breathing Technique: Educate the patient (or caregiver) on effective breathing techniques, such as
diaphragmatic breathing.
Monitor for Complications: Watch for signs of respiratory infections or other complications related to
ineffective breathing patterns.
Family Education: Educate family members on recognizing signs of respiratory distress and the importance
of prompt medical attention.
3. Risk for Aspiration: Associated with feeding difficulties as infants may struggle to breathe and swallow
simultaneously.
NURSING MANAGEMENT
Positioning: Place the infant in a semi-upright position during feedings to minimize the risk of aspiration.
This position helps keep the airway open and reduces the likelihood of fluids entering the respiratory tract.
In severe cases or postoperatively, position the infant with the head elevated to promote drainage and
prevent aspiration.
Suctioning: Frequent and gentle nasal suctioning may be necessary to remove secretions, especially if there
is unilateral choanal atresia, to prevent the pooling of secretions that can lead to aspiration.
Monitoring for Cyanosis and Respiratory Distress: Observe the infant closely for signs of cyanosis (blue tint
to the skin) or respiratory distress, particularly during feeding. Intervene promptly if these symptoms
appear, as they can indicate a risk of aspiration. Monitor oxygen saturation levels and provide supplemental
oxygen if necessary.
Feeding Methods: In cases of bilateral choanal atresia, feeding may need to be done using a specialized
bottle (like a McGovern nipple) or via a nasogastric tube to bypass the obstructed nasal airway until surgical
correction is performed. If surgical correction is delayed or the risk of aspiration remains high, alternative
feeding methods such as gastrostomy may be necessary to prevent aspiration.
Education: Educate parents on how to manage the infant's airway and feeding at home, including
recognizing signs of aspiration, when to suction, and proper positioning during feeds.
4. Anxiety related to deficient knowledge of the condition.
NURSING MANAGEMENT
Provide Emotional Support: Acknowledge the anxiety experienced by parents, especially when their
newborn is in respiratory distress. Offering empathetic listening and reassurance can help reduce feelings of
helplessness. Encourage parents to express their concerns and fears, ensuring that their emotions are
validated.
Education and Communication: Clearly explain the condition, the treatment plan, and the prognosis.
Knowledge often reduces anxiety. Provide information in understandable language and avoid medical
jargon. Walk parents through the procedures, especially surgery, and explain postoperative care.
Understanding the steps involved helps reduce uncertainty and fear.
Involve Parents in Care: Teach parents basic care techniques, such as suctioning and proper feeding
positions. This involvement gives them a sense of control and reduces anxiety about managing their infant's
condition at home. Offer hands-on guidance with feeding methods and respiratory care if necessary.
Address Long-Term Concerns: Discuss the long-term outcomes and potential challenges, while reassuring
parents about the typical success rates of treatment. For example, most infants with choanal atresia can lead
healthy lives after corrective surgery.
Referral to Support Groups: Encourage participation in support groups where parents can connect with
others facing similar challenges. Peer support can alleviate anxiety by sharing experiences and coping
strategies.
Relaxation Techniques: Teach relaxation techniques, such as deep breathing or mindfulness, to help parents
manage their stress during hospitalization or before surgical procedures.
PRE- OPERATIVE CARE.
Airway Management: Babies with choanal atresia may have breathing difficulties, especially during
feeding. Ensuring airway patency is critical before surgery. If bilateral choanal atresia is present, urgent
airway management, such as oral airway insertion or intubation, may be required.
Hydration: In preparation for surgery, if the child is placed on NPO, IV fluids are administered to maintain
proper hydration.
Medications such as antibiotics may be prescribed to prevent infection if nasal secretions are pooling or if
there is an ongoing upper respiratory infection.
Diagnosis and Imaging: Preoperative imaging, usually by CT scan, is essential for confirming the diagnosis
and determining the nature (bony vs. membranous) and extent of the atresia.
Parental Education: Parents should be informed about the surgical process, potential risks, and post-
operative care. Emotional support and counseling may be necessary.
POST-OPERATIVE CARE.
Airway Management: Post-operatively, the infant’s airway needs to be closely monitored. Stenting or nasal
packing may be placed to keep the nasal airway open, requiring careful observation to ensure patency.
