CLINICAL NOTE
Choanal Atresia
An Unusual Serious Complication
of Complementary and Alternative Medical Treatment
Chih-chieh Tseng, MD; Tung-Lung Tsai, MD; Kee-Tak Chen, MD; Ching-Zong Lin, MD
T
he use of complementary and alternative medicine (CAM) is common among patients with
chronic, long-standing nasal disease. Complications resulting from inappropriate CAM
practices are sometimes reported, but serious complications such as choanal atresia and
stenosis are rare. We report a case of choanal atresia and stenosis due to herbal drug (ie,
chemical) cauterization of the nasal cavity in a 39-year-old man. We reviewed the literature on why
patients previously given conventional treatment seek alternative therapies. The patient underwent
surgical intervention to relieve choanal atresia and stenosis. The postoperative course was unremark-
able, and follow-up for 1 year revealed no evidence of restenosis. Choanal atresia and stenosis result-
ing from CAM treatment are rare. Otolaryngologists should be aware of possible complications occur-
ring in patients receiving such treatments. Arch Otolaryngol Head Neck Surg. 2003;129:475-477
Acquired choanal atresia and stenosis are norrhea since his teenage years. At age 20
often complications of chemical cauter- years, he had undergone septomeato-
ization, radiotherapy,1 surgical trauma, and plasty to treat nasal blockage. Although his
infectious disease.2 Some alternative thera- nasal blockage disappeared after sep-
pists use herbal products to treat nasal dis- tomeatoplasty, sneezing and clear rhi-
ease, but inappropriate application of these norrhea persisted and were considered
herbs may cause problems. Serious com- bothersome.
plications such as choanal atresia have About 2 years before visiting our de-
been reported rarely. partment, he went to a private traditional
Many patients with chronic, long- Chinese medicine clinic for treatment. He
standing nasal problems seek treatment recalled the therapy procedure as fol-
from practitioners of complementary and lows: “The alternative practitioner put 2
alternative medicine (CAM) despite re- cotton balls rinsed with something like
ceiving previous treatment with conven- herbal material into both nasal passages
tional therapies.3 As primary physicians or and kept them in place for about 5 min-
otolaryngologists, we should be sensitive utes. The cotton balls were pushed all the
to the allure of CAM, discuss these thera- way to the deepest part of my nasal cham-
pies with patients who are interested in ber.” During that period, he said that he
trying them, and warn them about their felt intractable pain in his nose. After-
possible complications.3-5 wards, he did not go back to that clinic
because of the uncomfortable treatment
REPORT OF A CASE experience and persistent symptoms of
rhinorrhea and sneezing. Over a period
A 39-year-old man presented to our de- of 1 year after the treatment, nasal ob-
partment in October 2001 with the chief struction gradually developed.
complaint of nasal obstruction for about Initial examination showed the an-
2 years. The patient reported a history of terior nasal opening was patent, and the
nasal obstruction, sneezing, and clear rhi- nasal mucosa appeared pale and edema-
From the Department of Otolaryngology, Veterans General Hospital–Taipei, and tous on anterior rhinoscopy. Endoscopic
National Yang-Ming University, Taipei, Taiwan. The authors have no relevant nasopharyngoscopic examination re-
financial interest in this article. vealed that the right choana was almost
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nasopharynx, but no osseous com-
A B
ponent was identified (Figure 2).
The diagnoses of bilateral choanal
M atresia and stenosis were therefore
M established.
During surgery, the scarlike tis-
S S sue was resected from the bilateral
choana with partial resection of pos-
terior nasal septum, and 2 seg-
ments of nasogastric tube were
placed as stents. Histopathologic ex-
amination of the removed portion
I showed fibrosis and chronic inflam-
mation. Postoperative recovery was
uneventful. The 2 segments of na-
Figure 1. Nasopharyngoscopic findings: the right choana (A) was almost completely closed with just
a fissure remaining (arrow), and the left choana (B) measured only about 3 mm in diameter (arrow). sogastric tube were removed 6 weeks
I indicates inferior turbinate; M, middle turbinate; and S, nasal septum. later, and nasopharyngoscopic ex-
amination revealed a patent choa-
nal space (Figure 3). The wound
has shown no evidence of resteno-
sis for 1 year postoperatively.
