Late-diagnosed unilateral choanal atresia in a geriatric patient: a case report and literature review

INTRODUCTION

Choanal atresia (CA) is a rare congenital anomaly characterized by bony or membranous occlusion of the posterior nasal aperture. The overall incidence of CA or stenosis is approximately 0.92 per 10,000 live births, with isolated (non-syndromic) cases comprising 0.37 per 10,000.¹ Unilateral CA accounts for 60-75% of all cases and is more often right-sided, reflecting embryologic developmental asymmetries.^2-4

The clinical presentation varies markedly according to laterality and age at diagnosis. Bilateral CA manifests as a neonatal emergency, with obligate nasal breathing leading to respiratory distress and cyclic cyanosis.⁵ In contrast, unilateral CA rarely compromises neonatal airway patency because of contralateral compensation, often delaying diagnosis until childhood or adolescence. Affected individuals typically report persistent unilateral nasal obstruction and mucopurulent discharge.⁶ Adult presentations are even rarer, with symptoms evolving into chronic, nonspecific complaints such as lifelong rhinorrhea, intermittent obstruction, snoring, or fatigue, which are frequently misattributed to allergic rhinitis or chronic rhinosinusitis.^7,8

Diagnosis of CA relies on nasal endoscopy for direct visualization of the atretic plate, with paranasal sinus computed tomography (CT) as the gold standard for confirmation, delineating bony (90% of unilateral cases) versus membranous types, vomer thickness, and pterygoid plate morphology.^9-11 Management traditionally involves transnasal endoscopic repair, the preferred approach for symptomatic patients, although heterogeneity persists in techniques, stenting, and adjuncts such as mitomycin-C.^12,13

This report details an unusually late unilateral CA diagnosis in a 77-year-old woman managed conservatively, illuminating the diagnostic hurdles in geriatrics and reinforcing individualized, symptom-driven care.

CASE REPORT

This case report details the clinical presentation of a 77-year-old female patient with a medical history of hypertension, type 2 diabetes, and bronchial asthma, who was referred to the otolaryngology clinic for assessment of nasal obstruction. The patient has experienced a long-standing, intermittent left-sided nasal obstruction, occasionally accompanied by headaches. The symptoms have been non-progressive and persistent over time. The patient reported an absence of associated rhinorrhea, postnasal drip, facial pain, epistaxis, anosmia, or recurrent upper respiratory tract infections. Furthermore, she denied any history of nasal trauma or previous sinonasal surgery.

Treatment and management

The patient underwent a flexible fiberoptic nasal endoscopy. Upon suctioning a whitish mucous plug from the left nasal cavity, a complete posterior obstruction was identified, which could not be traversed endoscopically. The right nasal cavity was patent, and the remainder of the ear, nose, and throat examination, including otoscopic and oropharyngeal assessments, was unremarkable.

Based on the endoscopic findings, a structural etiology for the unilateral nasal obstruction was hypothesized. A non-contrast CT scan of the paranasal sinuses was conducted for further assessment, revealing mixed osseous and membranous atresia. Axial CT images illustrated a blind-ending left posterior nasal cavity with complete osseous membranous obstruction at the choanal level, indicative of left CA (Figure 1). Coronal images further depicted posterior vomer thickening with a patent contralateral choana and showed no evidence of sinonasal masses, mucosal disease, or inflammatory pathology (Figure 2). Sagittal reconstructions confirmed the absence of communication between the left nasal cavity and the nasopharynx, clearly delineating the atretic plate (Figure 3).

Upon follow-up, the patient reported satisfactory nasal breathing and a minimal burden of symptoms. Surgical intervention was deemed unnecessary due to the patient's advanced age, long-standing adaptation, and lack of significant functional impairment. Consequently, the patient was managed conservatively and discharged with routine follow-up instructions, with advice to return if symptoms progressed.

