Long-Term Outcomes of Endoscopic Choanal Atresia Repair Using Mucoperiosteal Flaps Without Stenting: Insights from a 10-Year Pediatric Cohort

Highlight

• Endoscopic repair of congenital choanal atresia (CCA) using mucoperiosteal flaps without stenting achieves excellent long-term neochoanal patency (97%) in children.
• Despite high patency, restenosis and postoperative complications such as granulation tissue formation (22%) and synechiae (33%) were common.
• Relook surgery was required in nearly half of patients (47%), mostly within the first postoperative month, indicating early vigilance is essential.
• Careful surgical technique combined with dedicated postoperative follow-up can optimize functional outcomes in this complex pediatric airway anomaly.

Study Background

Congenital choanal atresia (CCA) is a relatively rare but clinically significant craniofacial malformation characterized by a bony or membranous obstruction of the posterior nasal airway. The anomaly can present as a neonatal emergency, especially in bilateral cases due to neonates’ obligate nasal breathing, or with recurrent nasal symptoms later in childhood. CCA impacts airway patency, feeding, and respiratory function, necessitating timely surgical intervention.

The current gold standard for treatment is endoscopic endonasal repair, favored for its minimally invasive approach and reduced morbidity compared to traditional transpalatal methods. Surgical repair often involves mucosal flap creation to enhance healing and reduce restenosis. However, the role of postoperative stenting remains controversial due to concerns about mucosal injury, discomfort, and infection risk. Evidence on long-term functional outcomes and predictors of revision surgery after stentless repair approaches remains limited, especially in pediatric populations.

This study provides a comprehensive 10-year experience from a tertiary pediatric referral center examining unilateral and bilateral CCA repairs using mucoperiosteal flaps without stenting, focusing on clinical characteristics, complications, and surgical outcomes.

Study Design

This retrospective single-center cohort study included pediatric patients (≤18 years old) who underwent primary endoscopic endonasal repair of unilateral or bilateral CCA between 2015 and 2025. The institution is a tertiary referral pediatric hospital, ensuring a specialized clinical setting.

Surgical intervention involved meticulous mucoperiosteal flap elevation to expose the atretic plate followed by its resection. Notably, no postoperative stents were placed. Data extraction included patient demographics, type of atresia (unilateral vs bilateral), perioperative complications such as bleeding or infection, and long-term functional outcomes measured by neochoanal patency.

The primary endpoint was the rate of long-term neochoanal patency. Secondary outcomes included rates of granulation tissue formation, synechiae (adhesions), restenosis, and the frequency and timing of relook surgeries (revision procedures).

Key Findings

Thirty-six children underwent endoscopic repair; 23 had unilateral and 13 had bilateral choanal atresia. Despite the initial anatomical correction, postoperative complications occurred with notable frequency:

– Granulation tissue formation was observed in 22% of cases, potentially contributing to mucosal inflammation and healing challenges.
– Synechiae developed in 33% of patients, possibly impairing nasal airflow or predisposing to restenosis.
– Restenosis occurred in 39% of cases, representing a significant obstacle to sustained surgical success and patient comfort.

Due to these complications, nearly half of the cohort (47%) required relook surgery to manage obstruction or symptomatic recurrence. These reinterventions predominantly took place within the first postoperative month, indicating a narrow window where close monitoring is crucial for intervention.

Importantly, despite these challenges, long-term neochoanal patency was achieved in 97% of patients, which is a remarkable success rate and supports stentless repair when combined with mucoperiosteal flap technique.

The findings suggest that while restenosis and related complications remain prominent hurdles, the overall efficacy of endoscopic repair without stenting is high, possibly mitigating the risks associated with stents such as foreign body reaction and infection.

Expert Commentary

The present study complements evolving surgical paradigms that favor mucosa-preserving endoscopic techniques without stenting. It confirms that meticulous mucoperiosteal flap elevation optimizes healing by providing preserved vascularized tissue coverage over bony defects, crucial for patency.

Nevertheless, the considerable rate of postoperative complications and reoperations highlights ongoing challenges. Frequent granulation and synechiae formation underscore the delicate balance between adequate surgical exposure and mucosal trauma. The timing of reintervention within a month also points toward the critical early postoperative period where inflammation and scarring can be monitored and managed aggressively.

The lack of stenting might reduce patient discomfort and lower infection risks, but surgeons must be vigilant for restenosis, and infrastructure to support close follow-up should be emphasized.

Limitations of the study include its retrospective design and single-center scope, which may limit generalizability. Prospective controlled trials comparing stented versus non-stented approaches could further clarify optimal management.

Conclusion

Endoscopic endonasal repair of congenital choanal atresia using mucoperiosteal flaps without stenting offers excellent long-term neochoanal patency with comparatively low morbidity. However, nearly half of pediatric patients require relook surgery due to postoperative complications such as restenosis, granulation tissue, and synechiae.

This reflects a need for enhanced perioperative strategies, including meticulous surgical technique and vigilant postoperative monitoring during the early healing phase to optimize functional outcomes. The data support stentless approaches as safe and effective, with potential quality-of-life benefits. Future studies should explore adjunctive therapies to reduce inflammation and scar formation, and establish protocols for intensive early postoperative care.

Funding and Clinicaltrials.gov

The original study funding status was not specified, and no clinical trial registration number was provided for this retrospective analysis.

References

1. Uyttebroek S, et al. Choanal Atresia Repair Using Mucoperiosteal Flaps Without Stenting: 10-Year Experience. Laryngoscope. 2026 Jul 16. PMID: 42461216.
2. Rahbar R, et al. Endoscopic repair of choanal atresia: surgical outcomes and prognostic factors. Int J Pediatr Otorhinolaryngol. 2020.
3. Berdah SV, et al. Choanal atresia: an update on diagnosis and treatment. Int J Pediatr Otorhinolaryngol. 2021.
4. Kuo CL, et al. Outcomes of endoscopic choanal atresia repair with and without stenting. Laryngoscope. 2022.

These references provide supporting context on surgical techniques, outcomes, and ongoing debates regarding stenting in choanal atresia repair.