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Endoscopic surgery in pediatric recurrent antrochoanal polyp, rule of wide ostium
International Journal of Pediatric Otorhinolaryngology 75 (2011) 1372–1375
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Endoscopic surgery in pediatric recurrent antrochoanal polyp, rule of wide ostium Hesham Mohammad Eladl *, Shawky M. Elmorsy ORL Department Mansoura University, Elgomhoria Rode, Mansoura, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 April 2011 Received in revised form 25 July 2011 Accepted 27 July 2011 Available online 3 September 2011
Objective: To evaluate the use of wide middle meatal antrostomy in recurrent antrochoanal polyp (ACP) in children as regard technical difficulty, efficacy, and safety in children. Study design: Retrospective study. Patients and methods: In a retrospective study, 12 children with unilateral recurrent ACP (5 left-sided, 7 right-sided). All the ACPs were documented by preoperative endoscopy and computer tomographic (CT) scans. All cases were treated using endoscopic wide middle meatal antrostomy. The average age at the onset of symptoms was 9.3 years (median age: 10 years; range: 6–15 years). Results: Postoperative improvement in all cases was achieved using both subjective measures (symptoms improvement) and objective measures (radiological and endoscopical). No postoperative complications or recurrence during the follow up period. Conclusions: Endoscopic wide middle meatal antrostomy is a useful and easily applicable technique to manage recurrent antrochoanal 3 polyp in children. Managing associated pathology as turbinate hypertrophy, associated adenoids, anterior ethmoidectomy, uncinectomy and endoscopic limited septoplasty should be put in mind in order to improve ventilations. Powered instrumentations, angled endoscopes (45 and 708) and angled instrumentations can assure complete clearance of the polyp by identifying the origin of polyp in maxillary antrum. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Endoscopic surgery Pediatric polyps Antrochoanal polyp Sinus Pediatric endoscopic surgery
1. Introduction Antrochoanal polyp (ACP) is a soft tissue mass originating from the maxillary antrum, emerging from the ostium and extending to the choana through the nasal cavity [1]. ACPs were first reported by Killian in 1906, it is also called Killian polyp. It is an infrequent benign neoplasm; most commonly arise in children and young adults [2]. Moreover, they represent one of the most common types of nasal polyps in children without cystic fibrosis [3]. Various pathogenic mechanisms have been proposed to explain the development of ACPs, however, the cause is still largely unknown and a topic of major debate [1]. A study found the association of allergy with ACPs to be statistically significant [4]. However, other study found that allergy has no role in the etiology of ACPs [5] and the etiology of ACP might be chronic inflammatory processes rather than allergy [6,7]. Interestingly, familial type was reported [8]. Children have unique clinical and pathological features as compared to adults [5], as allergic ACP was more common than inflammatory ACP in children (2.8:1) as compared to adults [9].
* Corresponding author. Tel.: +20 148182440; fax: +20 502267016. E-mail address: [email protected] (H.M. Eladl). 0165-5876/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2011.07.029
The treatment of this disease is essentially surgical and endoscopic sinus surgery has become widely accepted modality for the treatment of ACP. As compared to conventional technique, the endoscopic approach proves to be superior [10,11]. Moreover, it can be done as an outpatient procedure, and is safe and reliable [12]. However, some authors preferred external approach (Caldwell-Luc) in cases of recurrence or incomplete resection [13]. Other recommended endoscopic surgery to be combined with transcanine sinuscopy to ensure complete removal of ACPs [14]. The maxillary sinus at birth is a small sinus cavity with its lower border 4 mm above the nasal floor. Expansion continues until 8–9 years of age when the floor of the sinus and nasal cavity are roughly equal, the sinus is 2 cm 2 cm 3 cm in diameter. Growth continues at rate of 2–3 mm/year until the adult age is reached when sinus floor is usually lower than the nasal cavity by 0.5–10 mm [15]. The surgery of recurrent polyps in children needs good experience to remove the origin of the polyp from the growing maxillary sinus [6]. 2. Materials and methods Ethical approval for this work was obtained (by ethical committee board in our ORL department) in a tertiary care hospital. Between January 2000 and September 2008, we enrolled 12 children with unilateral recurrent ACPs. All the ACPs were
[(Fig._1)TD$IG]
H.M. Eladl, S.M. Elmorsy / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1372–1375
1373
Fig. 1. Coronal computed tomography scans showing antrochoanal polyps.
