An unusually large choanal polyp that almost completely obstructed the oropharyngeal airway.

A 14-year-old girl presented with complaints of increasing difficulty in nasal breathing and difficulty swallowing solid food. Her symptoms had been present for approximately 2 years, and they were associated with a feeling of obstruction in the throat. According to her parents, the patient snored loudly during the night, and she frequently woke up choking.

Physical examination revealed that the patient breathed loudly through her mouth with her tongue protruded. Intraoral telescopic examination detected a large and roundish soft-tissue mass in the oropharynx. The mass originated in the nasopharynx, and it had almost completely obstructed the oropharyngeal airway (figure 1). The mass had expanded the nasopharynx and displaced the soft palate and the uvula anterosuperiorly. The growth was in direct contact with the sides of both tonsils, and it extended down toward the epiglottis and the base of the tongue.

[FIGURE 1 OMITTED]

Right telescopic nasal endoscopy showed that the middle turbinate was normal and the middle meatus was patent. As the telescope was advanced farther, it detected a polypoid mass that was occupying the posterior and inferior portion of the right nasal cavity. Findings on left nasal endoscopy were unremarkable except for the presence of a polypoid mass in the posterior portion of the cavity that had extended from the right side.

Computed tomography (CT) of the sinuses showed that all the paranasal sinuses were clear except for some mild mucosal thickening of the floor of the right antrum. The middle meatus on both sides was patent, and there was no sign of obstruction of the ostiomeatal complex on either side. Coronal CT of the nasopharynx demonstrated a large soft-tissue mass in the nasopharynx that extended down to the oropharynx (figure 2, A). Axial CT showed that the nasopharyngeal mass had arisen from the posterior portion of the choana on the right side (figure 2, B).

[FIGURE 2 OMITTED]

The patient underwent transpalatal excision of the mass under general anesthesia. The soft palate and the uvula were split in the midline, and the nasopharynx was exposed widely. Electrocautery was performed to excise the mass at its superior portion near the right choana. Transnasal endoscopic examination showed that the stalk of the mass originated in the posteromedial portion of the right interior turbinate. The stalk was carefully removed, and the area was electrocoagulated transnasally. The soft palate and the uvula were closed. The histopathologic diagnosis was a benign polyp. Postoperatively, the patient noted significant improvement in breathing and swallowing. Ten years later, she had not experienced any recurrence of the polyp, and she has remained asymptomatic.

Most choanal polyps originate in the maxillary sinus and extend into the nasopharynx through the natural or accessory ostium in the middle meatus, or through a postsurgical middle or inferior meatal antrostomy. (1) CT usually shows a choanal polyp in association with ipsilateral maxillary sinusitis. (1) Rarely do choanal polyps arise from the sphenoid or ethmoid sinus or their ostia. (2) Some choanal polyps extend down into the oropharynx. In the case described herein, the origin of the mass was identified only after it was debulked. Ordinarily, the oropharyngeal area can be easily visualized by transnasal or transoral endoscopy, but that was impossible in this case because of the enormous size of the mass.

The differential diagnosis of large nasopharyngeal masses should include (1) benign disease such as juvenile angiofibroma, teratoma, meningoencephalocele, chordoma, paraganglioma, and nasopharyngeal extension of a parapharyngeal parotid tumor and (2) malignant disease such as carcinoma, lymphoma, and sarcoma. (3-5)

A thorough endoscopic examination of the nose and nasopharynx is important to make a diagnosis of a nasopharyngeal lesion. CT and/or magnetic resonance imaging can delineate the location, size, and extent of a nasopharyngeal lesion. For a vascular lesion, magnetic resonance angiography of the nasopharynx is needed.

To manage a large nasopharyngeal mass such as this one, we recommend an initial transoral excision of the major portion of the mass by electrocautery or with a microdebrider. This should be followed by transnasal endoscopic excision of the intranasal portion of the mass with a microdebrider.

References

(1.) Yanagisawa E, Salzer SJ, Hirokawa RH. Endoscopic view of antrochoanal polyp appearing as a large oropharyngeal mass. Ear Nose Throat J 1994:73:714-15.

(2.) Yanagisawa K, Ho SY, Yanagisawa E. Endoscopic view of a sphenochoanal polyp. Ear Nose Throat J 2000:79:546-8.

(3.) Gustafson RO, Neel HB III. Cysts and tumors of the nasopharynx. In Paparella MM, ed. Otolaryngology. 3rd ed. Philadelphia: W.B. Saunders, 1991.

(4.) Yanagisawa E, Hirokawa R, Yanagisawa K. Endoscopic view of nasopharyngeal carcinoma. Eat- Nose Throat J 1994:73:12-14.

(5.)Yanagisawa E, Citardi MJ. Endoscopic view of malignant lymphoma of the nasopharynx. Ear Nose Throat J 1994:73:514-16.

Eaton Chen, MD, MPH, FACS; Eiji Yanagisawa, MD, FACS

From the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group: the Section of Otolaryngology, Hospital of St. Raphael: and the Section of Otolaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. Yanagisawa).