Anna Kasprzyk, Piotr Kwast, *Lidia Zawadzka-Głos
Clinical characteristics of antrochoanal polyps in patients treated in the Department of Pediatric Otolaryngology of the Medical University of Warsaw
Charakterystyka kliniczna pacjentów z polipem choanalnym leczonych w Klinice Otolaryngologii Dziecięcej WUM
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Associate Professor Lidia Zawadzka-Głos, MD, PhD
Streszczenie
Wstęp. Polip choanalny (ACP – ang. antrochoanal polyp) jest zmianą łagodną, wywodzącą się z błony śluzowej zatoki szczękowej, przechodzącą przez jej naturalne lub dodatkowe ujście do przewodu nosowego środkowego i sięgającą dalej do nozdrzy tylnych i nosogardła. Stanowi do 33% wszystkich polipów u dzieci.
Cel. Celem pracy była analiza kliniczna pacjentów z polipem choanalnym, hospitalizowanych w Klinice Otolaryngologii Dziecięcej Warszawskiego Uniwersytetu Medycznego w okresie od stycznia 2016 do kwietnia 2017 roku.
Materiał i metody. Historie chorób 15 pacjentów poddano analizie retrospektywnej. Określono płeć i wiek pacjentów, lokalizację polipa, choroby współistniejące, wcześniejsze interwencje chirurgiczne, zakres przeprowadzonej operacji.
Wyniki. Analizie poddano 10 chłopców i 5 dziewczynek (w wieku od 9 do 16 lat, średnia wieku 12,2 lat). Stwierdzono występowanie polipa po stronie prawej u 9 pacjentów, zaś po stronie lewej – u 6 pacjentów. Siedmiu pacjentów przebyło w przeszłości operacje laryngologiczne, w tym jeden z nich zabieg usunięcia ACP. Pacjenci cierpieli na następujące choroby współistniejące: przewlekłe zapalenie zatok przynosowych, przerost migdałka gardłowego, torbiele zatok przynosowych, skrzywienie przegrody nosa, przerost małżowin nosowych dolnych, wysiękowe zapalenie ucha środkowego, alergia wziewna. U 3 pacjentów podczas zabiegu usunięcia polipa wykonano inne procedury chirurgiczne.
Wnioski. ACP może być jedną z przyczyn niedrożności nosa. Warunkiem skutecznego leczenia jest doszczętne usunięcie zmiany.
Summary
Introduction. Antrochoanal polyp (ACP) is a benign lesion originating from the mucosa of the maxillary sinus, growing through the sinus’ ostium (natural or accessory) into the middle meatus and extending into the choana and nasopharynx. ACPs constitute 33% of all nasal polyps in children.
Aim. The aim of this study was to evaluate the clinical characteristics of ACP in children treated in the Department of Pediatric Otolaryngology of the Medical University of Warsaw between January 2016 and April 2017.
Material and methods. A retrospective analysis of 15 cases was conducted. The following clinical data were analyzed: sex, age, polyp side, associated pathologies, previous surgical procedures and their extent.
Result. Ten boys and 5 girls with a mean age of 12.2 (range 9-16) years were included in the study. There were 9 right-sided lesions and 6 left-sided lesions. Seven patients have undergone previous operations, including one patient that had undergone the removal of ACP. Following comorbidities were observed: chronic rhinosinusitis, adenoid hypertrophy, deviated septum, inferior turbinate hypertrophy, otitis media with effusion, and allergy. Three patients underwent other surgical procedures during ACP removal.
Conclusions. ACP can lead to unilateral nasal obstruction. Complete removal of the ACP is the key for the successful treatment.
Introduction
Antrochoanal polyps (ACPs) are also sometimes called Killian’s polyps – in honor of Professor Gustav Killian, who was the first to distinguish and describe the condition in detail in 1906 (1). ACP is a benign lesion originating from the mucosa of the maxillary sinus, passing through its natural or accessory ostium into the middle meatus and extending into the choana and nasopharynx (2, 3). It consists of 2 parts: antral part that fills the maxillary sinus and a solid part, located in the nasopharynx (3). In anterior rhinoscopy, ACP can be seen as a polyp with smooth walls and a bright, yellowish tinge. Large polyps are visible behind the uvula during oral examination. Additional examinations helpful in determining the diagnosis and in the selection of the best surgical approach include nasal endoscopy and computed tomography (4).
It is estimated that choanal polyps represent 4-6% of all nasal polyps in the general population (4). ACPs more often affect pediatric patients – up to one-third of polyps in children are APCs. The mean age of the first symptoms is 27 years; in 28% of cases, the symptoms first present under 18 years of age (2).
Aim
The aim of this study was to evaluate the clinical characteristics of ACP in children treated in the Department of Pediatric Otolaryngology of the Medical University of Warsaw.
Material and methods
The material for the study consisted of medical documentations of 15 children, hospitalized in the Pediatric Otolaryngology Department of the Medical University of Warsaw between January 2016 and April 2017. The following clinical data were analyzed: sex, age, polyp side, associated pathologies, previous surgical procedures and their extent.
Results
Fifteen patients aged 9-16 years (mean age 12.2 years, median: 11 years) were included in the study. There were more male patients (10 boys, 67%) than female (5 girls, 33%).
In the analyzed material, the polyp was observed on the right in 9 patients (60%), and on the left – in 6 patients (40%).
The study group was analyzed for surgical procedures that had been performed in the past (tab. 1). Seven patients (47%) had undergone a surgical procedure in the head and neck region. These were: functional endoscopic sinus surgery, adenoidectomy, and tympanocentesis with tube insertion. In one patient, a recurrence of ACP 12 months after the first surgery was diagnosed; the patient underwent another polyp removal surgery.