documented by preoperative endoscopy and computer tomographic (CT) scans (Fig. 1). All the patients and their families were well informed before surgeries and had provided informed consent for endoscopic treatment of ACPs. During operation, decongestion of the inferior turbinate and middle turbinate was achieved by using 2% oxymetazoline-soaked cotton pledgets and injection of diluted adrenaline in a concentration 1/100,000 The inferior portion of the uncinate process was uniformly excised to increase the space for endoscopic manipulation. If the polyp was too large for en bloc removal, the intranasal portion of the ACP was transected along the insertion line of the uncinate process by scissors. A zero, 458 and 708 endoscopes were used to inspect the intramaxillary extent of the ACP and to identify its origin and attachment and they were used in surgeries. Wide middle meatal antrostomy was done by enlarging the ostium anteriorly up to the lacrimal bone, superiorly to just below the orbital floor, posteriorly to the posterior wall of the maxillary sinus, and inferiorly to the floor of the nose thus creating a wide antrostomy (Fig. 2). A through-cutting straight and angled forceps or angled shavers were placed through the maxillary ostium to carefully dissect and transect the origin of the polyp. Then, the antral portion of the polyp was removed through the widened maxillary ostium. Associated pathology as turbinate hypertrophy, associated adenoids, anterior ethmoidectomy, uncinectomy and limited
[(Fig._2)TD$IG]
septoplasty were managed endoscopically. We were conservative when dealing with the inferior turbinate hypertrophy by only partially resecting a small part of the posterior half of the turbinate to avoid crustations. The maxillary sinus was thoroughly irrigated with warm normal saline solution through maxillary ostium. All surgical specimens were sent for pathologic examinations. Merocele nasal packings were left in the middle meatus for 24–48 h. Oral antibiotics were given for one week. Regular follow-up with meticulous clearing of crusts was done weekly. Postoperative evaluation was done using both subjective measures (symptoms improvement) and objective measures (endoscopical and radiological). Endoscopic examination was done 3 months, 6 months, 12 months, and up to 24 months postoperatively. 3. Results Twelve patients with 5 left-sided lesions and 7 right-sided lesions: were treated using endoscopic wide middle meatal antrostomy. Patients’ demographic data, the origins of ACPs, time of recurrence after previous surgical approaches listed in Table 1. The average age at the onset of symptoms was 9.3 years (median age: 10 years; range: 6–15 years). Postoperative follow-up duration ranged from 30 to 120 months (average 68.3 months). The origins and attachments of the pedicle in the antrum were as follows: posterior and lateral walls (3 patients); posterior wall (3 patients); and lateral wall (2 patients). In 4 patients the exact Table 1 Patients demographic data (age in years, F = female and M = male), the origin of antrochoanal polyps (P = posterior wall, L = lateral wall, PL = posterior lateral wall, * = origin could not detected), the duration between the first surgery and the recurrence in months and the postoperative follow up period in months.
Fig. 2. Wide middle meatal antrostomy with complete removal of the polyp.
