Background Although choanal atresia (CA) was first described 250 years ago, its description and understanding remain incomplete, as is the distinction between unilateral and bilateral CA. Among the surgical techniques introduced to manage this condition are intranasal Hegar\'s dilator (IHD) and transnasal endoscopic excision (TNEE). Objectives This study retrospectively evaluated the outcomes and effectiveness of IHD and TNEE in the treatment of patients with CA, including differences in the incidence of re-stenosis with these techniques. Methods Patients diagnosed with CA who underwent surgical interventions in the Otolaryngology Department of Al-Noor Specialist Hospital, Makkah, Saudi Arabia, between 1997 and 2017 were analyzed. Postoperative outcomes including re-stenosis rates were compared in patients who underwent IHD and TNEE. Factors associated with patient outcomes were analyzed, including ages at diagnosis and surgery, nationality, gender, type of atresia (unilateral/bilateral and bony/membranous/mixed), surgical intervention (IHD or TNEE), and re-stenosis and need for revision surgery after IHD and TNEE. Results A total of 30 patients were diagnosed with CA, including 21 (70%) girls and 9 (30%) boys. Of them, 18 (60%) patients were diagnosed at younger than one month of age, 28 (93%) were Saudi nationals, and 20 (67.70%) were aged younger than three months at the time of surgery. Of these 30 patients, 17 (56.70%, all Saudi nationals) underwent IHD, and 13 (43.30%), including 15 Saudi nationals, underwent TNEE. The 17 patients who underwent IHD included 13 (76.50%) girls and 4 (23.50%) boys, whereas the 13 patients who underwent TNEE included 8 (61.50%) girls and 5 (38.50%) boys. Fifteen patients (50%) had mixed-type CA, nine (30%) had bony-type CA, and six (20%) had membranous-type CA. Twenty-six (86.67%) patients underwent primary surgery, whereas four (13.33%) underwent revision surgery; of the latter, three (75%) had undergone primary IHD, and one had undergone primary TNEE. Only one (3.33%) patient experienced re-stenosis after revision surgery, which consisted of IHD. Twelve patients (40%) underwent stenting, with one developing re-stenosis. The relationships between surgical approach and re-stenosis after primary and secondary surgery were not statistically significant. Conclusion The outcomes in patients with CA treated with IHD and TNEE are comparable. Rates of re-stenosis and need for revision surgery do not differ significantly in patients treated with these surgical approaches.

Bilateral Choanal atresia is a medical emergency. Corrective surgery is the mainstay of the treatment. Hegar\'s dilator was used in all cases to break the bony/membranous atretic plate. The 22 cases of choanal atresia all operated by the first author were included in this study. Eight cases were 1-5 year old with bilateral choanal atresia and all required immediate surgery as they had repeated attacks of respiratory distress and cycle of cyanosis. Eight cases were of CHARGE Syndrome. All the cases were operated under general anaesthesia. Hegar\'s dilators were used and nasal stents were placed in all cases. Although complete nasal patency was achieved by surgery, in 8 cases, neonates could not survive due to the CHARGE Syndrome. The mortality was unrelated to the surgery. The 14 cases which were not related to CHARGE Syndroma had a good postoperative recovery. 3 cases were above 15 years old with unilateral complete bony/membranous choanal atresia and they presented with continuos nasal discharge. Hegar\'s dilators are a safe and simple method of surgery for choanal atresia. Nasal stenting is mandatory to prevent restenosis.

Choanal atresia is one of the more commonly observed congenital abnormalities of the nose. The condition is predominantly found in females with a M:F ratio of 1:2. 65-75 % of patients with choanal atresia are unilateral, and the rest are bilateral. About 50 % of the cases are associated with other congenital anomalies, the most common being coloboma, Heart disease, choanal atresia, mental and growth retardation, genital hypoplasia, ear deformities syndrome. The embryonic origin of choanal atresia is due to persistent bucco-pharyngeal or naso-buccal membrane. Our study was a retrospective study of 14 cases of choanal atresia. All the cases were operated by the first author. Each patient was investigated in detail and recorded by stratifying in sex of patient, age of presentation, type and site of atresia, and associated other congenital anomalies. Patient were operated under general anesthesia and Hegar\'s dilators were used to perforate the atretic plate as Hegar\'s dilators are believed to have ideal curvature with respect to the sloping contour of the nasal floor. Out of the total 14 cases, 9 (64 %, n = 14) cases were male and 5 (36 %, n = 14) females. The age variations varied from youngest of 3 days to the oldest 31 year old female. Stents were kept for a period of 6-8 weeks and regular follow up nasal endoscopy was done weekly for suctioning and visualizing the size of the airway. There are five different surgical approaches that have been described for surgical treatment of choanal atresia: (1) trans-nasal, (2) trans-palatal, (3) trans-septal, (4) trans-antral and (5) sublabial-transnasal. In our study M:F ratio was 1.8:1 which is comparable Gosepath et al. (Rhinology 45:158-163, 2007) (2:1). In our study bilateral atresia was seen in 43 % (6, n = 14) and unilateral in 57 % (8, n = 14) which is comparable to Newman et al. (44 % bilateral cases, n = 43). Amicable and prompt referral to the ENT surgeon can be of immense value so as to buy adequate time for the surgeon to decide and act as per the patient\'s clinical and radiological findings. Hegar\'s dilator is passed along the floor of the nose, pushed against the septum so as to avoid penetrating the basal sphenoid.