Literature review

Reported cases of CA across age groups

CA has been documented across a broad age range in the literature, from early childhood to late adulthood.^4,7,8,14-24 Diagnoses have been recorded in patients as young as 6 years and as old as 65 years at the time of presentation.^15,17 Several studies indicate delayed diagnosis into adolescence and adulthood, particularly in cases of unilateral disease.^7,20 Adult presentations have been reported in various geographic regions, including Australia, Turkey, Saudi Arabia, India, Portugal, Syria, and Pakistan, highlighting the global prevalence of delayed diagnosis.^{4,7,14,17,20,23} Across reported cases, unilateral CA is more prevalent than bilateral disease in adolescents and adults, with a predominance of right-sided involvement, although left-sided cases have also been observed.^14,18,20-23 Bilateral CA diagnosed beyond the neonatal period is rare but has been reported in adults aged 38 to 65 years, often associated with lifelong symptoms and adaptive breathing mechanisms.^4,8,17,22

Unilateral CA and delayed diagnosis

Unilateral CA is often associated with a delay in diagnosis. Patients typically exhibit long-standing, mild, or nonspecific symptoms that do not prompt early investigation.^20,24 Common complaints in unilateral cases include chronic unilateral nasal obstruction, persistent rhinorrhea, headache, and, less frequently, hyposmia or facial discomfort.^15,20,21 Several reports describe symptoms persisting for years or even decades before diagnosis, particularly in cases where the contralateral choana remains patent and compensatory nasal breathing is possible.^7,14,23 Right-sided unilateral CA appears to be more commonly reported in the literature; however, several left-sided cases have also been documented.^{14,16,18,20,21}

Bilateral CA beyond the neonatal period

Bilateral CA, when diagnosed beyond the neonatal phase, is an uncommon occurrence. Nonetheless, there have been instances reported in both adolescents and adults who have managed to survive infancy by adapting through compensatory mouth breathing and gradual acclimatization.^4,8,17,22 In adults, the age at which diagnosis occurs has been documented to range from 38 to 65 years, with symptoms typically including persistent nasal blockage, anosmia, and chronic nasal discharge.^4,8,17 In contrast to unilateral cases, bilateral instances are often characterized by a more pronounced symptomatology, which eventually necessitates diagnostic investigation despite the individual's long-term adaptation.^17,22

Diagnostic modalities used in reported cases

Nasal endoscopy served as the primary diagnostic modality in the reported cases, facilitating direct visualization of the blind-ending nasal cavity and the exclusion of alternative obstructive pathologies.^7,21,23 Additionally, CT of the paranasal sinuses was employed to confirm the diagnosis, classify the atresia as bony, membranous, or mixed, and evaluate associated anatomical features.^{8,17,18,20,22} Several reports have underscored common diagnostic challenges, including misdiagnosis as chronic rhinosinusitis, septal deviation, turbinate hypertrophy, or allergic rhinitis, particularly in unilateral cases with mild or intermittent symptoms.^15,21,23,24 In some earlier cases, additional investigations such as contrast studies, choanography, or nasal catheterization were utilized prior to the widespread availability of high-resolution CT imaging.^19,24

Management approaches reported in the literature

The majority of reported cases across all age groups were managed surgically, with endoscopic transnasal or transseptal approaches being the most commonly employed techniques.^7,18,20,21 Transpalatal approaches were less frequently described and were primarily utilized in earlier reports or in cases involving thick bony atresia.^14,19,24 Additionally, posterior septectomy was often incorporated in endoscopic repairs to enhance surgical exposure and mitigate risk of restenosis.^17,18,20,21

The practice of postoperative stenting shows considerable variation, with some researchers advocating for routine stent placement over several weeks, while others have reported successful outcomes without employing stents.^7,8,15,20 Selective use of adjunctive techniques, including topical mitomycin C, mucosal flap reconstruction, and silicone splints, is employed to maintain patency and minimize risk of scar formation.^7,17,18

Non-operative and conservative management in reported cases

The non-operative management of CA is rarely discussed in the literature, particularly concerning adolescents and adults who present with unilateral disease and exhibit minimal symptoms.²³

In few documented cases, selection of conservative management is predominantly driven by the patient's preference or their decision to opt out of surgical procedures, rather than being endorsed as the primary therapeutic approach (Table 1).²³

Reported outcomes and follow-up

The majority of surgically treated cases demonstrated positive outcomes, with sufficient choanal patency and either resolution or improvement of symptoms observed over follow-up durations ranging from several months to multiple years.^{8,14,15,20,21} Recurrence or restenosis was rare, but it was noted in isolated cases, especially when posterior septectomy was not initially conducted or when stenting methods were suboptimal.²⁰ Long-term follow-up data were inconsistently reported, with several case studies lacking comprehensive outcome documentation beyond the early postoperative phase.^21,23

*F: female; M, male; L, left; R, right; OSA, obstructive sleep apnea; CT, computed tomography; ET, endotracheal; FESS, functional endoscopic sinus surgery; NR, not reported.

