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Unusual case of sleep apnea in a child.

An 8-year-old boy presented with a 2-year history of snoring, witnessed apneas, and persistent adenotonsillar hypertrophy. He was noted to have mouth breathing and clear rhinorrhea, and he had hypertrophic tonsils on examination. The rest of his examination was normal, and his medical history was unremarkable.

A polysomnogram confirmed the patient's mild obstructive sleep apnea, and a routine adenotonsillectomy was planned. Once the patient was under general anesthesia, his palate was retracted and a large nasopharyngeal mass was noted (figure 1). The mass was clearly not adenoid tissue, and a computed tomography (CT) scan of his face and sinuses with contrast was obtained. A sagittal view of the mass is shown in figure 2.

The CT scan demonstrated a large, hypointense mass extending from the anterior wall of the right sphenoid sinus to the nasopharynx. The mass was fairly homogeneous in appearance but centrally appeared hypodense. Nasal endoscopy showed a polypoid mass located between the right middle turbinate and the nasal septum. When removed endoscopically, the choanal polyp measured about 6.5 cm (figure 3). The patients hypertrophic tonsils also were removed. Postoperatively, the patient reported complete resolution of his symptoms and said that "food tasted much better."

Most nasal masses are benign. Nasal polyps are considered the most common of these. The prevalence of nasal polyps is 2.1 to 4.4%. (1) The incidence of choanal polyps is unknown. Choanal polyps are unilateral, solitary, and often found in younger patients. Choanal polyps arise from the diseased mucosa of the paranasal sinuses.

In 1997, Lopatin et al described 4 kinds of choanal polyps: antrochoanal, sphenochoanal, ethmoidal-choanal, and turbinate choanal polyps. (2) Antrochoanal polyps are the most common form of choanal polyps. (3) The middle turbinate helps differentiate between the antrochoanal and sphenochoanal polyps: The antrochoanal polyp is found between the middle turbinate and the lateral nasal wall, extending into the choana; the sphenochoanal polyp is located between the middle turbinate and the nasal septum, extending into the choana. (4,5) Histologically, the antrochoanal polyp and sphenochoanal polyp look very similar. (2,6) The antrochoanal polyp involves the maxillary sinus, while the sphenochoanal polyp involves the sphenoid sinus.

Polyps are considered a disease that requires surgical treatment. However, appropriate surgical management is based on the distinction between the different kinds of polyps. CT scans are often instrumental in surgical planning for any polyps. Our patient's polyp was described as a choanal polyp because of the lack of involvement of the ipsilateral maxillary or sphenoid sinus and lack of clear attachment to the turbinates, ethmoid mucosa, or nasal septum.

Lisa Duffy, RN; Anita Jeyakumar, MD, FACS, FAAP

From Children's Hospital, New Orleans (Ms. Duffy); and the Section of Pediatric Otolaryngology, Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Va. (Dr. Jeyakumar). The case described in this article occurred at Children's Hospital, New Orleans.

References

(1.) Aydil U, Karadeniz H, Sahin C. Choanal polyp originated from the inferior nasal concha. Eur Arch Otorhinolaryngol 2008;265(4):477-9.

(2.) Lopatin A, Bykova V, Piskunov G. Choanal polyps: One entity, one surgical approach? Rhinology 1997;35(2):79-83.

(3.) Larsen PL, Tos M. Origin of nasal polyps. Laryngoscope 1991;101 (3):305-12.

(4.) Berg O, Carenfelt C, Silfversward C, Sobin A. Origin of the choanal polyp. Arch Otolaryngol Head Neck Surg 1988;114(11):1270-1.

(5.) Crampette L, Mondain M, Rombaux P. Sphenochoanal polyp in children. Diagnosis and treatment. Rhinology 1995;33(l):43-5.

(6.) Min YG, Chung JW, Shin JS, Chi JG. Histologic structure of antrochoanal polyps. Acta Otolaryngol 1995;115(4):543-7.

Caption: Figure 1. Endoscopic view of the oropharynx reveals the mass (star). Black arrows point to tonsils and the white arrow to the uvula.

Caption: Figure 2. Sagittal CT scan shows the mass.

Caption: Figure 3. Photograph shows the excised choanal polyp.
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Title Annotation:PEDIATRIC OTOLARYNGOLOGY CLINIC
Author:Duffy, Lisa; Jeyakumar, Anita
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Mar 1, 2017
Words:634
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