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Difference of antrochoanal polyp between children and adults
International Journal of Pediatric Otorhinolaryngology 84 (2016) 143–146
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Difference of antrochoanal polyp between children and adults Dong Hoon Lee, Tae Mi Yoon, Joon Kyoo Lee, Sang Chul Lim * Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School & Chonnam National University Hwasun Hospital, 160 Ilsimri, Hwasun, Jeonnam 519-809, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 28 December 2015 Received in revised form 3 March 2016 Accepted 4 March 2016 Available online 12 March 2016
Objective: The purpose of this study was to review the clinical characteristics of the antrochoanal polyp (ACP) and to compare the differences between children and adults. Patients and methods: This study was performed in 56 patients who underwent endoscopic surgery for ACP between 2004 and 2014. The study population was subdivided into children (8 years old) and adults (>18 years old). Clinical findings of ACP, including symptoms, CT stages, and surgical outcomes were retrospectively analyzed. Results: CT Stage II and III lesions were more common than CT stage I lesions in children (p < 0.001). Accompanying maxillary sinus diseases were more common in adults (p < 0.005). Purely endoscopic surgery for ACPs was performed in all children and 25 (86.2%) adults. The combined approach, endoscopic and canine fossa approach, was applied in 4 (13.8%) adults. The success rate was 88.9% in children and 93.1% in adults. According to the approach method, the success rate was 90.4% for the purely endoscopic approach and 100% for the combined approach. Conclusion: High incidence of CT stage II and III lesions in the child group with ACP in our study suggests that children with ACP present at a more advanced state because of late diagnosis. Accompanying maxillary sinus diseases can be present in patients with ACP, especially adults, which should be considered preoperatively and treated appropriately. ß 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Antrochoanal polyp Child Adult Endoscopic surgery Computed tomography
1. Introduction
2. Patients and methods
Antrochoanal polyps (ACPs) are benign polypoid lesions arising from the mucosa of the maxillary sinus, through the maxillary sinus ostium with extension into the choana [1–3]. ACPs represent approximately 4–6% of all nasal polyps in the general population; however, the incidence is increased to 35% in children [1,4]. ACPs are almost always unilateral, although there are few cases of bilateral ACPs in the literature, mainly in children [1–3]. The pathogenesis and etiology of ACPs are still unknown [2]. Nasal endoscopy and computed tomography (CT) are the gold standard for determining the diagnosis and the treatment plan [1,5]. Surgical removal of ACPs is the treatment of choice [1–4]. The purpose of this study was to review the clinical characteristics of the ACPs, and to compare the differences between the child and adult groups.
After obtaining approval from the Institutional Review Board of Chonnam National University Hwasun Hospital (CNUHH-2015145), this study was performed in 56 patients who underwent endoscopic surgery for ACP between 2004 and 2014. This study population was subdivided into children (18 years old) and adults (>18 years old). Demographic characteristics, sinonasal complaints, localization of ACPs, imaging findings, accompanying maxillary sinus diseases, histopathologic results, treatment outcomes, and postoperative complications were reviewed. We classified ACPs into 3 patterns according to the CT findings [6]: Stage I (antronasal polyp), Stage II (ACP extended to the nasopharynx and the ostium of the maxillary sinus was occluded fully by the neck of the ACP), and Stage III (ACP extended to the nasopharynx and the ostium of the maxillary sinus was occluded partially by the neck of the ACP). The type of surgical approach was determined by endoscopic accessibility for the antral portion of ACPs. The antral portion of ACPs was removed via endoscopic approach through the natural maxillary ostium after it was adequately widened. However, in some cases, it was difficult to access the antral portion of ACPs endoscopically, and additional access was obtained through the
* Corresponding author. Tel.: +82 61 379 8190; fax: +82 61 379 7761. E-mail address: [email protected] (S.C. Lim). http://dx.doi.org/10.1016/j.ijporl.2016.03.004 0165-5876/ß 2016 Elsevier Ireland Ltd. All rights reserved.
