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Paranasal Sinus Development and Choanal Atresia

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Paranasal Sinus Development and Choanal Atresia ORIGINAL ARTICLE Paranasal Sinus Development and Choanal Atresia Philomena Mufalli Behar, MD; N. Wendell Todd, MD Background: Although the determinates of paranasal Main Outcome Measures: Determination of maxil- sinus development and sinusitis are not well defined, a lary sinus volumes and mucoperiosteal thickening on pre- candidate factor is blockage of the choana. operative computed tomograms. Hypothesis: Maxillary sinuses ipsilateral to unilateral Results: Maxillary sinuses ipsilateral to unilateral choa- choanal atresia are comparatively small and have more nal atresia have slightly larger volumes than, and muco- evidence of sinusitis than do the contralateral sinuses. periosteal thickening that is similar to, the contralateral sinuses. Design: Retrospective. Conclusion: These data suggest that maxillary sinus de- Setting: Children’s hospitals. velopment and sinusitis are independent of posterior na- sal ventilation and drainage. Patients: Sixteen nonsyndomic children with isolated unilateral congenital choanal atresia. Arch Otolaryngol Head Neck Surg. 2000;126:155-157 BSTRUCTION of sinona- lary sinuses is adversely affected by severe sal drainage and ventila- sinus infection. This compromised growth tion is a well-accepted is exhibited by the small paranasal sinuses contributor to paranasal of patients with cystic fibrosis.17 Interest- sinusitis.1-11 Such a situ- ingly, Kim et al17 reported that children who ation exists in children with choanal atre- meet the criteria for chronic sinusitis, but O 12 sia. In 1927, Grove reported a case of uni- who do not have cystic fibrosis, have max- lateral choanal atresia, about the 180th at illary sinus development that is compa- the time, and noted that: rable to that of normal subjects. In children with unilateral choanal the free ventilation of the nose is one of the most atresia, ipsilateral anterior nasal dis- potent factors in the prevention of sinus disease charge is a presenting symptom.18 These and in the cure of an early existing sinus infec- children are frequently treated for months tion. As no air current is possible [through the for presumptive sinusitis before the choa- nose with unilateral choanal atresia], it must be- come apparent that the sinuses on the side of a nal atresia is recognized. Because nasal choanal atresia are particularly susceptible to in- breathing is absent on the side of the atre- fection. sia, poor gas exchange, leading to a lower partial pressure of oxygen and improved Proetz6 emphasized, in 1941, the im- environment for bacterial growth, would portance of sinus ventilation and drainage, be expected.2,5 The combination of abnor- noting that “it is generally agreed that stag- mal mucociliary flow, pooling of secre- nation of mucus in the closed side is apt to tions, and poor nasal ventilation would result ultimately in sinus disease.” Later, Fri- seem to predispose these children, in day et al13 and then Wald10 put choanal atre- particular, to sinusitis on the atretic side. sia at the top of the list of mechanical ob- With this background understand- structions predisposing to sinusitis. ing, we hypothesize that children with uni- Because ventilation of the middle ear lateral choanal atresia have abnormal mu- contributes to temporal bone pneumatiza- cociliary flow, relatively poor ventilation, tion, nasal ventilation may be important in and smaller sinuses and sinusitis on the the development of the paranasal si- atretic side. However, we were surprised 6,14-16 From the Department of nuses. Extensive paranasal sinus and and intrigued to encounter a child with Otolaryngology, Emory mastoid development indicate sinus and unilateral choanal atresia and well- University School of Medicine, middle ear health during a person’s growth developed, aerated maxillary sinuses. Was Atlanta, Ga. period.6 Conversely, growth of the maxil- this one case a fluke? Unilateral choanal ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 126, FEB 2000 WWW.ARCHOTO.COM 155 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 SUBJECTS AND METHODS DETERMINATIONS OF MAXILLARY SINUS VOLUMES STUDY POPULATION The volume of each maxillary sinus was calculated using a The medical records of all children with unilateral choanal technique described by Cavalieri, who was a contemporary atresia were requested from the 3 children’s hospitals in At- and disciple of Galileo. Each maxillary sinus volume was ap- lanta, Ga, and from a private otolaryngology practice in Mem- proximated by calculating the area of each individually traced phis, Tenn. Approval of the Clinical Research Coordinating CT section using a planimeter (Keuffel & Esser Co, Ger- Committee was obtained from