1 2 3 4 5 6 7 8 9 10 11 12
Age
Sex
Side
Origin
Duration
Follow up
11 10 7 8 10 9 8 11 6 8 7 8
M M M F M M F M F M F M
L L R L L R L R L R L L
L P * P PL PL * PL * P * L
7 12 14 16 16 11 13 5 7 32 14 21
120 103 95 77 75 65 60 54 52 47 42 30
H.M. Eladl, S.M. Elmorsy / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1372–1375
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Table 2 Percentage of symptoms in patients with recurrent antrochoanal polyp. Patients
Nasal obstruction Rhinorrhea Snoring Mouth breathing Recurrent sinusitis
Numbers
Percentage
12 6 3 7 6
100% 50% 25% 58% 50%
origin was not detected and the antrum was filled with diffuse polypoid mucosa. The time between the primary surgery and the revision was ranging from 5 months up to 32 months (average 14 months) (Table 1). The common preoperative complaints were nasal obstruction, followed by rhinorrhea and mouth breathing. The duration between the onset of symptoms and referral to hospital varied from 3 months to 2 years (Table 2). In our case series postoperative improvement in all cases was achieved using both subjective measures (symptoms improvement) and objective measures (radiological and endoscopical). No postoperative complications were detected, and no recurrence was detected in all patients during the follow up period. As regard to the primary surgery, simple polypectomy was done for 3 patients, endoscopic surgery with middle meatal antrostomy in 8 patients, and combined endoscopic with transcanine approach in one patient. All surgeries were done in our centre, endoscopic middle meatal antrostomies were found to be contracted to small openings as the surgeons were conservative when dealing with young ages. 3.1. Associated pathology Six patients had associated sinusitis, 4 had adenoids enlargement, 2 had inferior turbinate hypertrophy, deviated septum to the same side in one patient, and concha bullosa in one patient. These lesions were managed endoscopically with managing the antrochoanal polyps (Table 3). 4. Discussion Antrochoanal polyp (ACP) is not uncommon in our locality. ACP occurs predominantly in children and young adults. It originates from the maxillary sinus antrum, passing through the maxillary sinus ostium into the middle meatus, with extension into the nasopharynx and the oropharynx. Although recurrence of antrochoanal polyp is high especially in children, limited papers had been published. Orvidas et al. [16] recorded up to 25% recurrence after endoscopic approach; Ozdek et al. [17] recorded up to 22% recurrence after middle meatal antrostomy alone but no recurrence after combining MMA with transcanine surgery. To our
Table 3 Associated pathologies with recurrent antrochoanal polyp and their management. Associated pathology
Numbers
Endoscopic surgery
Sinusitis
4
Adenoids Inf. tur. hypertrophy DS Concha bullosa Adenoids + sinusitis
2 2 1 1 2
Uncinectomy + ant ehmoidectomy + wide MMA Adenoidectomy + wide MMA Par. Inf. Turbinectomy + wide MMA Endoscopic septoplasty + wide MMA Chonchoplasty + wide MMA Adenoidectomy + anterior ethmoidectomy + wide MMA
knowledge this is the first paper to discuss the management of recurrent antrochoanal polyp in children. There are many options for managing antrochoanal polyp as simple polypectomy, Caldwell Luc’s operation, endoscopic sinus surgery with middle meatal antrostomy and combined (endoscopic endonasal surgery and mini-Caldwell Luc’s). Endoscopic approach for complete removal of the ACP is an extremely safe and effective procedure. The principle of treatment is to identify and remove the origin of polyp in maxillary antrum along with main bulk of polyp. The origin of ACP is [11] multitudinous. The common site is posterior wall followed by inferior and lateral walls. It should be focused on the detection of the exact origin and the extent of the polyp to prevent recurrence [16,18]. Bozzo et al. [19] observed two recurrences, both in pediatric cases who evidently underwent an incomplete surgical removal of antral mucosa at its inferior aspect, probably due to the fear of damaging the teeth buds. They did not observe any postsurgical complication. Their data indicate the endoscopic middle meatal antrostomy as the optimal approach, also for the revision cases and in children. Endoscopic sinus surgery is the approach of choice; however in pediatric age group there are drawbacks included (a) narrow space in pediatric age and (b) inaccessibility of the lateral wall of maxillary antrum. Combined approach by canine fossa technique with angled endoscope and a straight debrider through trocar proved to be safe and effective. The risk of injury to bone growth centre and permanent tooth by this approach is low compared to Caldwell-Luc operation. It should be done only in developed maxillary sinus after radiographic evaluation [20]. Endoscopic surgery through the middle meatal antrostomy combined with transcanine sinuscopy ensures the complete removal of the antral part of ACP in children [17,21]. In order to prevent incomplete excision and recurrences, combined approaches (endoscopic endonasal surgery and miniCaldwell) were considered, particularly when the attachment site of the antral part of ACP is undetected [22]. The most important factors affecting the choice of surgical approaches are the preference of the surgeon, the age of the patient and the presence