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canine fossa. A 5 mm diameter window was created 1 cm above the canine fossa by trocar puncture. A powered instrumentation was inserted into the maxillary sinus through the canine fossa puncture, and removed the antral portion of ACPs. Fisher’s exact test was used for the statistical analysis with SPSS version 14.0. Statistical significance was defined as a p-value <0.05. 3. Results Fifty-six patients with ACPs were identified. There were 27 (48.2%) patients in children and 29 (51.8%) patients in adults. Clinical findings in children and adults are summarized in Table 1. In children, there were 16 males and 11 females; the mean age was 15.5 1.5 years, with a range of 4 to 17 years. In adults, there were 19 males and 10 females; the mean age was 49.0 3.0 years, with a range of 19 to 65 years. The sinonasal complaints in both groups were nasal obstruction, followed by nasal discharge. Nasal obstruction prevalence is similar in adults (79.3%) and children (66.7%). Of the 56 lesions, 30 ACPs (53.6%) were located in the left maxillary sinus and 25 ACPs (44.6%) were located in the right maxillary sinus. Bilateral ACP was detected in 1 case (1.8%, Fig. 1). There was a slight predominance of the left maxillary sinus in both the child (15/26, 57.7%) and adult (15/29, 51.7%) groups. On CT classification of the ACPs, there was a significant difference between children and adults. In children, the majority of patients were stage II (22/27, 81.5%), followed by stage III (4/27, 14.8%) and stage I (1/27, 3.7%). However, in adults, the majority of patients were stage I (13/29, 44.8%), followed by stage II (12/29, 41.4%) and stage III (4/29, 13.8%). In this study, stage II and III lesions were more common than stage I lesions in children (p < 0.001). We reviewed accompanying maxillary sinus diseases of ACPs, excluding chronic sinusitis. There were no accompanying maxillary sinus diseases in children. However, in adults, accompanying maxillary sinus diseases included fungus ball in 4 patients, inverted papilloma in 2 patients, and odontogenic sinusitis in 2 patients. All fungus balls were present in the ipsilateral maxillary sinus. Two inverted papillomas were detected in the ipsilateral maxillary sinus and ipsilateral ethmoid sinus. In this study, accompanying maxillary sinus diseases were more common in adults than in children (p < 0.005). No one needed additional endoscopic sinus surgery for other sinuses, except ACPs. In all patients, histopathological findings of the resected specimens were consistent with ACPs. In particular, two patients in children were diagnosed as having angiomatous polyps, the rare variant of sinonasal polyp. These patients included 1 male (14 years old) and 1 female (17 years old, Fig. 2). Both patients presented with nasal obstruction. After endoscopic surgery, the patients were followed up with endoscopic examination and recurrence was not observed in any patient. The mean follow-up period after surgery was 60.7 35.7 months (mean follow-up standard deviation), with a range of 8 to 120 months in children. In adults the mean
Fig. 1. In a 9-year-old male patient, coronal CT scans show a soft tissue mass in bilateral maxillary sinus, extending to the nasopharynx.
follow-up period after surgery was 55.4 29.8 months, with a range of 11 to 122 months. Purely endoscopic surgery for ACPs was performed in all (100%) children and 25 (86.2%) adults. The combined approach, endoscopic and canine fossa approach, was applied in 4 (13.8%) adults in whom it was difficult to access the antral portion of ACPs endoscopically. The success rate was 88.9% in children and 93.1% in adults. According to the approach method, the success rate was 90.4% (47/52 patients) for the purely endoscopic approach and 100% (4/4 patients) for the combined approach. Recurrence of ACPs was identified in 3 (11.1%) children and 2 (6.9%) adults. The recurrence of ACPs did not differ significantly between the two groups. All five cases with recurrence were previously treated by the purely endoscopic approach. Among the three children, two patients were disease-free after re-operation through endoscopic approach. One patient was regularly followed up without surgery because she had intermittent and mild symptoms. In the two adults, one patient had been disease-free after re-operation through endoscopic approach, and the other patient had been on regular follow-up without surgery. There were no major complications resulting from surgical intervention. Middle turbinate synechiae occurred in 1 child patient and septal perforation was noted in 1 adult patient. 4. Discussion It is known that ACPs most commonly occur in children and young adults [1,4]. However, only 48.2% of all cases occurred among children in this study. In addition, approximately 40% of the patients were between 30 and 65 years. Therefore, the findings in
Table 1 Clinical findings of antrochoanal polyps in child and adult groups. Children (N = 27)
Adults (N = 29)
Age (years) Sex (M:F) Main sinonasal complain Location (R:L:B) CT classification (I:II:III) Surgery
4–17 (15.5 1.5) 16:11 Nasal obstruction (66.7%) 11:15:1 1:22:4 Purely endoscopic (100%)
Accompanying maxillary sinus diseases Recurrence
None 3 (11.1%)
19–65 (49.0 3.0) 19:10 Nasal obstruction (79.3%) 14:15:0 13:12:4 Purely endoscopic (86.2%) Combined approach (13.8%) FB (n = 4), IP (n = 2), Odontogenic sinusitis (n = 2) 2 (6.9%)
M, male; F, female; R, right; L, left; B, both; FB, fungus ball; IP, inverted papilloma.
