Evolution of managing choanal atresia towards mucosal flap surgery

Introduction

Choanal atresia (CA) is a rare condition in which there is congenital obstruction of one or both of the posterior nasal apertures. The embryological mechanism is a form of incomplete resorption of the nasopharyngeal mesoderm, and the atretic plate is most commonly a mixed membranous and bony wall (1). The pathology is not just a nasal obstruction, but a malformation of the whole posterior nasal structures. Bilateral CA requires surgical intervention near the time of birth since newborns are obligatory nasal breathers. In contrast, unilateral CA may be diagnosed at birth or much later in life, having been fairly asymptomatic or with unilateral nasal obstruction and discharge.

Surgery to manufacture a patent nasal airway is the only definitive treatment option. There are several operative factors to consider such as early versus delayed surgery, the fashioning of mucosal flaps, and the use of post-operative stents. The presence of a genetic syndrome in a significant proportion of cases, coloboma, heart disease, atresia of the choanae, retarded growth and mental development, genital anomalies, and ear malformations and hearing loss (CHARGE) syndrome being the most common (2), adds a further layer of complexity to the management of these infants. Due to the rarity of CA, the majority of the evidence in the literature to guide surgical decision making has been derived from observational studies (3). The surgical approach is tailored to the individual patient’s pathology and clinical circumstances, taking into account surgeon preferences and expertise, which can vary across different institutions (4).

The aim of the present study was to examine surgical outcomes for CA over a 20-year period at a tertiary paediatric referral centre. There was a focus on restenosis rates and the need for revision operations to optimize the nasal airway. With a 20-year review, the secondary aim was to describe how the surgical approach to CA has evolved at The Children’s Hospital at Westmead, with a shift away from the use of stents and serial dilatations, and towards the use of mucosal flaps. In particular, we introduce a novel bi-directional mucosal flap technique (BMFT) via a transnasal endoscopic approach which has become our standard surgical approach with promising early results in a limited number of patients.

Methods

This study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-24-23/rc).

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Sydney Children’s Hospital Network Human Research Ethics Committee (HREC), with the HREC Reference number 2025/ETH009201. Because of the retrospective nature of the research, the requirement for informed consent was waived.

Study design & patient cohort

A retrospective review was conducted on patients who underwent endoscopic transnasal CA surgery at The Children’s Hospital at Westmead between 2000 and 2001. Data was collected by the lead investigator (S.M.) from the institutional electronic medical records system known as PowerChart. Surgery was performed by any one of eight surgeons.

Children with both bilateral and unilateral congenital CA were included in this study. The former were newborns who had been identified as having bilateral CA at birth and were emergently admitted to the neonatal intensive care unit (NICU). The latter were children at various stages of childhood who were admitted electively for surgical management. Patients were excluded if there was an incomplete data set, specifically pertaining to operation reports, surgical technique employed, or clinical descriptions of the nature of restenosis encountered in subsequent operations. A clear description of restenosis warranting surgical intervention documented in an operation report, or on a clinical note based on bedside nasendoscopy findings pre-operatively, was deemed sufficient to confirm the presence of restenosis. Patients for whom clinical notes had not been scanned onto the current electronic medical record system from years where clinical notes were handwritten on hardcopy files were excluded as no data was available.

Data were collected on a range of clinical parameters, including: sex; laterality of CA (bilateral or unilateral); anatomical classification of the atresia (mixed membranous and bony versus purely bony); prematurity (defined as <37 weeks gestational age); Appearance, Pulse, Grimace, Activity, Respiration (APGAR) scores (a standardized assessment of neonatal condition at 1 and 5 minutes after birth); presence of a genetic syndrome or dysmorphic features; relevant co-morbidities; results of genetic investigations [karyotype, fluorescence in situ hybridization (FISH), and comparative genomic hybridization (CGH) microarray]; radiological findings from computed tomography (CT) and magnetic resonance imaging (MRI); age and weight at the time of first surgery; surgical technique (including approach, use of mitomycin C, post-operative stenting, and mucosal flap creation); and the methods used in any revision surgeries. Early surgery was defined as surgery performed before 7 days of age in patients with bilateral CA, and before 1 year of age in those with unilateral CA.

Surgical outcomes

The surgical outcomes analyzed included mortality relating to the surgical intervention, respiratory support pre- and post-operatively, restenosis, number of revision procedures required, number of dilatations performed as part of revision surgeries, other complications pertaining to the endoscopic transnasal approach (such as alar dehiscence), and length of stay in hospital. Revision surgery numbers referred to procedures after and excluding the initial surgery.

