Vilnius University hospitals Santara clinics A very significant operation was performed - a four-day-old newborn born with a rare and life-threatening respiratory defect called bilateral choanal atresia underwent successful surgical intervention.
Modern methodology – for the first time in Lithuania
The medical team of Vilnius University Hospital Santaros Clinics applied a modern treatment method that has not yet been used in Lithuania – minimally invasive endoscopic choanal plastic surgery using local mucosal flaps. During the operation, extremely small endoscopes and microinstruments intended for ear surgery were used, which allowed for extremely gentle and precise removal of the nasal septum, reaming out part of the bone and forming a new nasal opening (choana). In order to reduce the risk of scarring and recurrent stenosis, the newly formed opening was covered with local mucosal flaps.
"This complex operation required extreme precision and care, because we worked in a very narrow anatomical area with extremely small instruments," emphasizes Donata Šukytė-Raubė, an otolaryngologist at the Santara Clinics Ear, Nose, and Throat Diseases Center, who performed the operation. "The patient's nostril is the size of a pinhead, there is very little space in the nose, so the instruments used during the operation are very tiny - the size of their working part was like a needle."
According to the doctor, another challenge is to form mucosal patches that protect the little patient from unpleasant nasal stenting and scarring that could re-close the choanae. This is difficult to do in such a tiny nose. The doctor vividly describes how performing such a procedure is like using chopsticks to weave a net of cooked noodles while sitting in a moving car.
In addition to otolaryngologist D. Šukytė-Raubė, the operation, which lasted about 2 hours, was attended by two anesthesiologists and resuscitators, assisted by a resident doctor, and the smooth course of the operation was ensured by a team of operating room nurses and other specialists.
What is choanal atresia?
Choanal atresia is a congenital defect of the nasal cavity in which the opening between the nasal cavity and the pharynx (back of the nose) is blocked or enlarged. This opening, called the choana, allows air from the nose to enter the throat and then the lungs. In choanal atresia, this opening may be closed by a bony or membranous septum, and the blockage may be unilateral or bilateral.
Due to the blockage of the nasal cavities, babies cannot breathe or eat, so urgent medical care, intubation and surgical intervention are required. According to the head of the Pediatric Ear, Nose and Throat Diseases Department of the Santara Clinics Ear, Nose and Throat Diseases Center, otolaryngologist Dr. Vaiva Mickevičienė, choanal atresia is a rare congenital pathology that occurs in one in 5000–8000 newborns. Bilateral choanal atresia is a very serious condition that requires urgent surgical intervention. It is much rarer than unilateral. Unilateral choanal atresia occurs more often, and although the nasal symptoms are quite pronounced – thick, more unilateral, constant secretion, nasal congestion, difficulty breathing through the nose – the operation is usually performed later, when the patient grows up.
"There is no single specific cause of choanal atresia. This is a congenital pathology when the tissues separating the nasal and pharyngeal (nasopharyngeal) cavities do not completely separate during fetal development. Choanal atresia can occur as an isolated developmental disorder, when there are no changes in other organs or their systems, or be a component of various genetic syndromes (CHARGE, Treacher-Collins or Crouzon syndrome). CHARGE syndrome is characterized by a complex of congenital defects affecting different parts of the body: eye and heart defects, choanal atresia, developmental and growth disorders. Treacher-Collins syndrome causes congenital deformations of the skull and face, lower jaw, ears, nose, upper jaw, 11 percent of which can also be diagnosed with choanal atresia," says the head of the department, otolaryngologist Dr. V. Mickevičienė, who lists the causes of the respiratory tract defect.
Without nasal stents – safer and gentler for the patient
Unlike previous techniques, nasal stents were not used in this case – they were abandoned in favor of a safer and gentler treatment method. “The mucosal patches were fixed with biological glue, which significantly improved the postoperative period of the little patient – the baby was quickly extubated and soon began to breathe through the nose. The method we chose allows us to avoid some of the previously existing complications, such as long-term use of stents, infections or discomfort for the little patient,” says otolaryngologist D. Šukytė-Raubė.
A team of specialists providing care for a newborn
Newborns with a respiratory tract defect are cared for by neonatologists in the Neonatal Intensive Care Unit, where babies spend the first weeks of their lives. In cases of bilateral choanal atresia, intubation may be necessary, and it is necessary to constantly monitor vital signs and perform all necessary tests to confirm the diagnosis. If unilateral or bilateral choanal atresia is suspected, the newborn is consulted by an otolaryngologist: “The nasal passages are examined with narrow endoscopes, which allow them to be assessed all the way to the nasopharynx, but the final diagnosis is made after radiological imaging studies – computed tomography,” explains otolaryngologist Dr. V. Mickevičienė. “The radiologist assesses whether the choanal atresia is unilateral or bilateral, bony or membranous. This determines the further treatment tactics – the otolaryngologist decides whether the operation should be urgent (in the case of bilateral bony choanal atresia) or can be performed later, in the case of unilateral choanal atresia. The participation of an anesthesiologist with experience with newborns is extremely important during the operation.”
Further care and attention of the little patient after a successful operation
After the operation, it is necessary to clean the nose at least once, and sometimes several times, to suction out the secretions and liquefied glue. “For newborns, this must be done each time under sedation (short-term sleep with medication), since the procedure is not pleasant. Later, the patient is regularly monitored by otolaryngologists on an outpatient basis. Although the operation performed endoscopically, without the use of stents, reduces the risk of stenosis (narrowing), it still remains, therefore, as the child grows, the nasal passages are periodically evaluated with an endoscope,” comments otolaryngologist Dr. V. Mickevičienė on postoperative care.
An important step in pediatric otolaryngology
"This is a significant step in the field of pediatric otorhinolaryngology. The new methodology not only reduces the risk of complications, but also speeds up the recovery of young patients and improves treatment outcomes," summarizes D. Šukytė-Raubė, the otorhinolaryngologist who performed the operation.
This operation marks a new stage in pediatric respiratory surgery in Lithuania. Less surgical trauma, shorter recovery period, and higher quality of treatment open up wider opportunities to effectively and safely help the smallest patients with rare and complex congenital pathologies.