COMMENT
Choanal atresia can be either congen-
ital or acquired, although most cases
are congenital. Causes of acquired
choanal atresia and stenosis include
complications of drug cauterization,
nasopharyngeal carcinoma after ra-
diotherapy,1 and trauma.2 Treat-
ment includes surgical repair via tran-
snasal, transpalatal, transantral, or
transseptal approaches.6 Stents are of-
ten kept in place intranasally from 2
weeks to 2 months to prevent reste-
nosis. In our patient, acquired choa-
nal atresia was diagnosed because no
Figure 2. Computed tomographic findings of the face demonstrate a membranelike soft tissue density osseous component was detected on
that obliterated the bilateral choanae (lower arrow), but no osseous component was identified. The
anterior nasal passage was quite patent (upper arrow). R indicates right side; L, left side. computed tomographic scan, surgi-
cal findings, or pathologic examina-
tion, and his illness developed after
he had undergone an alternative treat-
ment method.
According to a report by Eisen-
M berg et al,7 one third of the people
in the United States have used some
S S form of unconventional medicine.
Seventy-five percent of these pa-
tients did not inform their physi-
cians of this practice. 3 In a fol-
low-up study, it was found that total
expenditures on CAM increased
from $14 billion to $23 billion be-
tween 1991 and 1997.8 In some east-
Figure 3. Endoscopic view of the choanal passage 6 weeks postoperatively. Bilateral choanae were quite
ern countries, the use of CAM is even
patent (arrows). S indicates nasal septum; M, middle turbinate. more prevalent.
In surveys of users of CAM,
completely obliterated with just a mography of the sinus demon- about 80% report being satisfied with
small fissure remaining, and the left strated a membranelike soft tissue the treatment they received.3-5 How-
choana measured about 3 mm in di- density that obliterated the bilat- ever, this satisfaction was not always
ameter (Figure 1). Computed to- eral choanae and upper part of the dependent on improvements in pre-
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senting complaints of patients. There ity. Practitioners of CAM claim that means “safer” treatment should be
is little scientific evidence to support this therapy is effective for treating na- challenged. To prevent patients from
the claim of effectiveness of alterna- [Link],these suffering the possible severe compli-
tive medicine beyond the benefits ob- sorts of chemical regimens are corro- cations from CAM therapies, otolar-
tained through the placebo effect, cog- sive to the nasal mucosa, and if un- yngologists should inform and edu-
nitive dissonance, and the natural qualified CAM practitioners use these cate the public about the possible
resolution of disease.3-5 However, the herbal products to manipulate nasal dangers of receiving treatment from
attraction for complementary medi- mucosa inappropriately, it can result unqualified therapists and the pos-
cine may include the relationship pa- in undesirable complications, includ- sible complications of inappropriate
tients have with their practitioners, ing intractable pain, nasal synechia, CAM therapies.
the way in which their illness is ex- epistaxis, and choanal atresia. In our
plained, and the environment in case, the nasal passages were quite
which treatment is given. In addi- patent because of the previous septo- Accepted for publication November 13,
tion, the misconception that CAM is meatoplasty. Therefore, the alterna- 2002.
safer than conventional medicine also tive practitioner was able to put herbal Corresponding author and re-
plays a role.9 In fact, some herbal drugs deep into the choana without prints: Tung-Lung Tsai, MD, Depart-
products can cause undesired and of- difficulty. It may be for this reason that ment of Otolaryngology, Veterans
ten harmful effects. For example, the unusual complications of choanal General Hospital–Taipei, 201 Sec-
acute hepatitis has been reported to atresia and stenosis occurred. tion 2 Shih-Pai Rd, Taipei, Taiwan 112
be associated with the use of ma huang (e-mail: tltsai@[Link]).
for treating nasal problems.10 In our CONCLUSIONS
case, although the previous septome- REFERENCES
atoplasty had relieved the symptom Many patients with chronic, long-
of nasal blockage, the other symp- standing symptoms of nasal disease 1. Peter KM. Acquired posterior choanal stenosis and
toms (clear rhinorrhea and sneez- will not find relief with simple, uni- atresia: management of this unusual complica-
tion after radiotherapy for nasopharyngeal carci-
ing) persisted. The patient reported modal, and traditional therapies, in- noma. Am J Otolaryngol. 2001;22:225-229.
that he feared adverse effects from cluding nasal surgical procedures. The 2. Miho H, Kato I, Iwatake H, Akaio I, Takeyama I. A
conventional medicine and, want- otolaryngologist must consider a wide case report of acquired choanal atresia. Acta Oto-
laryngol Suppl. 1996;522:111-115.
ing a permanent cure for his nasal al- range of diagnostic and therapeutic 3. Krouse JH, Krouse HJ. Patient use of traditional
lergy problems, turned to alterna- options before deciding what treat- and complementary therapies in treating rhino-
tive treatment methods for help. ment for these chronically ill pa- sinusitis before consulting an otolaryngologist. La-
ryngoscope. 1999;109:1223-1227.