Restenosis following the first surgery incorporated both partial and complete restenosis. Partial restenosis was not subdivided into anatomical failure and functional failure, which are distinguished on whether there is resolution of symptoms (5). The reason for this was that a large proportion of our cohort were bilateral CA newborns in whom distinguishing between anatomical and functional failure was not reliably ascertained from retrospective notes and highly clinician dependent.

Surgical techniques and post-operative care

A transnasal approach was used in all cases with 0-/30-/120-degree rigid endoscopes available. For example, the 120-degree rigid endoscope was used to directly visualize transnasal instrumentation on the atretic choanae via the oral cavity. In other cases, endoscopes were used together with instruments within the nasal cavity if there was enough space. The technique and instruments used were tailored to the individual patient, such as the use of a back-biter to the vomer, microdebrider, drill, posterior septectomy, and Hegar dilator to name a few. Topical mitomycin C (0.4 mg/mL) was selectively applied for 4–5 minutes in cases with endoscopic evidence of early restenosis due to granulation tissue. Stents were used at the discretion of the operating surgeon based on anatomical or clinical concerns.

Bilateral CA patients were re-admitted to the NICU post-operatively, whereas older children with unilateral CA were typically admitted to a surgical ward. All patients received a combination of steroid drops (such as 0.1% dexamethasone) and saline drops to the nasal cavity in the immediate post-operative period. Nasal saline drops were continued routinely three to four times a day until further outpatient follow-up. For patients with bilateral CA, it was common practice for some surgeons to re-examine the nasal cavity after the first operation and perform a routine dilatation or debridement of minor granulation tissue formation, and this was not considered to be indicative of partial restenosis.

BMFT

In a subset of patients (n=4), we started using a BMFT via a transnasal endoscopic approach. The development of this novel technique has been facilitated by advances in surgical equipment, particularly the availability of high quality 0-degree endoscopes of varying sizes (2.7/3/4 mm), the microdebrider which was used in conjunction with the 15-degree 3.5 mm coarse diamond burr, and the advent of endoscopic ear instruments which are fine enough to work in the confined space of a newborn nasal cavity. The nose was topically prepped with neuropatties soaked with oxymetazoline hydrochloride (500 microg/mL, up to 5 mL in volume) in combination with 1:1,000 adrenaline/epinephrine (up to 1 mL in volume).

• A posteriorly-based septal flap was raised in the more patent nasal cavity (for bilateral CA) using the anterior mucosal layer of the atretic plate, as it was easier to raise a flap in an antegrade fashion rather than retrogradely towards the operator.
• The underlying atretic bone and the septal vomer were then drilled via the more patent nasal cavity. This step was also performed in unilateral CA cases, with the posterior mucosal layer of the atretic plate incised laterally to form an anteriorly-based septal flap which wrapped around the drilled edge of vomer.
• For bilateral CA, the anteriorly-based septal flap was raised in the more narrow nasal cavity using the anterior mucosal layer of the atretic plate. The purpose of this flap was to wrap around the drilled edge of the vomer.
• It was important to incise low onto the floor of the nasal cavity when fashioning the inferior border of the mucosal flaps in order to preserve maximal mucosa.
• Once the mucosal flaps were raised, the cavity was widened by drilling the atretic plate, extending to the medial pterygoid plates laterally, and to the body of the sphenoid and clivus postero-superiorly. The vomer and posterior maxillary crest were drilled down to the nasal floor to encourage side-to-side mucosal healing of flaps.
• The mucosal flaps were then used to cover exposed bony surfaces. The anteriorly-based septal flap (fashioned from the anterior mucosal layer of the atretic plate on the more narrow nasal cavity for bilateral CA) was wrapped around the free edge of the posterior septum. The posteriorly-based flap (fashioned from the anterior mucosal layer of the atretic plate on the more patent nasal cavity for bilateral CA) was used to line exposed bony surfaces of the neo-choana including the basisphenoid and postero-superior limits of drilling. The flaps were precisely trimmed with a 3.5 mm microdebrider blade, allowing mucosa-to-mucosa apposition, with minimally exposed bone. To provide added support to the mucosal flaps, fibrin glue was used to line the wound.