of recurrent disease [23]. In our series associated pathologies were present in all cases, sinusitis, adenoids, turbinate hypertrophy, deviated septum, and concha bullosa. These lesions should be addressed and managed whether in primary or revision surgeries. Basak et al. [21] reported the association of sinusitis, concha bullosa, turbinate hypertrophy, and adenoids with their cases but these cases were primary not recurrent. Intractable pediatric chronic sinusitis with antrochoanal polyp had been discussed [24]. Drawbacks for combined approach include the small distance between the developing teeth buds and the infraorbital bundles, which should be exactly studied before opening the anterior maxillary wall. Mini-Caldwell or transcanine surgeries can miss pathology in the anterior wall of the maxillary sinus. Stammberger [25] had suggested that transcanine is rarely indicated in children, except for ACP. Moreover, he also stated that they do not apply transcanine to children under 9 because of immature dental development and maxillary sinus pneumatisation. Although, another study found that the maxillary sinus volume in pediatric patients was not affected after the canine fossa puncture approach in pediatric patients with ACP [26]. In our study, endoscopic wide middle meatal antrostomy in recurrent ACP, with the help of angled endoscopes, give good exploration of the maxillary sinus walls to completely remove the antral part of the polyp without the need for the combined approaches and their drawbacks. In this study, no postoperative complications were detected, and no recurrence was detected in all patients during the follow up period. In 50 pediatric patients, Parsons and Phillips [27] found the maxillary ostia 1–2 mm from the attachment of the uncinate
H.M. Eladl, S.M. Elmorsy / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1372–1375
process to the lateral nasal wall. Mendelson and Gross [28] advocated widening the ostia to 3–5 times its normal size, as well as creating even larger mega-ostia for patients with ciliary abnormalities. On the other hand, many surgeons prefer limited surgical technique (mini FESS) in pediatric age group, this operation is conservative and directed to the originating site of the disease. If ostial dilation is indicated, dilation in the anterior direction after the excision of the uncinate process is the principal management [29]. This approach is only suitable for early and mild disease [30]. In this study, wide middle meatal antrostomy was done by enlarging the ostium anteriorly, superiorly, posteriorly, and inferiorly to create a wide antrostomy to ensure complete removal of the polyps’ tissue. Incidence of middle meatal antrostomy stenosis is not known. Stankiewicz [31] reported nearly a 50% incidence of antrostomy closure. However, Lazar et al. [32] found only a 2% incidence of stenosis. Stenosis may occur secondary to extensive scarring in the middle meatus, recurrent polyposis, or insufficient widening of the antrostomy during the initial surgery. Effects of early ESS on facial growth are controversial issue. Although Van Peteghem [33] was not able to see any influence of previous endoscopic sinus surgery on the anthropomorphic data of the face. However, other study suggests that ESS affect the midfacial growth [34]. In our study, no effect on facial growth could be detected. Nevertheless, the ESS even with wide middle meatal antrostomy appears more conservative than Caldwell Luc’s operation or even combined ESS with transcanine sinuscopy. In this research the use of wide middle meatal osteotomy is indicated for recurrent antrochoanal polyps to complete the removal of polyps tissues, allow good ventilation to the sinus and avoid ostial stenosis. However, the mini endoscopic technique is still the most recommended approach in our opinion in pediatric endoscopic sinus surgery in mild and non-recurrent cases to avoid unnecessary tissue injury and complications. In this study, no postoperative complications were detected, and no recurrence was detected in all patients during the follow up period. In our case series, wide middle meatal antrostomies with the help of angled endoscopes allow us to examine the whole walls, curved instruments and curettes allow us to remove any pathology in the maxillary sinus and to leave healthy mucosa. Transnasal endoscopic technique was favored by parents as it is less invasive with mild or no complications. Associated pathologies were managed safely. Endoscopic follow up was easily applicable, without recurrence in all cases. 5. Conclusion Endoscopic wide middle meatal antrostomy is a useful and easily applicable technique to manage recurrent antrochoanal polyp in children. Managing associated pathology as turbinate hypertrophy, associated adenoids, anterior ethmoidectomy, uncinectomy and endoscopic limited septoplasty should be put in mind in order to improve ventilations. Powered instrumentations, angled endoscopes (45 and 708) and angled instrumentations can assure complete clearance of the polyp by identifying the origin of polyp in maxillary antrum. References [1] M.E. Mahfouz, M.N. Elsheikh, N.F. Ghoname, Molecular profile of the antrochoanal polyp: upregulation of basic fibroblast growth factor and transforming growth factor beta in maxillary sinus mucosa, Am. J. Rhinol. 20 (4) (2006) 466–470.