Pain Management: Appropriate analgesia should be provided to manage post-surgical pain, tailored to the
needs of the infant or child.
Infection Control: Post-operative antibiotics may be administered to prevent infection. The surgical site
must be kept clean, and any signs of infection should be promptly addressed.
Monitoring and Follow-up: Regular follow-up with endoscopic examinations is necessary to check for
restenosis (re-blockage). In some cases, additional surgeries may be needed if restenosis occurs.
Stent or Packing Removal: If nasal stents are placed during surgery, they are usually removed within 1-2
weeks, depending on the surgeon’s protocol. Post-removal monitoring is crucial to ensure proper healing
and maintenance of airway patency.
Feeding and Respiratory Care: Feeding may initially be affected post-surgery. Gradual reintroduction of
oral feeding may be necessary. Respiratory function should be regularly assessed, and the parents educated
about the signs of respiratory distress.
PREVENTIONS
1) Preconception Counseling: Women planning to conceive should seek preconception counseling to identify any risk
factors, such as underlying medical conditions or genetic predispositions, that may contribute to congenital
abnormalities.
2) Folic Acid Supplementation: Adequate folic acid intake before and during pregnancy is essential. Folic acid
supplementation (400-800 mcg daily) has been shown to reduce the risk of neural tube defects and may contribute
to overall fetal development, potentially reducing the risk of craniofacial abnormalities.
3) Avoidance of Teratogens: Pregnant women should avoid exposure to known teratogens (substances that can cause
birth defects), such as:
Tobacco smoke
Alcohol
illicit drugs
Certain medications (e.g., retinoids or isotretinoin, which are known to cause craniofacial defects)
Environmental toxins (e.g., chemicals, heavy metals, and radiation)
4. Control of Maternal Health Conditions: Proper management of maternal health conditions like diabetes, thyroid
disorders, or autoimmune diseases during pregnancy
may reduce the risk of congenital defects, including choanal atresia.
5. Regular Prenatal Care: Attending regular prenatal check-ups ensures early detection of potential developmental
abnormalities. Ultrasound screening and other prenatal tests can help identify craniofacial anomalies or associated
syndromes that may include choanal atresia, allowing for timely intervention planning.
6. Genetic Counseling: If there is a family history of choanal atresia or other congenital defects, genetic counseling
can help assess the risk of passing on hereditary conditions, such as CHARGE syndrome. This can guide
prospective parents in making informed decisions about family planning and pregnancy management.
COMPLICATIONS OF CHOANAl ATRESIA
Respiratory Distress and Cyanosis: Bilateral choanal atresia can cause severe respiratory distress in
newborns, leading to hypoxia and cyanosis. This is a medical emergency because newborns are obligate
nasal breathers.
Failure to Thrive: Difficulty in breathing during feeding can cause poor feeding, leading to inadequate
nutritional intake. This may result in failure to thrive and poor weight gain in infants.
Aspiration: Due to breathing difficulties during feeding, infants may aspirate milk or food, leading to a risk
of aspiration pneumonia or recurrent respiratory infections.
Recurrent Infections: Unilateral choanal atresia can lead to chronic nasal discharge and an increased risk of
sinusitis or recurrent respiratory infections due to the obstruction and retention of secretions.
Airway Obstruction Post-surgery: After surgical repair of choanal atresia, complications can include nasal
stenosis (narrowing of the nasal passages), the formation of scar tissue, or restenosis of the choanae. This
can require further surgical interventions.
Chronic Mouth Breathing: Children with unresolved or unrecognized unilateral choanal atresia may become
chronic mouth breathers, leading to dental malocclusions and other craniofacial growth abnormalities due to
altered airflow and oral posture.
CONCLUSION
Choanal atresia is a congenital condition characterized by the blockage of the nasal airway, typically due to
abnormal bony or membranous tissue. It can be unilateral (one side) or bilateral (both sides), with bilateral cases
often causing immediate respiratory distress in newborns, as they are obligate nasal breathers. Symptoms may
include difficulty breathing, cyanosis, and feeding challenges. Diagnosis is usually confirmed via physical
examination and imaging studies, such as CT scans. Treatment involves surgical intervention to remove the
obstruction, with stents sometimes used post-operatively to maintain airway patency. Full recovery is expected, but
complications can include respiratory issues and restenosis after surgery.
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