DISUCSSION

CA demonstrates a well-documented dichotomy in clinical presentation based on laterality. Bilateral CA results in immediate neonatal respiratory distress, whereas unilateral CA permits long-term physiological adaptation.^4,17,25 Although diagnostic criteria are well established, focusing on the failure of catheter passage, nasal endoscopy, and computed tomography, unilateral cases remain frequently underdiagnosed.^5,26 This diagnostic trend in unilateral CA is attributed to a combination of anatomical compensation and progressive behavioral adaptation rather than complex anatomical structures. The capacity to sustain adequate ventilation through a single patent choana allows survival without acute respiratory distress, even from infancy, resulting in mild or nonspecific symptoms.^11,17,26,27 Over time, compensatory mouth breathing further reduces symptom severity, leading to the misattribution of symptoms to chronic inflammatory or structural nasal conditions.^17,20,21 The present case exemplifies this mechanism, wherein effective long-term adaptation facilitated survival into advanced age with minimal symptomatology.

Computed tomography remains a fundamental tool for anatomical evaluation, revealing distinctive features such as posterior vomer thickening and medialization of the pterygoid plates, with the majority of cases exhibiting mixed bony-membranous atresia.^7,20,26 In cases of long-standing disease, these characteristics likely represent stable congenital anatomy rather than progressive remodeling.^11,21 Notably, the severity observed radiologically does not consistently correlate with clinical symptoms, particularly in unilateral cases.²⁶ This dissociation is evident in the present case, where complete anatomical obstruction coexisted with preserved functional tolerance and minimal symptoms.

Surgical intervention is reported as the definitive treatment for symptomatic CA, with endoscopic transnasal repair currently preferred due to its association with reduced morbidity and favorable outcomes.^5,15,26 Alternative approaches are typically reserved for cases involving complex anatomy or revisions, underscoring the importance of individualized surgical planning.^14,17,20 Nevertheless, the literature predominantly exhibits a bias towards surgical intervention, with limited exploration of non-operative strategies. In contrast, the present case demonstrates that surgery may not be necessary for patients with minimal symptoms.

The use of postoperative stenting and adjunctive therapies remains a contentious issue, with no established consensus on their routine implementation or effectiveness.^12,13 Research suggests that the presence of foreign-body irritation and exposed bone surfaces may facilitate the development of granulation tissue and restenosis, potentially undermining the anticipated benefits.^12,16 The absence of definitive evidence favoring stented or adjuvant-based strategies emphasizes the need for a selective rather than a routine approach. With our patient, a conservative strategy effectively mitigates these risks, reinforcing the value of personalized management. Non-operative management of CA is seldom reported, as the majority of literature focuses on surgical correction and patency outcomes.^7,26 When documented, conservative management is generally restricted to adults with mild symptoms or those declining surgery, leaving the natural progression of untreated disease inadequately characterized.²³ This gap underscores the necessity for cautious, symptom-oriented decision-making rather than interventions based solely on anatomical considerations. The current case offers direct clinical evidence that conservative management can be suitable for carefully selected elderly patients.

Clinical implications and future directions

This case underscores the critical need to maintain a high index of suspicion for CA in patients of all ages who present with persistent unilateral nasal obstruction, even in absence of severe or progressive symptoms. Routine application of nasal endoscopy in evaluating refractory unilateral nasal complaints may mitigate diagnostic delays and prevent misattribution to more common inflammatory or structural conditions. The findings further highlight that radiological completeness of obstruction does not necessarily correlate with symptom severity, particularly in unilateral cases, emphasizing importance of prioritizing functional assessment and patient-reported outcomes in clinical decision-making.

From a management perspective, this case advocates for a more individualized approach, especially in elderly or minimally symptomatic patients, where conservative management may be appropriate to avoid unnecessary surgical risks. Shared decision-making should incorporate symptom burden, patient preferences, comorbidities, and anticipated quality-of-life benefits rather than relying solely on anatomical findings. Future research should aim to systematically document conservatively managed adult cases to better define the natural history of untreated unilateral CA and to develop evidence-based guidelines for patient selection, surveillance strategies, and long-term outcomes beyond surgical patency rates.

CONCLUSION

Unilateral CA may remain undiagnosed into advanced adulthood due to effective physiological adaptation and minimal symptom burden. This case demonstrates that conservative management can be a valid option in carefully selected elderly patients. Clinicians should consider CA in the differential diagnosis of persistent unilateral nasal obstruction and adopt individualized, symptom-driven management strategies rather than routine surgical intervention.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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