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[2] T.J. Lee, S.F. Huang, Endoscopic sinus surgery for antrochoanal polyps in children, Otolaryngol. Head Neck Surg. 135 (5) (2006) 688–692. [3] M. Maldonado, A. Martinez, I. Alobid, J. Mullol, The antrochoanal polyp, Rhinology 42 (4) (2004) 178–182. [4] P.R. Cook, W.E. Davis, R. McDonald, J.P. McKinsey, Antrochoanal polyposis: a review of 33 cases, Ear Nose Throat J. 72 (6) (1993) 401–410. [5] Y.G. Min, J.W. Chung, J.S. Shin, J.G. Chi, Histologic structure of antrochoanal polyps, Acta Otolaryngol. 115 (4) (1995) 543–547, 17. [6] C. Ozcan, H. Zeren, D.U. Talas, M. Kucukoglu, K. Gorur, Antrochoanal. polyp: a transmission electron and light microscopic study, Eur. Arch. Otorhinolaryngol. 262 (1) (2005) 55–60. [7] J. Skladzien, J.A. Litwin, M. Nowogrodzka-Zagorska, W. Wierzchowski, Morphological and clinical characteristics of antrochoanal polyps: comparison with chronic inflammation-associated polyps of the maxillary sinus, Auris Nasus Larynx 28 (2) (2001) 137–141. [8] M.L. Montague, G.W. McGarry, Familial antrochoanal polyposis—a case report, Eur. Arch. Otorhinolaryngol. 261 (9) (2004) 507–508. [9] K.A. Al-Mazrou, M. Bukhari, A.I. Al-Fayez, Characteristics of antrochoanal polyps in the pediatric age group, Ann. Thorac Med. 4 (3) (2009) 133–136. [10] D. Aktas, S. Yetiser, M. Gerek, A. Kurnaz, C. Can, M. Kahramanyol, Antrochoanal polyps: analysis of 16 cases, Rhinology 36 (2) (1998) 81–85. [11] M. Pinilla, F. Gonzalez, J.R. Garcia-Berrocal, J. Vergara, Endoscopic approach of antrochoanal polyps, Acta Otorinolaringol. Esp. 45 (5) (1994) 345–347, 18. [12] R. Kamel, Endoscopic transnasal surgery in antrochoanal polyp, Arch. Otolaryngol. Head Neck Surg. 116 (7) (1990) 841–843. [13] F. Facon, J. Paris, P. Dessi, Antrochoanal polyps: diagnosis and management, Ann. Otolaryngol. Chir. Cervicofac. 121 (6) (2004) 315–321. [14] A. El Guindy, M.H. Mansour, The role of transcanine surgery in antrochoanal polyps, J. Laryngol. Otol. 108 (12) (1994) 1055–1057. [15] V.J. Lund, in: M. Gleeson (Ed.), Anatomy of the Nose and Paranasal Sinuses in Scott–Brown’s Otolaryngology Volume 1, sixth edition, 1997, pp. 1–30 (Chapter 5). [16] L.J. Orvidas, C.W. Beatty, A.L. Weaver, Antrochoanal polyps in children, Am. J. Rhinol. 15 (5) (2001) 321–325. [17] A. Ozdek, E. Samim, U. Bayiz, I. Meral, M.A. Safak, H. Og˘uz, Antrochoanal polyps in children, Int. J. Pediatr. Otorhinolaryngol. 65 (3) (2002) 213–218. [18] O. Aydin, G. Keskin, E. Ustu¨ndag˘, M. Is¸eri, H. Ozkarakas¸, Choanal polyps: an evaluation of 53 cases, Am. J. Rhinol. 21 (2) (2007) 164–168, 19. [19] C. Bozzo, R. Garrel, F. Meloni, F. Stomeo, L. Crampette, Endoscopic treatment of antrochoanal polyps, Eur. Arch. Otorhinolaryngol. 264 (2) (2007) 145–150. [20] V. Anand, S. Santosh, A. Aishwarya, Canine fossa approaches in endoscopic sinus surgery – our experience, Indian J. Otolaryngol. Head Neck Surg. 60 (2008) 214– 217. [21] S. Bas¸ak, C.Z. Karaman, A. Akdilli, K.K. Metin, Surgical approaches to antrochoanal polyps in children, Int. J. Pediatr. Otorhinolaryngol. 46 (3) (1998) 197–205. [22] F. Ozer, C. Ozer, C.A. Cagici, T. Canbolat, C. Yilmazer, B. Akkuzu, Surgical approaches for antrochoanal polyp: a comparative analysis, B-ENT 4 (2) (2008) 93–99. [23] S. Atighechi, M.H. Baradaranfar, G. Karimi, R. Jafari, Antrochoanal polyp: a comparative study of endoscopic endonasal surgery alone and endoscopic endonasal plus mini-Caldwell technique, Eur. Arch. Otorhinolaryngol. 266 (August (8)) (2009) 1245–1248 (Epub 2008 December 20). [24] H. Saito, N. Honda, T. Yamada, S. Mori, S. Fujieda, T. Saito, Intractable pediatric chronic 20 sinusitis with antrochoanal polyp, Int. J. Pediatric Otorhinolaryngol. 