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Fig. 2. Atypical presentation of an antrochoanal polyp as a reddish and hypervascularized mass (A), with focal necrosis behind the soft palate (B). MRI scan shows heterogeneous nodular and patch enhancement on T1-weighted imaging (C), and histopathological sections shows angiomatous polyp containing thin-walled vessels, hemorrhage, and necrosis (hematoxylin–eosin staining, 40).
our study are consistent with the claim that ACPs may manifest at any age, as shown in few previous reports [5,7]. This study showed that ACPs were more common in males than in females (male–female ratio, 1.7:1). There was a slight predominance of the left maxillary sinus in both children and adults, as shown in previous reports [9,10]. The presenting symptoms are similar to those of many paranasal sinus diseases, including nasal obstruction, rhinorrhea, headache, and snoring [1]. The most common sinonasal complaints is nasal obstruction [1,8,9]. Nasal endoscopy and CT are excellent tools for diagnosing ACPs [1,5,9]. On nasal endoscopy, ACP typically appears as a smooth polypoid mass originating in the middle meatus, and it extends into the choana and nasopharynx, eventually to the oral cavity [1,4,5]. CT reveals a soft tissue masses occupying the maxillary sinus through the maxillary sinus ostium and extending into the choana without bony erosion or expansion [1,4,5,9]. On magnetic resonance imaging (MRI), ACP shows hypointensity on T1-weighted image and hyperintensity on T2-weighted image [1,5]. The differential diagnosis is between ACPs and ipsilateral nasal tumors such as angiofibroma, nasal glioma, encephalocele, mucocele, retention cyst, inverted papilloma, or hemangioma [1,5,9]. According to the CT classification [6], the most common CT finding of ACPs in this study was stage II lesions (81.5%) in children. Only one patient in children had stage I lesion. However, in adults, the majority of patients were stage I and II (86.2%). In this study, stage II and III lesions were more common than stage I lesions in children (p < 0.001). Chung et al. [6] reported that stage I may correspond to an early proliferative stage, stage II to active proliferative stage, and stage III to a late regressive stage. Therefore, it can be speculated that the difference in CT staging between the two groups may be due to late diagnosis of ACPs in children. Children usually do not complain of early nasal
symptoms, which leads to delayed diagnosis and they often present at an advanced stage. In this study, we found that two patients in children presented with a necrotic mass and it was postoperatively diagnosed as angiomatous polyp, which is rare, representing only 4–5% of all sinonasal polyps [10]. Angiomatous polyps are characterized by extensive vascular proliferation and ectasia [11]. Because angiomatous polyp develops as a result of infarction, ACP is more likely to develop as angiomatous polyp because of strangulation of the long pedicle of ACP. CT of angiomatous polyp reveals a heterogeneous mass with minimal peripheral enhancement [10]. MRI of angiomatous polyp shows hypointensity on T1-weighted image (WI), heterogeneous hyperintensity with peripheral hyperintensity on T2-WI, and marked heterogeneous nodular and patchy enhancement on enhanced T1-WI [12]. Angiomatous polyps are benign; however, the clinical and radiological features of these lesions have considerable potential for confusion with neoplastic processes [10,11]. In patients with ACP, accompanying maxillary sinus diseases should be thoroughly evaluated preoperatively. Accompanying maxillary sinus diseases in ACP can aggravate ACP or cause recurrence of ACP postoperatively or there can be residual accompanying disease if not treated properly. In our study, there were no accompanying maxillary sinus diseases in children. However, adults had several accompanying maxillary diseases, such as fungus ball in 4 patients, inverted papilloma in 2 patients, and odontogenic sinusitis in 2 patients. In this study, accompanying maxillary sinus diseases were more common in adults than in children (p < 0.005). All accompanying maxillary sinus diseases and ACPs were simultaneously removed via endoscopic approach. However, two patients, one patient with odontogenic sinusitis and another patient with inverted papilloma, had recurrence. When