A link is provided for video demonstration of the BMFT (Video 1), and the anatomy of mucosal flap arrangements are illustrated in Figure 1. The video demonstrates surgery in a newborn with bilateral CA, although the inset CT scan illustrates a case of unilateral CA to emphasize that the BMFT can be tailored to both pathologies.

Figure 1 Key steps in bi-directional mucosal flap technique. (A) Posteriorly-based septal flap raised in left nasal cavity (more patent side in this case of bilateral choanal atresia). (B) Diamond burr drill to remove abnormally thickened vomer, indicated by arrow on axial CT scan. (C) Anteriorly-based septal flap is raised on more narrow contralateral side (right side in this case of bilateral choanal atresia), with dashed line indicating border of intended flap. (D) Sickle knife being used to raise superior aspect of anteriorly-based septal flap on right side. (E) A probe is used to reflect the anteriorly-based septal around the remaining vomer from the right side to the left side (arrow). (F) Abnormal hard palate is polished down with diamond burr drill (arrow: drilled down hard palate bone). (G) Mucosa-to-mucosa apposition achieved (arrows), and fibrin glue subsequently applied. (H) Final view of neo-choana. ABSF, anteriorly-based septal flap; IT, inferior turbinate; MT, middle turbinate; PBSF, posteriorly-based septal flap; S, septum.

Statistical analysis

Statistical analyses were performed using SPSS Statistics Software (Version 31.0.1.0, IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarise baseline and clinical characteristics. Continuous variables were reported as means with standard deviations (SDs) or medians with interquartile ranges (IQRs), depending on data distribution. Categorical variables were summarized as frequencies and percentages. The Mann-Whitney U test was used to compare the number of revision surgeries between groups, while Chi-squared test was applied to assess differences in restenosis rates. A P value <0.05 was considered statistically significant.

Results

Fifty-five children were identified as having bilateral or unilateral CA operated upon at The Children’s Hospital at Westmead during the 20-year period from 2001 to 2021.

Cohort characteristics

A description of the cohort is summarized in Table 1. There was a female-to-male ratio of 1.75:1 and there was a mixed membranous and bony atretic plate in 55% (n=30) of cases. This was followed by a purely bony atretic plate in 29% (n=16) of cases and a purely membranous atresia in 16% (n=9) of cases. Bilateral CA was present in 44% (n=24) of cases, and unilateral CA was present in 56% (n=31) of cases. Cohort characteristics are separated into bilateral and unilateral CA in Table 2.

Within the overall cohort, abnormalities were detected on genetic testing included pathogenic mutations on CHD7 mutation analysis to confirm CHARGE syndrome in two cases, detection of partial trisomy 4 by karyotype in one case, detection of a pathogenic microdeletion on CGH microarray to diagnose Prader Willi Syndrome in one case, and detection of 22q11.2 microdeletion syndrome by fluorescence in situ hybridization (FISH) in two cases.

Surgical techniques and follow-up

Transnasal posterior puncture under direct vision with a 120-degree telescope was performed in 17 cases. In addition to mucosal flaps, techniques were used in combination to achieve a patent neo-choana, including back-biter to vomer (n=20), use of a microdebrider (n=26), posterior septectomy (n=12), and Hegar dilatation (n=21). For the entire cohort, the mean (± SD) duration of follow-up in the ear/nose/throat (ENT) outpatient clinic was for 30±41 months, often for other ENT issues that arose throughout childhood.

Surgical outcomes

A total of 24 patients (44%) developed restenosis following their first operation. Surgical outcomes have been presented separately for bilateral and unilateral CA, since these reflect patients with different ages, weights, respiratory support statuses and disparate operative approaches. The median length of stay for bilateral CA was 39 days (IQR, 17–83 days), in comparison to 2 days (IQR, 2–3 days) for unilateral CA.

Bilateral CA (n=24)

For bilateral CA, there were 19 patients intubated pre-operatively and five patients requiring a Guedel airway or oral stent. In contrast, 22 patients were managed on room air post operatively, with two patients on nasal prong respiratory support. Restenosis developed in 13 patients (54%) following their first operation in at least one side.