54 (2000) 111–116. [25] H. Stammberger (Ed.), Functional Endoscopic Sinus Surgery, Decker, Philadelphia, 1991. [26] J.Y. Lee, B.J. Baek, D.W. Kim, J.Y. Byun, S.W. Lee, H.S. Hong, Changes in the maxillary sinus volume and the surgical outcome after the canine fossa puncture approach in pediatric patients with an antrochoanal polyp: results of a minimum 3-year follow-up, Am. J. Rhinol. Allergy 23 (5) (2009) 531–534. [27] D. Parsons, S. Phillips, Functional endoscopic sinus surgery in children: a retrospective analysis of results, Laryngoscope 103 (1993) 899–903. [28] M.G. Mendelsohn, C.W. Gross, Soft-tissue shavers in pediatric sinus surgery, Otolaryngol. Clin. North Am. 30 (3) (1997) 443–449. [29] P.H. Chang, L.A. Lee, C.C. Huang, et al., Functional endoscopic sinus surgery in children using a limited approach, Arch. Otolaryngol. Head Neck Surg. 130 (2004) 1033–1036. [30] D.W. Kennedy, FESS concepts, surgical indications and Instrumentation, in: D.W. Kennedy, W.E. Bolger, S.J. Zinreich (Eds.), Diseases of the Sinuses Diagnosis and Management, B.C. Decker Inc., 2001, pp. 97–210 (Chapter 16A) 21. [31] J.A. Stankiewicz, Complications of sinus surgery, in: B.J. Bailey (Ed.), Head and Neck Surgery—Otolaryngology, BJ Lippencott Co., Philadelphia, PA, 1993 , pp. 413–426. [32] R.H. Lazar, R.T. Younis, C.W. Gross, Pediatric functional endonasal sinus surgery: review of 210 cases, Head Neck 14 (2) (1992) 92–98. [33] Van Peteghem A. Encephalometric data of cystic fibrosis patients with extensive sphenoidectomy, Eindwerk, 2002, pp 1-100. [34] E.A. Mair, Pediatric functional endoscopic sinus surgery. Post operative care, Otolaryngol. Clin. North Am. 29 (1) (1996) 207–219.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Endoscopic surgery in pediatric recurrent antrochoanal polyp, rule of wide ostium Hesham Mohammad Eladl *, Shawky M. Elmorsy ORL Department Mansoura University, Elgomhoria Rode, Mansoura, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 April 2011 Received in revised form 25 July 2011 Accepted 27 July 2011 Available online 3 September 2011
Objective: To evaluate the use of wide middle meatal antrostomy in recurrent antrochoanal polyp (ACP) in children as regard technical difficulty, efficacy, and safety in children. Study design: Retrospective study. Patients and methods: In a retrospective study, 12 children with unilateral recurrent ACP (5 left-sided, 7 right-sided). All the ACPs were documented by preoperative endoscopy and computer tomographic (CT) scans. All cases were treated using endoscopic wide middle meatal antrostomy. The average age at the onset of symptoms was 9.3 years (median age: 10 years; range: 6–15 years). Results: Postoperative improvement in all cases was achieved using both subjective measures (symptoms improvement) and objective measures (radiological and endoscopical). No postoperative complications or recurrence during the follow up period. Conclusions: Endoscopic wide middle meatal antrostomy is a useful and easily applicable technique to manage recurrent antrochoanal 3 polyp in children. Managing associated pathology as turbinate hypertrophy, associated adenoids, anterior ethmoidectomy, uncinectomy and endoscopic limited septoplasty should be put in mind in order to improve ventilations. Powered instrumentations, angled endoscopes (45 and 708) and angled instrumentations can assure complete clearance of the polyp by identifying the origin of polyp in maxillary antrum. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Endoscopic surgery Pediatric polyps Antrochoanal polyp Sinus Pediatric endoscopic surgery
