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Giant antrochoanal polyp--case report and literature review/Dzinovski antrohoanalni polip--prikaz slucaja i pregled literature.

Introduction

Antrochoanal polyp is a benign change of the mucous membrane of the maxillary sinus. During its growth, it passes through the sinus ostium and extends into the nasal cavity and through choana, into the gullet [1]. It represents 4 to 6% of all nasal polyps, and it was first described by G. Killian in 1906. Antrochoanal polyp often occurs in children and young adults and it is almost always unilateral [2]. Nasal obstruction is a symptom found in all patients. This symptom is sometimes accompanied by headaches, foreign body sensation, unilateral rhinorrhea, and snoring [1-4]. Recurrent epistaxis is a problem occurring in angiomatous polyps which have highly vascular stoma with multiple dilated blood vessels in their pathohistological structure [5]. Before a diagnosis is made, the mass may disguise the real origin of the polyp. For this reason, it is necessary to consider possibility of antrochoanal polyp formation in patients who have undergone a surgery or had a trauma and computerized tomography indicates a mass inside the maxillary sinus [6, 7]. Diagnosis of the disease is made using anterior rhinoscopy, nasal endoscopy, standard radiography, computerized tomography and magnetic resonance [8, 9]. Pathohistological diagnosis is mandatory after polyp extirpation, especially because inverted papilloma may present as a polyp [10].

Case report

A 28-year old female reported to an ear, nose and throat (ENT) specialist complaining of breathing difficulty, unilateral nasal secretion, headache and deformity of the nasal pyramid, which she had been experiencing for one year. Examination of the nose showed that the right side of the nose was obstructed by a large polypous formation, moving the nasal pyramid to the left. The same change was found during oropharynx examination. Preoperative computerized tomography indicated a complete obstruction of the right side of the nose and maxillary sinus due to a soft tissue tumor (Figure 1). Anterior rhinoscopy and endoscopic examination of the left side of nose indicated a prominent swelling of the mucous membrane of the nose without polypoid changes. Significant mucosal thickening in all paranasal sinuses and complete occlusion of the ostiomeatal complex on the left were confirmed by computerized tomography of the nose and paranasal cavities. Under general endotracheal anesthesia, endoscopy of the nose was performed which indicated that the medial wall of the right maxillary sinus was destroyed by the mass of a giant polyp. A short separation from the neighboring structures was made. The antrochoanal polyp was extirpated completely through the oropharynx using forceps. The length of the giant polyp was 16 cm (Figure 2). A follow-up examination of the nose and right maxillary sinus was performed using a rigid endoscope (0, 40 and 70 degrees), but no remains of the polyp were found. After that, the septum was medially located and tamponaded to fix the septum in the medial line. The postoperative course was uncomplicated. Pathological findings proved that the formation was an antrochoanal polyp.

Discussion

Many pathological masses in the nose may look like antrochoanal polyp, for example dermoid cysts, meningoencephaloceles, teratomae or sphenochoanal polyps [8]. Diagnosis by clinical examination, computerized tomography and magnetic resonance imaging before extirpation of pathological masses, sinuses and nose is of utmost importance [1, 8, 9]. Giant antrochoanal polyps can become dangerous in case of auto amputation [11]. Obstruction of breathing may require urgent tracheostomy before the polyp removal [12]. Preoperative airway maintenance was performed by endotracheal intubation. Prevention of antrochoanal polyp recurrence was enabled by endoscopy of the nose and maxillary sinus. According to Freitas et al. [13], recurrence after polypectomy was up to 12.5%. Prevention of serious postoperative bleeding was carried out using tamponade of the nose. In the case presented here, the symptoms were common to nasal polyp, but the clinical findings and computerized tomography findings indicated existence of a giant antrochoanal polyp.

By searching published articles in the PubMed database, using keywords "antrochoanal polyp" for the ten year period (October 2004 - July 2014), 74 articles were found which contain terms "nasal", "choanal" and "antrochoanal" polyp in their headlines. They are related to children, young adults and adults. By adding terms "giant" for the same period, only five articles were found.

Zivic et al. [14] extirpated a polyp of an "unusual size" of 8x5 cm by removing antral portion of the polyp applying the Caldwell-Luc procedure, and the epipharyngeal portion was extirpated by using forceps, through oropharynx. Yaman et al. [3] present a 9-cm polyp removed completely by functional endoscopic sinus surgery, which they believe is a safe and efficient method for antrochoanal polyp removal. Cetinkaya [15] reports a case of a giant antrochoanal polyp of 14 cm, removed completely through oropharynx using forceps, while the inferior portion was ligated with 1/0 silk. Kolwadkar et al. [12] removed a giant antrochoanal polyp of 15x4 cm completely through oropharynx. Bhat et al. [16] report a case of a giant antrochoanal polyp of 15 x 6 cm in an adult person, which was removed by endoscopy.