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patients have ACPs with accompanying maxillary sinus diseases, clinicians should consider the possibility of disease recurrence. Surgical removal is the generally accepted treatment of choice for ACPs [1,3–5,8,9,13]. Endoscopic surgery is now the main treatment modality for ACPs because of its shorter recovery time and fewer side effects [1,4,5,8,13]. This technique consists of complete removal of the nasal and antral portions of the ACPs with resection of its site of origin. Identification and removal of antral portion of ACPs are cornerstones to successful treatment [5]. In some cases, an additional combined approach using a canine fossa approach may be required to ensure optimum visualization within the confines of the maxillary sinus [4,5,13]. We performed the combined approach only in adults because dentition interference, infraorbital paresthesia, or facial growth disturbance after canine fossa puncture can occur in children [4,9]. The success rate was 88.9% in children and 93.1% in adults. According to the approach method, the success rate was 90.4% (47/52 patients) for purely endoscopic approach and 100% (4/4 patients) for combined approach. These success rates were similar to those in previous reports [1,3,5,8,9]. The recurrence rate in endoscopic surgical treatment of ACPs is usually low [8]. Recurrence of ACPs is most probably due to regrowth of any missed residual polypoid lesions within the maxillary antrum [3]. In this study, recurrence of ACPs was identified in 3 (11.1%) children and 2 (6.9%) adults. All adults with recurrence had accompanying maxillary sinus diseases. Among them, three patients had been disease-free after re-operation through endoscopic approach. There were no major surgical complications such as orbital injury. Septal perforation was noted in 1 adult patient, which was due to excessive septal trauma caused by manipulation of curved forceps to reach the anterior and/or lateral wall of the maxillary sinus. However, septal perforation was small and asymptomatic and the patient had been followed up without repair of perforation. 5. Conclusion In our study, high incidence of CT stage II and III lesions in children with ACP in our study suggests that children with ACP present at a more advanced state because of late diagnosis. Accompanying maxillary sinus diseases may occur with ACPs, especially in adults. Therefore, clinicians should consider the
possibility of coexistence of ACPs and another maxillary sinus disease. Endoscopic surgery for complete removal of ACPs is a safe and effective procedure for both children and adults.
Competing interest The authors have no sponsorships or competing interests to disclose for this article. Acknowledgments The authors have no acknowledgements to disclose for this article.
References [1] H. Yaman, S. Yilmaz, E. Karali, E. Guclu, O. Ozturk, Evaluation and management of antrochoanal polyp, Clin. Exp. Otorhinolaryngol. 3 (2010) 110–114. [2] S. Aydin, U. Taskin, I. Orhan, B. Altas, M.F. Oktay, M. Tokso¨z, et al., The analysis of the maxillary sinus volumes and the nasal septal deviation in patients with antrochoanal polyps, Eur. Arch. Otorhinolaryngol. 272 (2014) 3347–3352. [3] A.A. El-Sharkawy, Endoscopic management of paediatirc antrochoanal polyp: our experience, Acta Otorhinolaryngol. Ital. 33 (2013) 107–111. [4] N. Choudhury, A. Hariri, H. Saleh, Endoscopic management of antrochoanal polyps: a single UK centre’s experience, Eur. Arch. Otorhinolaryngol. 272 (2014) 2305–2311. [5] P. Frosini, G. Picarella, E. De Campora, Antrochoanal polyps: analysis of 200 cases, Acta Otorhinolaryngol. Ital. 29 (2009) 21–26. [6] S.K. Chung, B.C. Chang, H.J. Dhong, Surgical, radiologic, and histologic findings of the antrochoanal polyp, Am. J. Rhinol. 