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OBJECTIVE: To evaluate the short- and long-term success of the repair of congenital choanal atresia using the transnasal endoscopic approach with and without power instruments. DESIGN AND SETTING: Retrospective case series in a tertiary care center. PATIENTS: Fifteen patients with either unilateral or bilateral congenital choanal atresia were treated using the transnasal endoscopic approach. Postoperative stenting was used in all 15 patients. INTERVENTIONS: The senior surgeon (C.W.G.) currently uses the transnasal endoscopic drill-out technique. We describe our experience and long-term follow-up of 15 patients (9 with unilateral atresia, 5 with bilateral atresia, and 1 with unilateral stenosis) who were treated with the use of the transnasal endoscopic technique during a 7-year period. In 8 patients, the transnasal endoscopic technique was performed using conventional biting instruments, and in 7 patients, the transnasal endoscopic technique with power instruments was used. MAIN OUTCOME MEASURE: The patency of the surgical repair of congenital choanal atresia by the transnasal endoscopic approach. RESULTS: Of 14 patient procedures, 12 remained patent. One patient required minor debridement of granulation tissue 1 week following stent removal, and 1 patient required surgical transnasal revision 2 months after the primary procedure, with a patent result after the second procedure. Despite patent choanae being achieved, 1 patient died of cardiac anomalies 8 months after the atresia repair. CONCLUSIONS: The transnasal endoscopic route offers excellent visualization of the posterior choana and, hence, the ability to open the defect widely with a high surgical success rate. Newer powered instrumentation further enhances the ability to perform this technique cleanly.

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Congenital choanal atresia is a challenging clinical problem requiring prompt diagnosis and intervention. The method of repair is controversial, with no technique having gained universal acceptance. Proponents of the transnasal repair must acknowledge the variability of results, especially with thick bony plates, and the technical difficulties associated with this method. Advocates of the transpalatal route must recognize the associated morbidity of this technique in the newborn. The adaptation of the endoscopic technique and the development of new powered instrumentation have significantly improved the transnasal technique so that safe controlled repair may now be accomplished in the newborn.

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Current surgical treatment of the frontal sinus disease include external approaches to obliterate or ablate the sinus and both external and transnasal methods to restore drainage into the nasal cavity. The original Lothrop procedure resects the medial frontal sinus floor, superior nasal septum, and intersinus septum, creating a large frontonasal communication. However, as described, the external approach used in this procedure often allowed medial collapse of soft tissue and the stenosis of the nasofrontal communication. This report further relates our experience with the modified transnasal endoscopic Lothrop procedure using suction drills for cases in which frontal recess exploration had failed to relieve obstruction of the frontal sinus. We present an update of the University of Virginia experience in performing the modified Lothrop procedure in 20 patients from 10/93 to 4/95. Our findings over the follow-up period (average 12 months) have verified that this procedure is effective, with a 95% patency rate for the surgically enlarged frontal sinus ostium. When compared to osteoplastic flap with fat obliteration, the modified transnasal Lothrop procedure offers the advantages of a less invasive procedure with a shorter and usually no hospitalization, less morbidity, and the increased ability to evaluate post-operatively for recurrent disease. A patient charge analysis was also performed comparing patients undergoing frontal sinus obliteration during the same time period, revealing an additional benefit of decreased patient costs for the modified transnasal Lothrop procedure. None of our patients experienced complications, and all showed significant improvement, if not complete resolution of their symptoms. Although this procedure has produced favorable results, it should be noted that this procedure is technically demanding and will require further long term follow-up to verify its efficacy and proper role in the spectrum of surgical approaches for the treatment of chronic sinusitis.

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Osler-Weber-Rendu disease remains a challenging clinical management problem. We have found the potassium-titanyl-phosphate laser (KTP/532) for photocoagulation of intranasal telangiectases to be useful in controlling epistaxis refractory to traditional surgical therapy. We present the case of a patient who had Osler-Weber-Rendu disease previously treated with partial septectomy, turbinectomy, and intranasal dermoplasty. A technique using the KTP laser for photocoagulation of intranasal telangiectases is described. This technique has resulted in reducing the frequency of epistaxis, decreasing the need for transfusions, diminishing hospital admissions, and improving quality of life for this patient. The KTP laser plays an important role in the management of recurrent epistaxis in patients with Osler-Weber-Rendu disease.

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Plain films of the paranasal sinus were the imaging technique most frequently used before the advent of computed tomography. With improved resolution, computed tomography imaging has become the standard for evaluating patients with disease of the paranasal sinuses. With the widespread availability of computed tomography scanning, patients are likely to undergo multiple examinations during the treatment of their disease. Concern has been raised over the radiation exposure to the patient, in particular, with regard to radiation-induced cataracts. The purpose of this study is to measure the radiation dose associated with a variety of techniques for imaging the paranasal sinuses. A cadaveric specimen with thermoluminescent dosimeters placed over the orbits was used to measure radiation exposure during plain-film imaging, limited computed tomography, standard axial and coronal computed tomography, thin-cut axial computed tomography, and thin-cut coronal computed tomography. The measured dose in all these techniques is less than 4% of the acute dose associated with cataract formation.

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