Tab. 1. Procedures that patients had underwent in the past. FESS – functional endoscopic sinus surgery, AT – adenoidectomy, PE – polyp excision
| Type of surgery | No. of patients |
| FESS | 3 |
| AT + FESS | 1 |
| AT + tube insertion | 1 |
| AT | 1 |
| PE | 1 |
The incidence of coexisting diseases was also analyzed (tab. 2). In all the patients, chronic sinusitis was diagnosed. Other comorbidities included: adenoid hypertrophy, cysts of paranasal sinuses, nasal septum deviation, hyperplastic inferion nasal turbinates, exudative otitis media, and allergy.
Tab. 2. Comorbidities in patients with ACP
| Disease | No. of patients |
| Chronic sinusitis | 15 |
| Paranasal cyst | 2 |
| Adenoid hypertrophy | 2 |
| Deviated nasal septum | 1 |
| Hyperplastic nasal turbinates | 1 |
| Exsudative otits media | 1 |
| Allergy | 1 |
In 3 patients (20%), additional surgical procedures were performed during ACP removal: adenoidectomy with tube insertion, adenoidectomy with conchoplasty, and removal of sphenoid sinus cyst.
One patient was admitted and operated as an emergency due to the episodes of apnea and nasal obstruction.
Discussion
Antrochoanal polyps, due to their characteristic morphology, are a separate disease entity. They are relatively common in the pediatric population. Main signs of ACP include: nasal obstruction, usually unilateral, rhinitis, snoring, and oral breathing (4, 5). Other signs include: nose bleeding, strangulation, spontaneous amputation, dysphagia, weight loss, cachexia, and obstructive sleep apnea (2, 3, 6). Other diseases resulting in impaired nasal patency, such as juvenile hemangiofibroma, tumors of nasopharynx, encephalocele, significant adenoid hypertrophy, hyperplastic turbinates, and mucocele, should be taken into account in the differential diagnosis (3, 5).
The vast majority of ACPs are one-sided, however, there are reports of bilateral antrochoanal polyps (4, 7). According to the literature, ACPs are more common in boys and usually develop on the left side (contrary to our study, in which polyps on the right side were more common) (4, 5). Typically, ACPs originate from the maxillary sinus, however, there are case reports of antrochoanal polyps origination from the sphenoid sinus, ethmoidal sinuses, palate or nasal septum (1, 3).
Although it has been more than 100 years since Gustav Killian first described antrochoanal polyps, the exact patomechanism of their formation has not been known. It is believed to originate from an intramural maxillary cyst. Increased intracranial pressure (caused by e.g. chronic mucositis due to an allergy or inflammation, as well as altered anatomical conditions, associated with deviated nasal septum, hyperplastic turbinates, concha bullosa, etc.) results in pushing the cyst into the middle nasal meatus (1, 4). To this date, the role of individual factors predisposing to the development of ACP has not been determined. In literature, there are reports both confirming and denying the influence of allergy and chronic sinusitis in the pathogenesis of ACP (1, 4, 7). In our analyzed material, anatomical abnormalities of nasal cavity and sinus was diagnosed in 4 patients (27%), and allergy was diagnosed in one child (7%).
The treatment consists of surgical removal of the antrochoanal polyp (3, 5). The basis for the success of the surgery and the lack of recurrence is the complete removal of both parts of ACP (antral and solid) (4, 7). The place of origin of the polyp should be sought and then, the complete removal of the polyp should follow (8, 9). This is particularly difficult when the mucous membrane of the sinuses is altered by a chronic inflammatory process (9). The decision on the type of surgical procedure should be based on a complete clinical picture, including age, comorbidities and prior surgeries (10). So far, a few surgical techniques have been described.
Simple polypectomy is associated with a high percentage of recurrences (up to 25%) due to the risk of leaving fragments of the polyp inside the sinus; therefore, this method is not currently recommended (11).
Due to a number of possible serious complications, Callwell–Luc procedure is also not performed as a treatment for ACP (8, 12). This procedure, in spite of providing a good access to the operative field, results in a risk of swelling and hyperaemia of the cheek, inhibition of maxillar growth and damage to the teeth buds (8, 12).
Functional endoscopic sinus surgery (FESS) remains the method of choice (8, 12). The procedure is performed under general endotracheal anesthesia. The patient is placed in a supine position with their head slightly raised (8, 12). After introducing the endoscope to the nasal cavity and visualizing the polyp’s pedicle emerging from the middle nasal duct, ACP should be removed with a microdebrider or cutting forceps (8, 12). In case of big polyps, when it is impossible to excise the polyp en bloc, the solid part of the polyp is removed through the nose or oral cavity (8, 12). Sometimes it is necessary to widen the natural aperture of the maxillary sinus in order to better visualize the place of origin of the polyp (8, 12).
Combined endoscopic surgery with sinoscopy through the canine fossa is useful in cases of ACPs originating from the anterior wall of the maxillary sinus (9).
In case of a recurrence, it is recommended to perform a wide antrostomy in the middle nasal meatus (11).
Conclusions
Antrochoanal polyp should be included in the differential diagnosis of nasal congestion, particularly unilateral. It must be taken into consideration that ACP may have atypical symptoms, including nasal bleeding, obstructive sleep apnea, dysphagia, and weight loss. Only the complete removal of the lesion guarantees a successful treatment and prevents recurrences. In case of the coexistence of anatomical abnormalities that may affect the final outcome of the treatment (deviated nasal septum, hyperplastic nasal turbinates, concha bullosa), their simultaneous correction is indicated.
Piśmiennictwo
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