16 (2002) 71–76. [7] P.R. Cook, W.E. Davis, R. McDonald, J.P. McKinsey, Antrochoanal polyposis: a review of 33 cases, Ear Nose Throat J. 72 (1993) 401–402. [8] K.A. Al-Mazrou, M. Bukhari, Al. Al-Fayez, Characteristics of antrochoanal polyps in the pediatric age group, Ann. Thorac. Med. 4 (2009) 133–136. [9] T.J. Lee, S.F. Huang, Endoscopic sinus surgery for antrochoanal polyps in children, Otolaryngol. Head Neck Surg. 135 (2006) 688–692. [10] L.B. Dai, S.H. Zhou, L.X. Ruan, Z.J. Zheng, Correlation of computed tomography with pathological features in angiomatous nasal polyps, PLoS ONE 12 (2012) e53306. [11] P. Sheahan, P.L. Crotty, S. Hamilton, M. Colreavy, D. McShane, Infarcted angiomatous nasal polyps, Eur. Arch. Otorhinolaryngol. 262 (2005) 225–230; V.L. Scharmm Jr., M.Z. Effron, Nasal polyps in children, Laryngoscope 90 (1980) 1488–1495. [12] Y.Z. Wang, B.T. Yang, Z.C. Wang, L. Song, J.F. Xian, MR evaluation of sinonasal angiomatous polyp, AJNR Am. J. Neuroradiol. 33 (2012) 767–772. [13] Y.A. Nour, Variable extent of nasonantral window for resection of antrochoanal polyp: selection of the optimum endoscopic approach, Eur. Arch. Otorhinolaryngol. 272 (2014) 1127–1134.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Difference of antrochoanal polyp between children and adults Dong Hoon Lee, Tae Mi Yoon, Joon Kyoo Lee, Sang Chul Lim * Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School & Chonnam National University Hwasun Hospital, 160 Ilsimri, Hwasun, Jeonnam 519-809, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 28 December 2015 Received in revised form 3 March 2016 Accepted 4 March 2016 Available online 12 March 2016
Objective: The purpose of this study was to review the clinical characteristics of the antrochoanal polyp (ACP) and to compare the differences between children and adults. Patients and methods: This study was performed in 56 patients who underwent endoscopic surgery for ACP between 2004 and 2014. The study population was subdivided into children (8 years old) and adults (>18 years old). Clinical findings of ACP, including symptoms, CT stages, and surgical outcomes were retrospectively analyzed. Results: CT Stage II and III lesions were more common than CT stage I lesions in children (p < 0.001). Accompanying maxillary sinus diseases were more common in adults (p < 0.005). Purely endoscopic surgery for ACPs was performed in all children and 25 (86.2%) adults. The combined approach, endoscopic and canine fossa approach, was applied in 4 (13.8%) adults. The success rate was 88.9% in children and 93.1% in adults. According to the approach method, the success rate was 90.4% for the purely endoscopic approach and 100% for the combined approach. Conclusion: High incidence of CT stage II and III lesions in the child group with ACP in our study suggests that children with ACP present at a more advanced state because of late diagnosis. Accompanying maxillary sinus diseases can be present in patients with ACP, especially adults, which should be considered preoperatively and treated appropriately. ß 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Antrochoanal polyp Child Adult Endoscopic surgery Computed tomography
1. Introduction
2. Patients and methods
Antrochoanal polyps (ACPs) are benign polypoid lesions arising from the mucosa of the maxillary sinus, through the maxillary sinus ostium with extension into the choana [1–3]. ACPs represent approximately 4–6% of all nasal polyps in the general population; however, the incidence is increased to 35% in children [1,4]. ACPs are almost always unilateral, although there are few cases of bilateral ACPs in the literature, mainly in children [1–3]. The pathogenesis and etiology of ACPs are still unknown [2]. Nasal endoscopy and computed tomography (CT) are the gold standard for determining the diagnosis and the treatment plan [1,5]. Surgical removal of ACPs is the treatment of choice [1–4]. The purpose of this study was to review the clinical characteristics of the ACPs, and to compare the differences between the child and adult groups.