Although 13 out of 24 patients developed restenosis after their first operation, 20 patients had a revision or relook procedure. For the seven cases where there was no restenosis but a revision or relook procedure was still performed, operative details were: routine debridement of minimal granulation tissue (three cases); routine dilatation in the absence of restenosis (two cases); minor trimming of choanal septum edge (one case); and replacement of stent and debridement of limited granulation tissue respectively (one case). Restenosis was not present in any of these seven cases. Thirteen children underwent a dilatation as part of a revision or relook procedure, and for those receiving dilatation a mean of 2.2±2.0 dilatations were performed (Table 3). There were eight patients with bilateral CA who had stents inserted post-operatively and five developed restenosis.

Although there was no mortality related to CA surgery, three patients with bilateral CA suffered mortality from other causes during their admission. These causes included hypoxic brain injury; progression of severe genetic defect and associated complications; and enterococcus faecium causing severe gastroenteritis, dehydration, sepsis and death. One patient with bilateral CA suffered alar dehiscence of the left nostril requiring suturing with 6-0 nylon.

Unilateral CA (n=31)

Table 3 shows restenosis rates and clinical features for unilateral CA. The median age at the time of first surgery was 1.5 years (IQR, 0.5–5.8 years), ranging from 3 days to 18 years. For patients with unilateral CA, 11 (36%) developed restenosis following their first operation.

For the three children with unilateral CA who required continuous positive airway pressure (CPAP) support pre-operatively, this was due to the presence of other co-morbidities, such as congenital heart disease. In one case, surgery for unilateral CA resulted in weaning of CPAP to nasal prong respiratory support post-operatively. Although 11 patients developed restenosis, 12 patients underwent a revision or relook procedure. In the one case where there was no restenosis but a relook procedure was performed, this was for minor trimming and debridement of limited granulation tissue which was not causing any obstruction of the nasal airway. Six children underwent a dilatation as part of a revision or relook procedure, and for those receiving dilatation a mean of 1.7±0.5 dilatations were performed (Table 3). There were three patients with unilateral CA who had stents inserted post-operatively and two developed restenosis.

Restenosis rates

As shown in Figure 2, bilateral CA was associated with an odds ratio (OR) 1.53 [95% confidence interval (CI): 0.84–2.78] for restenosis. In contrast, the use of mucosal flaps as part of CA surgery was associated with an OR 0.29 (95% CI: 0.08–1.09) for restenosis. The OR for BMFT could not be calculated since no patients who received the BMFT developed restenosis (n=0).

Figure 2 OR for developing restenosis by clinical sub-group. CI, confidence interval; OR, odds ratio.

Number of revision procedures

The mean number of revision surgeries for a variety of clinical sub-groups are illustrated in Figure 3. Patients who received stent insertion underwent the highest mean number of revision surgeries (2.8±2.2). This was followed by patients with bilateral CA (2.3±2.1). Where a mucosal flap was fashioned as part of CA surgery, patients had a lower mean number of revision procedures (0.5±1.0). Of note, the BMFT group required 0 revision procedures.

Figure 3 Mean number of revision surgeries by sub-group in patients with choanal atresia. BMFT, bi-directional mucosal flap technique; SD, standard deviation.

Compared to patients with unilateral CA, those with bilateral CA required more revision procedures (mean difference 1.3 more procedures, 95% CI: 0.3–2.3, P<0.01). Similarly, patients who received a stent as part of their operation required a significantly greater number of revision procedures (mean difference 1.6 more procedures, 95% CI: 0.4–2.9, P<0.01). In contrast, patients who had mucosal flaps fashioned as part of their surgery required significantly fewer revision surgeries compared to those who did not (mean difference 1.4 fewer procedures, 95% CI: 0.2–2.6, P<0.01). In particular, patients who received the BMFT also required fewer revision operations (mean difference 1.6 fewer procedures, 95% CI: 0.4–3.6, P=0.04). No statistically significant difference was seen for patients who had a genetic syndrome (P=0.96) or mitomycin C application (P=0.46).

Mucosal flap technique

There were 13 patients who had a mucosal flap raised as part of their operation. In four cases, this was according to the BMFT, a specific method of mucosal flap creation. For the remaining seven cases, mucosal flaps were raised in a non-specific way to optimally cover exposed bony surfaces created during the primary operation.

The four patients who received BMFT were non-syndromic with no significant cardio-pulmonary co-morbidities, with three patients having unilateral and one patient having bilateral CA. These four operations were performed in the period between 2015 and 2021, and stenting or mitomycin C were not required in conjunction with the BMFT.