In the case presented in this paper, the polyp of 16 cm probably represents the longest giant antrochoanal polyp extirpated completely and without postoperative complications.

Conclusion

In cases of tumor of the nose and maxillary sinus, the existence of a giant antrochoanal polyp should be considered. The authors believe that this is a rare published case of a giant antrochoanal polyp extirpated completely and without postoperative complications.

DOI: 10.2298/MPNS1412410C

Rad je primljen 9. VIII 2014.

Recenziran 8. IX 2014.

Prihvacen za stampu 12. IX 2014.

BIBLID.0025-8105:(2014):LXVII:11-12:410-412.

References

[1.] Yuca K, Bayram I, Kiroglu AF, Etlik O, Cankaya H, Sakin F, et al. Evaluation and treatment of antrochoanal polyps. J Otolaryngol. 2006; 35(6):420-3.

[2.] Frosini P, Picarella G, De Campora E. Antrochoanal polyp: analysis of 200 cases. Acta Otorhinolaryngol Ital. 2009; 29(1):21-6.

[3.] Yaman H, Yilmaz S, Karali E, Guclu E, Ozturk O. Evaluation and management of antrochoanal polyps. Clin Exp Otorhinolaryngol. 2010; 3(2):110-4.

[4.] Lee JC, Chou YL. Images in clinical medicine. Antrochoanal polyp. N Engl J Med. 2010; 362(22):2113.

[5.] Sayed RH, Abu-Dief EE. Does antrochoanal polyp present with epistaxis? J Laryngol Otol. 2010; 124(5):505-9.

[6.] Jadia S, Goyal R, Biswas R. Nasal mass mimicking antrochoanal polyp. BMJ Case Rep. 2010 Apr 12; 2010. pii: bcr1220092578. doi:10.1136/bcr.12.2009.2578. Pub Med PMID: 22736058; Pub Med Central PMCID: PMC 3047578.

[7.] Lin ZH, Lin M, Teng YS. Antrochoanal polyp derived from periapical granuloma. Chin Med J (Engl). 2008; 121(9):855-8.

[8.] Cunningham JM, Derrick TL, William TC Jr, Ebb HD, Yock IT, Hugh DC, et al. Case 20-2007 - an 11-year-old boy with a calcified mass in the nose. N Engl J Med. 2007; 356:2721-30.

[9.] Bahadir O, Arslan S, Arslan E, Turk A, Ural A. Sphenoid sinus mucocele presenting with unilateral visual loss: a case report. B-ENT. 2011; 7(1):65-8.

[10.] Kizil Y, Aydil U, Ceylan A, Uslu S, Baturk V, Leri F. Analysis of choanal polyps. J Craniofac Surg. 2014; 25(3):1082-4.

[11.] Rashid AM, Soosav G, Morgan D. Unusual presentation of a nasal (antrochoanal) polyp. Br J Clin Pract. 1994; 48(2):108-9.

[12.] Kolwadkar BP, Ankale NR, Bagewadi SB, Patil RN. Unusual presentation of an antrochoanal polyp. Bombay Hospital Journal [Internet]. Available from: http://www.bhj.org.in/journal/2005_4701_jan/case_reports.htm

[13.] Freitas MR, Giesta RP, Pinheiro SD, Silva VC. Antroc hoanal polyp: a review of sixteen cases. Braz J Otorhinolaryn gol. 2006; 72(6):831-5.

[14.] Zivi? L, Jovanovi? D, Stojanovi? S. Antrochoanal polyp of unusual size. Med Glas (Zenica). 2013; 10(1):185-7.

[15.] Cetinkaya EA. Giant antrochoanal polyp in an elderly patient: case report. Acta Otorhinolaryngol Ital. 2008; 28(3):147-9.

[16.] Bhat M, Vaidyanathan V. Sausage in the throat. A case of giant antrochoanal polyp. J Clin Diagn Res. 2010; 4:2281-5.

Karol V. CANJI (1) and Slobodan M. MITROVIC (1,2)

Clinical Center of Vojvodina, Novi Sad

Department of Ear, Nose and Throat Diseases (1)

University of Novi Sad, Faculty of Medicine (2)

Corresponding Author: Dr Karol V. Canji, Klinicki centar Vojvodine, Klinika za bolesti uva, grla i nosa, 21000 Novi Sad, Hajduk Veljkova 1-7, E-mail: canjikarol@gmail.com
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Title Annotation:Case report/Prikaz slucaja
Author:Canji, Karol V.; Mitrovic, Slobodan M.
Publication:Medicinski Pregled
Article Type:Case study
Date:Nov 1, 2014
Words:1365
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