After obtaining approval from the Institutional Review Board of Chonnam National University Hwasun Hospital (CNUHH-2015145), this study was performed in 56 patients who underwent endoscopic surgery for ACP between 2004 and 2014. This study population was subdivided into children (18 years old) and adults (>18 years old). Demographic characteristics, sinonasal complaints, localization of ACPs, imaging findings, accompanying maxillary sinus diseases, histopathologic results, treatment outcomes, and postoperative complications were reviewed. We classified ACPs into 3 patterns according to the CT findings [6]: Stage I (antronasal polyp), Stage II (ACP extended to the nasopharynx and the ostium of the maxillary sinus was occluded fully by the neck of the ACP), and Stage III (ACP extended to the nasopharynx and the ostium of the maxillary sinus was occluded partially by the neck of the ACP). The type of surgical approach was determined by endoscopic accessibility for the antral portion of ACPs. The antral portion of ACPs was removed via endoscopic approach through the natural maxillary ostium after it was adequately widened. However, in some cases, it was difficult to access the antral portion of ACPs endoscopically, and additional access was obtained through the
* Corresponding author. Tel.: +82 61 379 8190; fax: +82 61 379 7761. E-mail address: [email protected] (S.C. Lim). http://dx.doi.org/10.1016/j.ijporl.2016.03.004 0165-5876/ß 2016 Elsevier Ireland Ltd. All rights reserved.
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canine fossa. A 5 mm diameter window was created 1 cm above the canine fossa by trocar puncture. A powered instrumentation was inserted into the maxillary sinus through the canine fossa puncture, and removed the antral portion of ACPs. Fisher’s exact test was used for the statistical analysis with SPSS version 14.0. Statistical significance was defined as a p-value <0.05. 3. Results Fifty-six patients with ACPs were identified. There were 27 (48.2%) patients in children and 29 (51.8%) patients in adults. Clinical findings in children and adults are summarized in Table 1. In children, there were 16 males and 11 females; the mean age was 15.5 1.5 years, with a range of 4 to 17 years. In adults, there were 19 males and 10 females; the mean age was 49.0 3.0 years, with a range of 19 to 65 years. The sinonasal complaints in both groups were nasal obstruction, followed by nasal discharge. Nasal obstruction prevalence is similar in adults (79.3%) and children (66.7%). Of the 56 lesions, 30 ACPs (53.6%) were located in the left maxillary sinus and 25 ACPs (44.6%) were located in the right maxillary sinus. Bilateral ACP was detected in 1 case (1.8%, Fig. 1). There was a slight predominance of the left maxillary sinus in both the child (15/26, 57.7%) and adult (15/29, 51.7%) groups. On CT classification of the ACPs, there was a significant difference between children and adults. In children, the majority of patients were stage II (22/27, 81.5%), followed by stage III (4/27, 14.8%) and stage I (1/27, 3.7%). However, in adults, the majority of patients were stage I (13/29, 44.8%), followed by stage II (12/29, 41.4%) and stage III (4/29, 13.8%). In this study, stage II and III lesions were more common than stage I lesions in children (p < 0.001). We reviewed accompanying maxillary sinus diseases of ACPs, excluding chronic sinusitis. There were no accompanying maxillary sinus diseases in children. However, in adults, accompanying maxillary sinus diseases included fungus ball in 4 patients, inverted papilloma in 2 patients, and odontogenic sinusitis in 2 patients. All fungus balls were present in the ipsilateral maxillary sinus. Two inverted papillomas were detected in the ipsilateral maxillary sinus and ipsilateral ethmoid sinus. In this study, accompanying maxillary sinus diseases were more common in adults than in children (p < 0.005). No one needed additional endoscopic sinus surgery for other sinuses, except ACPs. In all patients, histopathological findings of the resected specimens were consistent with ACPs. In particular, two patients in children were diagnosed as having angiomatous polyps, the rare variant of sinonasal polyp. These patients included 1 male (14 years old) and 1 female (17 years old, Fig. 2). Both patients presented with nasal obstruction. After endoscopic surgery, the patients were followed up with endoscopic examination and recurrence was not observed in any patient. The mean follow-up period after surgery was 60.7 35.7 months (mean follow-up standard deviation), with a range of 8 to 120 months in children. In adults the mean
Fig. 1. In a 9-year-old male patient, coronal CT scans show a soft tissue mass in bilateral maxillary sinus, extending to the nasopharynx.