None of these patients develop restenosis or require further revision surgeries, and no complications were observed from the operation. The length-of-stay in hospital for the three unilateral CA cases was 2, 2, and 3 days respectively. For the patient with bilateral CA, surgery was performed at 3 days of age. The patient was returned to the NICU post-operatively in an extubated state and was saturating on room air. Total length-of-stay in hospital was 11 days with an uneventful post-operative recovery. The OR of not developing restenosis was 1.89 (95% CI: 1.46–2.45).

Discussion

Our study reported on a large cohort of children presenting to a tertiary pediatric hospital over a 20-year period. In our study, the restenosis rates were higher for bilateral atresia (54%, n=13) compared with unilateral atresia (36%, n=11), stented cases (64%, n=7), and those where mitomycin C (75%, n=3) was used. Unilateral CA surgery can be performed when the child is older, nutritionally more mature, the choana size is larger, and there is an area of the repair unaffected by the underlying pathology, allowing intact healthy mucosa to be part of the final neo-choana. In our experience, the surgical step of particular importance, in addition to the use of mucosal flaps, was resection of the posterior septum (posterior septectomy).

The primary goals of CA surgery were to create an adequate nasal airway, allow inspiration and expiration through the nose, promote effective secretion flow to the pharynx, facilitate forceful expiration of secretions from the nose, and to avoid injury to olfactory mucosa, skull base and growth centres in the nose. Our study showed an overall restenosis rate of 44% (n=24), which was in line with restenosis rates reported in the literature which ranged from 0% to 79% in recent studies (6-12). The spectrum of restenosis rates reported in the literature likely reflects varying patient populations, with different proportions of patients with bilateral CA and genetic syndromes, as well as varying surgical approaches used at different institutions.

Two of the aforementioned studies are of particular interest, as they focused on surgical techniques with mucosal flaps. The study by Wormald et al. in 2016, examined outcomes for a novel technique where the anterior mucosal layer of the atretic plate was used to fashion an anteriorly-based flap on the lateral nasal wall, and the combined posterior mucosal layer of the atretic choanae was used to fashion a posteriorly-based flap which was positioned onto the superior surface of the neo-choana (12). Similar to the BMFT in the present study, they reported a 0% restenosis rate in their small cohort of 17 patients, however two patients required blood transfusions and one patient developed nasal vestibule scarring from an alar incision. Our BMFT had no such complications, and particularly for the newborns may be considered a safer procedure. Nevertheless, we have only four patients to date and the majority were unilateral CA cases. The study by Saraniti et al. in 2017 (11) also examined outcomes for a mucosal flap technique where the anterior mucosal layer of the atretic plate was repositioned onto the lateral nasal wall, demonstrating an 11.11% restenosis rate in their cohort of 18 patients.

In contrast to these two studies, the mucosal layers of the atretic plates in the BMFT were used to create bi-directional flaps. On the narrower side of bilateral CA, an anteriorly-based mucosal flap from the septum was fashioned to swing around the posterior septum of the neo-choana. On the more patent side, a posteriorly-based mucosal septal flap was fashioned to position itself onto exposed posterior bony surfaces of the neo-choana including the basisphenoid and both pterygoid plates. It is apparent that there are a variety of mucosal flap techniques being pioneered at different institutions, and at this stage there is no evidence to support the superiority of any given mucosal flap technique over another, given the small patient numbers and non-randomized nature of patient recruitment. The breadth of the BMFT mucosal flaps allow good vascular supply and has the advantage of being a long broad base flap. In our experience, short flaps may retract and lead to exposure of the underlying bone or cartilage, which then predisposes to granulation tissue formation, a feature which may increase the risk of restenosis.

The use of mucosal flaps dates back to early descriptions by surgeons employing a trans-palatine approach (13). The architecture with which flaps are rearranged to optimally cover exposed bony surfaces may vary on a case-by-case basis, but the general trend in the aforementioned studies by Wormald and Saraniti on mucosal flaps is a tendency toward low restenosis rates (0–11.11%). The Cochrane review on CA surgery by Cedin et al. in 2012 acknowledged a lack of randomized controlled trials in the literature to draw conclusions from. However, a descriptive analysis of the observational studies on mucosal flaps prior to 2012 reported a 9% absolute risk of restenosis with mucosal flaps, compared to 30% without mucosal flaps (3). These results have been mirrored in the present study, where patients who received mucosal flaps had a restenosis rate of 15% (n=2), compared to 44% (n=24) for the entire cohort (OR =0.29; 95% CI: 0.08–1.09 for restenosis). Our previous experience with flap techniques has led us to the current BMFT which we have found to be robust and reproducible by appropriately trained surgeons.