the one institution that required many). Correction for magnification (ie, correction for lin- such approval. Excluded from the study were patients with ear compression of each CT image) was accomplished by mea- bilateral atresia or anterior nasal piriform aperture stenosis suring the actual number of centimeters represented by the and patients with any other congenital anomaly or syndrome. centimeter reference on the CT scan. Thus, the volume of Also excluded were children whose initial preoperative com- each maxillary sinus was calculated according to the follow- puted tomographic (CT) scan was unavailable or did not in- ing formula: (linear correction)2 3 (centimeters between sec- clude the posterior choanae and maxillary sinuses. tions) 3 (sum of the object’s areas). The initial preoperative noncontrast axial sinus CT Similarly, the volume of each maxillary sinus contain- scans of 15 children and the coronal CT scan of 1 child were ing soft tissue density (rather than air) was calculated. The available for study. Each sinus was tomographically sec- aerated volume of the sinus was determined by subtract- tioned at regular parallel intervals ranging from 1 to 5 mm. ing the soft tissue–containing volume from the bony out- The identity of each patient and the side of the atresia were line of the maxillary sinus. known and concealed by the first author (P.M.B.) using opaque adhesive tape so that the reviewing author (N.W.T.) STATISTICS could view the scans without bias. Using an x-ray film re- view box for illumination, the bony contours of all maxil- The paired t test was used to compare the mean of the vol- lary sinus sections (caudal to cranial extent) were traced umes of the maxillary sinuses ipsilateral to the choanal atre- onto paper by the reviewing author. Similarly, the area of sia with the mean of the volumes of the maxillary sinuses mucosal thickening (soft tissue density) within each max- contralateral to the atresia. The 1-tailed P value was used illary sinus was traced to compare aerated with nonaer- to reject the null hypothesis (that the mean of the differ- ated maxillary sinus volumes. ences of the pairs is different from 0). atresia may be considered an experiment of nature, pro- tors include upper respiratory tract infections, both aller- viding an opportunity to explore the relationship of na- gic and nonallergic rhinitis, immunodeficiency states, sal obstruction and sinusitis in children. primary ciliary dyskinesia, cystic fibrosis, Down syn- drome, inhalant pollutants, and aspirin sensitivity. The RESULTS list of local factors includes dental infections, cleft palate, and swimming, but mostly items related to nasal ob- Sixteen children, aged 1 month to 17 years, with iso- struction: adenoid hypertrophy or infection, foreign bod- lated unilateral choanal atresia were identified. Twelve ies, tumors, polyps, septal deviation, and choanal atre- children were female and 4 were male, similar to the 2:1 sia.10,13,20 All of these conditions presumably interfere ratio reported by Brown.19 Nine patients had right-sided with normal nasal ventilation and sinonasal mucociliary atresia and 7 had left-sided atresia. flow and lead to obstruction of the osteomeatal unit. A wide range of maxillary sinus volumes was noted Lifelong, persistent, severe paranasal sinusitis is (Figure). The mean maxillary sinus volume ipsilateral thought to be represented radiographically by nonaer- to the choanal atresia was 4.84 mL, compared with 4.48 ated sinuses that are smaller than usual. The nonaerated mL for the contralateral side. The sinuses ipsilateral to (ie, opaque) sinus is attributed to stagnated mucus or pus the atresia were, on average, larger than the contralat- or to thickened mucoperiosteum. Proetz6 suggested that eral sinuses (P,.06). Symmetry of maxillary sinus size “the failure of some sinuses to develop may be on a kin- was apparent (r = 0.97; P,.001). dred basis [to Wittmaack’s contention that inflammatory The volumes of the soft tissue (presumably muco- middle ear disease limits mastoid pneumatization].” How- periosteal thickening) in the maxillary sinuses ap- ever, Ritter21 stated, “For unknown reasons, during growth peared symmetrical: 6 patients had more soft tissue in the maxillary sinuses may cease development and pro- the sinus ipsilateral to the atresia; 5 patients had more duce a sinus lumen of less than normal size.” soft tissue in the sinus contralateral to the atresia; and 5 Notwithstanding the consensus of conventional wis- patients had complete opacification of both maxillary si- dom, sinusitis is not universal in children with choanal nuses; ie, sinusitis as assessed by the preoperative CT scans atresia. Proetz6 observed that newborns with bilateral was unrelated to the unilateral choanal atresia. choanal atresia do not have clinical infection
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