Choanal Atresia

What this deck covers

Choanal Atresia in ten clinical teaching cases with worked explanations. Each case gives you a clinical vignette, four options, the correct answer, and an explanation of why each of the other three is wrong.

Diagnoses and management options tested

Across the ten cases you are asked to choose between options such as: Bilateral choanal atresia, Unilateral choanal atresia, Transient tachypnea of the newborn, Nasal endoscopy, Flexible laryngoscopy, High-resolution CT scan of the sinuses, Buccopharyngeal membrane, First pharyngeal arch, Frontonasal process, Primary palate, Lateral neck X-ray, Barium swallow study, Purely membranous, Fibrous tissue only.

Clinical pearls from this deck

• Neonates are obligate nasal breathers, so bilateral choanal atresia produces the hallmark paradoxical (cyclical) cyanosis — cyanosis at rest that resolves with crying (the open mouth bypasses the blocked nose). No air movement from either nostril indicates a complete, bilateral obstruction. Unilateral atresia presents later with persistent unilateral nasal discharge, not acute neonatal cyanosis.
• The bedside catheter-passage test is the quick confirmatory step: inability to pass a 5–6 Fr catheter beyond ~3–3.5 cm into the nasopharynx confirms choanal obstruction. Nasal endoscopy is the gold standard but needs ENT equipment; HRCT is reserved for surgical planning, not initial bedside screening.
• Choanal atresia results from failure of the buccopharyngeal membrane (the nasobuccal membrane of Hochstetter) to rupture between weeks 3–7, leaving persistent tissue blocking the posterior choanae. Other proposed mechanisms include incomplete resorption of nasopharyngeal mesoderm and misdirected neural-crest migration.
• High-resolution CT of the skull base is the gold-standard imaging — it distinguishes bony from membranous components and shows the thickened vomer, narrowed posterior nasal cavity, and medial pterygoid bowing needed for surgical planning. MRI is reserved for a suspected encephalocele/skull-base defect; plain films and barium swallow have no role.
• About 70–90% of atretic plates are mixed bony-membranous with a predominantly bony component (vomer + lateral pterygoid plate); only ~10% are purely membranous. Composition is surgically important — bony plates require drilling.
• Roughly 50% of choanal atresia is syndromic, and CHARGE syndrome (CHD7 mutation, chromosome 8q12) is the most common association. Every neonate with choanal atresia — especially bilateral — should be evaluated for CHARGE features and other associations (Crouzon, DiGeorge, Treacher-Collins).
• The McGovern nipple (a modified oral airway) breaks the tongue–palate seal and establishes oral breathing — the simple, rapid, first-line emergency fix in bilateral choanal atresia. A nasopharyngeal airway cannot work because the choanae are blocked; stabilize first, then plan definitive repair (tracheostomy and emergent surgery are not first-line).
• The transnasal endoscopic approach is the current gold standard — minimally invasive, excellent visualization, no external incision, less palatal scarring, and repeatable if restenosis occurs. The transpalatal approach is reserved for complex revisions or very thick bony plates. Postoperative stenting ± mitomycin C may reduce restenosis (10–36%).
• In the Blake criteria for CHARGE, the MAJOR criteria are the four C’s — Coloboma, Choanal atresia, Cranial-nerve dysfunction, and Characteristic ear anomalies. Heart defects, genital hypoplasia, and TE fistula are minor criteria. Diagnosis needs 3 major, or 2 major + 2 minor.

The deck above is free and needs no sign-in. Work through it once for recognition, then again a week later to test yourself — each question has one best answer and a worked explanation.

More from this system: all ent decks and question sets · pediatric reference values.