follow-up period after surgery was 55.4 29.8 months, with a range of 11 to 122 months. Purely endoscopic surgery for ACPs was performed in all (100%) children and 25 (86.2%) adults. The combined approach, endoscopic and canine fossa approach, was applied in 4 (13.8%) adults in whom it was difficult to access the antral portion of ACPs endoscopically. The success rate was 88.9% in children and 93.1% in adults. According to the approach method, the success rate was 90.4% (47/52 patients) for the purely endoscopic approach and 100% (4/4 patients) for the combined approach. Recurrence of ACPs was identified in 3 (11.1%) children and 2 (6.9%) adults. The recurrence of ACPs did not differ significantly between the two groups. All five cases with recurrence were previously treated by the purely endoscopic approach. Among the three children, two patients were disease-free after re-operation through endoscopic approach. One patient was regularly followed up without surgery because she had intermittent and mild symptoms. In the two adults, one patient had been disease-free after re-operation through endoscopic approach, and the other patient had been on regular follow-up without surgery. There were no major complications resulting from surgical intervention. Middle turbinate synechiae occurred in 1 child patient and septal perforation was noted in 1 adult patient. 4. Discussion It is known that ACPs most commonly occur in children and young adults [1,4]. However, only 48.2% of all cases occurred among children in this study. In addition, approximately 40% of the patients were between 30 and 65 years. Therefore, the findings in
Table 1 Clinical findings of antrochoanal polyps in child and adult groups. Children (N = 27)
Adults (N = 29)
Age (years) Sex (M:F) Main sinonasal complain Location (R:L:B) CT classification (I:II:III) Surgery
4–17 (15.5 1.5) 16:11 Nasal obstruction (66.7%) 11:15:1 1:22:4 Purely endoscopic (100%)
Accompanying maxillary sinus diseases Recurrence
None 3 (11.1%)
19–65 (49.0 3.0) 19:10 Nasal obstruction (79.3%) 14:15:0 13:12:4 Purely endoscopic (86.2%) Combined approach (13.8%) FB (n = 4), IP (n = 2), Odontogenic sinusitis (n = 2) 2 (6.9%)
M, male; F, female; R, right; L, left; B, both; FB, fungus ball; IP, inverted papilloma.
D.H. Lee et al. / International Journal of Pediatric Otorhinolaryngology 84 (2016) 143–146
145
Fig. 2. Atypical presentation of an antrochoanal polyp as a reddish and hypervascularized mass (A), with focal necrosis behind the soft palate (B). MRI scan shows heterogeneous nodular and patch enhancement on T1-weighted imaging (C), and histopathological sections shows angiomatous polyp containing thin-walled vessels, hemorrhage, and necrosis (hematoxylin–eosin staining, 40).
our study are consistent with the claim that ACPs may manifest at any age, as shown in few previous reports [5,7]. This study showed that ACPs were more common in males than in females (male–female ratio, 1.7:1). There was a slight predominance of the left maxillary sinus in both children and adults, as shown in previous reports [9,10]. The presenting symptoms are similar to those of many paranasal sinus diseases, including nasal obstruction, rhinorrhea, headache, and snoring [1]. The most common sinonasal complaints is nasal obstruction [1,8,9]. Nasal endoscopy and CT are excellent tools for diagnosing ACPs [1,5,9]. On nasal endoscopy, ACP typically appears as a smooth polypoid mass originating in the middle meatus, and it extends into the choana and nasopharynx, eventually to the oral cavity [1,4,5]. CT reveals a soft tissue masses occupying the maxillary sinus through the maxillary sinus ostium and extending into the choana without bony erosion or expansion [1,4,5,9]. On magnetic resonance imaging (MRI), ACP shows hypointensity on T1-weighted image and hyperintensity on T2-weighted image [1,5]. The differential diagnosis is between ACPs and ipsilateral nasal tumors such as angiofibroma, nasal glioma, encephalocele, mucocele, retention cyst, inverted papilloma, or hemangioma [1,5,9]. According to the CT classification [6], the most common CT finding of ACPs in this study was stage II lesions (81.5%) in children. Only one patient in children had stage I lesion. However, in adults, the majority of patients were stage I and II (86.2%). In this study, stage II and III lesions were more common than stage I lesions in children (p < 0.001). Chung et al. [6] reported that stage I may correspond to an early proliferative stage, stage II to active proliferative stage, and stage III to a late regressive stage. Therefore, it can be speculated that the difference in CT staging between the two groups may be due to late diagnosis of ACPs in children. Children usually do not complain of early nasal