Some local and intranasal treat- tients is most appropriate.3 4. Raghavan U, Jones NS. Complementary and al-
ments for hypertrophic rhinitis have Because a large number of pa- ternative therapy for nasal conditions. J Laryn-
gol Otol. 2000;114:919-924.
been reported, such as silver nitrate tients have sought the opinion of al- 5. Asher BF, Seidman M, Snyderman C. Comple-
and trichloroacetic acid .11,12 Surgery ternative practitioners and have used mentary and alternative medicine in otolaryngol-
of hypertrophic inferior turbinates, CAM therapies to treat their nasal dis- ogy. Laryngoscope. 2001;111:1383-1389.
6. Coniglio JU, Manzione JV, Hengerer AS. Ana-
such as partial inferior turbinec- ease, otolaryngologists should ask tomic findings and management of choanal atre-
tomy, has long been used to treat na- their patients about the use of herbs, sia and the charge association. Ann Otol Rhinol
sal symptoms. Recently, laser cauter- nutritional supplements, and other al- Laryngol. 1988;97:448-453.
7. Eisenberg DM, Davis RB, Ettner SL. Trends in al-
ization of hypertrophic turbinates has ternative therapies. If a reasonable op- ternative medicine use in the United States. JAMA.
proved safe and effective in improv- tion for an alternative therapy exists, 1997;290:1569-1575.
8. Eisenberg DM, Davis RB, Ettner SL. Trends in al-
ing symptoms of rhinorrhea and na- it may be prudent to discuss and con- ternative medicine use in the United States, 1990-
sal blockage. The current lasers used sider its use with interested patients. 1997: results of a follow-up national survey. JAMA.
to perform turbinectomy include the As specialists, we must educate our- 1998;280:1569-1575.
9. Astin JA. Why patients use alternative medicine: re-
carbon dioxide laser, Nd:YAG laser, selves about the variety of CAM thera- [Link].1998;279:1548-1553.
and KTP laser.13-15 In this case, local pies available so that we can respon- 10. Nadir A, Agrawal S, King PD, Marshall JB. Acute
treatment of the nose (including sil- sibly advise our patients without hepatitis associated with the use of a Chinese
herbal product, ma-huang. Am J Gastroenterol.
ver nitrate, trichloroacetic acid, and shutting the door on their interests. 1996;91:1436-1438.
laser surgery) could have been con- Often, patient outcome may be posi- 11. Bhargave KB, Abhyankar US. Treatment of aller-
gic rhinitis and vasomotor rhinitis by the local ap-
sidered before the use of alternative tively affected by getting patients more plication of silver nitrate. J Laryngol Otol. 1980;
medicine if more aggressive thera- involved in their care.3-5 94:1025-1036.
pies were requested. Finally, quality control and stan- 12. Yao K, Shitara T. Chemosurgery to inferior turbi-
nate-trichloroacetic acid application. Nippon Jibi-
A variety of herbal products are dardization are important to con- inkoka Gakkai Kaiho. 1988;91:1031-1041.
reported in the traditional Chinese lit- sider in the area of CAM. Lack of fed- 13. Kawamura S, Fukutake T, Kubo N, Yamashita T,
erature to be used “externally” to treat eral standards for natural remedies Kumazawa T. Subjective results of laser surgery
for allergic rhinitis. Acta Otolaryngol Suppl. 1993;
[Link],theprac- and often lack of certification of CAM 500:109-112.
titioners may dissolve minerals con- practitioners should make our pa- 14. Kunachak S, Kulapaditharom B, Prakunhungsit S.
Minimally invasive KTP laser treatment of peren-
taining sulfated aluminum (eg, tients wary. Therefore, CAM should nial allergic rhinitis: a preliminary report. J Oto-
Al2[SO4]3[NH4]2 ·24 H2O) or arsenic be further investigated and analyzed laryngol. 2000;29:139-143.
compounds (eg, AsS2O3) into water. through the use of “evidence-based 15. Vagnetti A, Gobbi E, Algieri GM, D’Ambrosio L.
Wedge turbinectomy: a new combined photoco-
Then the cottonoids soaked with this medicine.” In addition, the concep- agulative Nd:YAG laser technique. Laryngo-
solution are placed into the nasal cav- tion that CAM is more “natural” and scope. 2000;110:1034-1036.
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