Endoscopic removal of the antral and choanal portions of an antrochoanal polyp.

A 24-year-old white woman presented with a 1-month history of a rather sudden nasal obstruction. She also reported dysphagia with frequent gagging and a foreign-body sensation behind her palate.

Examination revealed an extremely narrow left nasal cavity secondary to a severely deviated septum. Endoscopic examination could not be performed through the narrow side, but flexible fiberoptic endoscopy through the right nasal cavity detected a polypoid mass emanating from the left choana. Oropharyngeal examination identified the tip of the polypoid mass behind the free edge of the soft palate (figure, A). Computed tomography of the sinuses detected a large lobulated mass in the left nasal cavity that extended down to the nasopharynx and oropharynx. Opacification was noted in the left maxillary sinus. The paranasal sinuses were otherwise clear of disease.

[FIGURE A OMITTED]

The patient was brought to the operating room for endoscopic evaluation and excision of a presumed left antrochoanal polyp. Following correction of the severely deviated septum, endoscopic examination with a 4-mm, 0[degrees] telescope clearly revealed a large antrochoanal polyp emanating from an accessory ostium of the left maxillary sinus (figure, B). The stalk of this polyp was transected at a point medial to the accessory ostium with a microdebrider (figure, B). Because the mass was too large to be removed transnasally, it was removed transorally (figure, C). This choanal portion of the polyp measured approximately 6 X 3 cm. The left uncinate process was removed, and the natural ostium of the maxillary sinus was identified. It was clearly separated from the accessory ostium from which the polyp emanated. The two ostia were connected, creating a large maxillary antrostomy through which the inferior base of the antral polyp was well visualized and removed with an angulated Blakesley forceps (figure, D). A 70[degrees] telescope was used to inspect the inferior portion of the maxillary sinus to ensure that the polyp had been completely removed. Histologic analysis confirmed that the mass was an inflammatory polyp. The patient tolerated the procedure well, and she remained asymptomatic and disease-flee at the 8-month follow-up.

[FIGURE B OMITTED]

Antrochoanal polyps are uncommon, accounting for only 3.7 to 6% of all nasal polyps. (1,2) They are more common in children, representing 7.8 to 28% of all pediatric nasal polyps. (3,4) Bilateral antrochoanal polyps have been described, but they are rare. (5) No definitive pathophysiology has been proven, but chronic sinusitis, allergy, and lower respiratory disease have all been implicated. A higher incidence of antrochoanal polyps has been described in patients with cystic fibrosis. (4)

Patients with an antrochoanal polyp often present with unilateral nasal obstruction, but if the polyp extends into the nasopharynx, bilateral obstruction may occur. (6) When a polyp extends down to the oropharynx, as was the case with our patient, the patient may complain of an obstructive feeling in the mouth or frequent gagging.

An antrochoanal polyp typically appears as a smooth, gray or bluish intranasal mass that arises from the ipsilateral maxillary sinus. It usually passes into the nasal cavity through the accessory or natural maxillary sinus ostium via a pedicled stalk. The polyp can exit from any ostium, including the postsurgical middle or inferior meatal window.

The antral component can be cystic or polypoid.

Treatment entails the complete removal of both the choanal (nasal) and antral portions of the polyp. The choanal portion can be easily removed transnasally or transorally after the stalk has been transected. The antral portion can be removed via a Caldwell-Luc procedure, inferior meatal antrostomy, or middle meatal antrostomy. The traditional method of ensuring complete removal of the antral portion has been the Caldwell-Luc procedure. (4-6)

Endoscopic excision of antrochoanal polyps has emerged as a safe and effective procedure in recent years. (6-8) With this approach, the antral portion is removed endoscopically through the middle meatus; there is no need to perform a Caldwell-Luc procedure or inferior meatal antrostomy. In our patient, complete endoscopic removal of the antral polyp was possible. The use of 30[degrees], 70[degrees], and 120[degrees] telescopes along with an angulated Blakesley or giraffe forceps or microdebrider has resulted in excellent outcomes and minimal morbidity. (6-8) If any residual polyp remains in the inferior maxillary sinus, a transcanine antrostomy with an antral polypectomy can be combined with a middle meatal antrostomy. (8-10) In technically difficult cases of endoscopic antral polypectomy, a mini--Caldwell-Luc approach, (11) with or without powered instrumentation, can help complete the procedure.

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

References

(1.) Heck WE, Hallberg OE, Williams HL. Antrochoanal polyp. Arch Otolaryngol 1950;52:538-48.

(2.) Sirola R. Choanal polyps. Acta Otolaryngol 1966;61:42-8.

(3.) Orvidas LJ, Beatty CW, Weaver AL. Antrochoanal polyps in children. Am J Rhinol 2001;15:321-5.

(4.) Chen JM, Schloss MD, Azouz ME.Antro-ehoanal polyp: A 10-year retrospective study in the pediatric population with a review of the literature. J Otolaryngol 1989;18:168-72.

(5.) Basu SK, Bandyopadhyay SN, Bora H. Bilateral antrochoanal polyps. J Laryngol Otol 2001;115:561-2.

(6.) Yanagisawa E, Joe JK, Pastrano JA. Unilateral antrochoanal polyp with bilateral nasal obstruction. Ear Nose Throat J 1998;77:170-1.

(7.) Kamel R. Endoscopic transnasal surgery in antrochoanal polyp. Arch Otolaryngol Head Neck Surg 1990;116:841-3.

(8.) Loury MC, Hinkley DK, Wong W. Endoscopic transnasal antrochoanal polypectomy: An alternative to the transantral approach. South Med J 1993;86:18-22.

(9.) Hong SK, Min YG, Kim CN, Byun SW. Endoscopic removal of the antral portion of antrochoanal polyp by powered instrumentation. Laryngoscope 2001; 111:1774-8.

(10.) el-Guindy A, Mansour MH. The role of transcanine surgery in antrochoanal polyps. J Laryngol Otol 1994;108:1055-7.

(11.) Yanagisawa E, Yanagisawa K, Fortgang P. Endoscopic excision of a large benign antral lesion via a modified ("mini") Caldwell-Luc procedure. Ear Nose Throat J 1995;74:620-1.

Ken Yanagisawa, MD, FACS; Daniel H. Coelho, MD; Eiji Yanagisawa, MD, FACS