symptoms, which leads to delayed diagnosis and they often present at an advanced stage. In this study, we found that two patients in children presented with a necrotic mass and it was postoperatively diagnosed as angiomatous polyp, which is rare, representing only 4–5% of all sinonasal polyps [10]. Angiomatous polyps are characterized by extensive vascular proliferation and ectasia [11]. Because angiomatous polyp develops as a result of infarction, ACP is more likely to develop as angiomatous polyp because of strangulation of the long pedicle of ACP. CT of angiomatous polyp reveals a heterogeneous mass with minimal peripheral enhancement [10]. MRI of angiomatous polyp shows hypointensity on T1-weighted image (WI), heterogeneous hyperintensity with peripheral hyperintensity on T2-WI, and marked heterogeneous nodular and patchy enhancement on enhanced T1-WI [12]. Angiomatous polyps are benign; however, the clinical and radiological features of these lesions have considerable potential for confusion with neoplastic processes [10,11]. In patients with ACP, accompanying maxillary sinus diseases should be thoroughly evaluated preoperatively. Accompanying maxillary sinus diseases in ACP can aggravate ACP or cause recurrence of ACP postoperatively or there can be residual accompanying disease if not treated properly. In our study, there were no accompanying maxillary sinus diseases in children. However, adults had several accompanying maxillary diseases, such as fungus ball in 4 patients, inverted papilloma in 2 patients, and odontogenic sinusitis in 2 patients. In this study, accompanying maxillary sinus diseases were more common in adults than in children (p < 0.005). All accompanying maxillary sinus diseases and ACPs were simultaneously removed via endoscopic approach. However, two patients, one patient with odontogenic sinusitis and another patient with inverted papilloma, had recurrence. When
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patients have ACPs with accompanying maxillary sinus diseases, clinicians should consider the possibility of disease recurrence. Surgical removal is the generally accepted treatment of choice for ACPs [1,3–5,8,9,13]. Endoscopic surgery is now the main treatment modality for ACPs because of its shorter recovery time and fewer side effects [1,4,5,8,13]. This technique consists of complete removal of the nasal and antral portions of the ACPs with resection of its site of origin. Identification and removal of antral portion of ACPs are cornerstones to successful treatment [5]. In some cases, an additional combined approach using a canine fossa approach may be required to ensure optimum visualization within the confines of the maxillary sinus [4,5,13]. We performed the combined approach only in adults because dentition interference, infraorbital paresthesia, or facial growth disturbance after canine fossa puncture can occur in children [4,9]. The success rate was 88.9% in children and 93.1% in adults. According to the approach method, the success rate was 90.4% (47/52 patients) for purely endoscopic approach and 100% (4/4 patients) for combined approach. These success rates were similar to those in previous reports [1,3,5,8,9]. The recurrence rate in endoscopic surgical treatment of ACPs is usually low [8]. Recurrence of ACPs is most probably due to regrowth of any missed residual polypoid lesions within the maxillary antrum [3]. In this study, recurrence of ACPs was identified in 3 (11.1%) children and 2 (6.9%) adults. All adults with recurrence had accompanying maxillary sinus diseases. Among them, three patients had been disease-free after re-operation through endoscopic approach. There were no major surgical complications such as orbital injury. Septal perforation was noted in 1 adult patient, which was due to excessive septal trauma caused by manipulation of curved forceps to reach the anterior and/or lateral wall of the maxillary sinus. However, septal perforation was small and asymptomatic and the patient had been followed up without repair of perforation. 5. Conclusion In our study, high incidence of CT stage II and III lesions in children with ACP in our study suggests that children with ACP present at a more advanced state because of late diagnosis. Accompanying maxillary sinus diseases may occur with ACPs, especially in adults. Therefore, clinicians should consider the
possibility of coexistence of ACPs and another maxillary sinus disease. Endoscopic surgery for complete removal of ACPs is a safe and effective procedure for both children and adults.
Competing interest The authors have no sponsorships or competing interests to disclose for this article. Acknowledgments The authors have no acknowledgements to disclose for this article.
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