The use of nasal stenting has been a controversial topic in the area of CA surgery. A systematic review with meta-analysis demonstrated no difference in benefit with nasal stenting on restenosis rates, reporting 35% restenosis in the stented group and 36% restenosis in the non-stented group across 15 included studies (14). Although the number of patients who received nasal stents was small in the present study (n=11), this was associated with a greater number of revision procedures (mean of 2.8±2.2 revision surgeries, P<0.01). The use of stents over the length of nasal mucosa potentially causes ongoing wound injury from regular movement of the stent, possible mucosal ischaemia and subsequent bacterial overgrowth. Considering the added complications of mucosal scarring and granulation tissue formation, alar injury or necrosis, vestibular stenosis and need for further general anaesthetic for removal, nasal stenting has fallen out of favour at The Children’s Hospital at Westmead as our techniques have improved with greater understanding of CA pathophysiology.

Topical mitomycin C was selectively applied in a small subset of patients (n=4). The number of patients in this sub-group was small and did not permit any conclusions on efficacy. A case series examining the value of mitomycin C by Uzomefuna et al. in 2012 showed no statistical benefit in preventing restenosis (15). However, based on our experience we advocate for an individualized assessment of risk of granulation tissue formation in those needing revision surgery rather than all primary cases, as some patients tend to granulate more excessively than others. This observation will require further research.

There were 18 patients in the present cohort with a genetic syndrome, the most common of which was CHARGE (n=10). These children had anomalies in other organ systems which made a patent nasal airway even more important, especially for the management of cardio-pulmonary co-morbidities. The widely patent nasal airway was crucial for effectively delivering therapies such as CPAP for obstructive sleep apnoea, which is more common in Trisomy 21, CHARGE syndrome and Treacher Collins syndrome (16,17). In our study, the presence of a genetic syndrome was not associated with an increased rate of restenosis (OR =1.23; 95% CI: 0.67–2.26) or need for revision surgeries (mean 1.7±2.3 revision surgeries, P=0.96). This was in keeping with other studies in the literature which also found no increase in the need for revision surgeries for patients with genetic syndromes (6,7,18).

Following BMFT, there was no further manipulation of the neo-choana other than endoscopic assessment using flexible nasendoscopy at the bedside to assess clinical outcome measures. Regular toileting of the surgical site with normal saline drops and 0.1% dexamethasone nasal drops in the immediate post-operative period was vital to our management algorithm. This post-operative care was a key contributor to surgical outcomes following mucosal flap surgery, and patients who received the BMFT required no revision surgeries, without the need for stenting or mitomycin C application.

The limitations of this study included the lack of a grading system for CA, creating a possible selection bias as it was not possible to be certain if restenosis was due to anatomical factors relating to the atresia, rather than the surgical technique employed. Furthermore, the BMFT is a novel technique which was performed by experienced surgeons on a small number of patients in our cohort, limiting our ability to draw firm conclusions on efficacy. We intend to publish further results in subsequent studies with larger case numbers. We believe there is potential for more widespread adoption of the BMFT through collaboration and further assessment of outcomes for this technique in the future. At this early stage, the BMFT is a new technique and its efficacy is still being explored at The Children’s Hospital at Westmead, and we cannot demonstrate superiority over any other specific surgical approach due to the small sample size. Overall, the small sample size and lack of statistically significant results illustrated in Figure 2 limit the strength of our conclusions particularly as it relates to risk factors for restenosis.

Conclusions

In conclusion our 20-year cohort of 55 children with congenital CA achieved excellent results using a variety of surgical approaches. The trend towards the use of mucosal flaps reflects a progression in our understanding of this malformation of the posterior nasal airway. We favour ongoing research and experience with the bidirectional mucosal flap technique which has recently been adopted at The Children’s Hospital at Westmead.

Acknowledgments

We would like to acknowledge the late Dr. Edward Beckenham who pioneered the philosophy on which this paper has since evolved. He was instrumental in driving the concept of mucosal flaps and we will always be indebted to his graciousness and guidance.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/10.21037/ajo-24-23/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-24-23/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-24-23/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-24-23/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Sydney Children’s Hospital Network Human Research Ethics Committee (HREC), with the HREC Reference number 2025/ETH009201. Because of the retrospective nature of the research, the requirement for informed consent was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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