1. Introduction Antrochoanal polyp (ACP) is a soft tissue mass originating from the maxillary antrum, emerging from the ostium and extending to the choana through the nasal cavity [1]. ACPs were first reported by Killian in 1906, it is also called Killian polyp. It is an infrequent benign neoplasm; most commonly arise in children and young adults [2]. Moreover, they represent one of the most common types of nasal polyps in children without cystic fibrosis [3]. Various pathogenic mechanisms have been proposed to explain the development of ACPs, however, the cause is still largely unknown and a topic of major debate [1]. A study found the association of allergy with ACPs to be statistically significant [4]. However, other study found that allergy has no role in the etiology of ACPs [5] and the etiology of ACP might be chronic inflammatory processes rather than allergy [6,7]. Interestingly, familial type was reported [8]. Children have unique clinical and pathological features as compared to adults [5], as allergic ACP was more common than inflammatory ACP in children (2.8:1) as compared to adults [9].
* Corresponding author. Tel.: +20 148182440; fax: +20 502267016. E-mail address: [email protected] (H.M. Eladl). 0165-5876/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2011.07.029
The treatment of this disease is essentially surgical and endoscopic sinus surgery has become widely accepted modality for the treatment of ACP. As compared to conventional technique, the endoscopic approach proves to be superior [10,11]. Moreover, it can be done as an outpatient procedure, and is safe and reliable [12]. However, some authors preferred external approach (Caldwell-Luc) in cases of recurrence or incomplete resection [13]. Other recommended endoscopic surgery to be combined with transcanine sinuscopy to ensure complete removal of ACPs [14]. The maxillary sinus at birth is a small sinus cavity with its lower border 4 mm above the nasal floor. Expansion continues until 8–9 years of age when the floor of the sinus and nasal cavity are roughly equal, the sinus is 2 cm 2 cm 3 cm in diameter. Growth continues at rate of 2–3 mm/year until the adult age is reached when sinus floor is usually lower than the nasal cavity by 0.5–10 mm [15]. The surgery of recurrent polyps in children needs good experience to remove the origin of the polyp from the growing maxillary sinus [6]. 2. Materials and methods Ethical approval for this work was obtained (by ethical committee board in our ORL department) in a tertiary care hospital. Between January 2000 and September 2008, we enrolled 12 children with unilateral recurrent ACPs. All the ACPs were
[(Fig._1)TD$IG]
H.M. Eladl, S.M. Elmorsy / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1372–1375
1373
Fig. 1. Coronal computed tomography scans showing antrochoanal polyps.
documented by preoperative endoscopy and computer tomographic (CT) scans (Fig. 1). All the patients and their families were well informed before surgeries and had provided informed consent for endoscopic treatment of ACPs. During operation, decongestion of the inferior turbinate and middle turbinate was achieved by using 2% oxymetazoline-soaked cotton pledgets and injection of diluted adrenaline in a concentration 1/100,000 The inferior portion of the uncinate process was uniformly excised to increase the space for endoscopic manipulation. If the polyp was too large for en bloc removal, the intranasal portion of the ACP was transected along the insertion line of the uncinate process by scissors. A zero, 458 and 708 endoscopes were used to inspect the intramaxillary extent of the ACP and to identify its origin and attachment and they were used in surgeries. Wide middle meatal antrostomy was done by enlarging the ostium anteriorly up to the lacrimal bone, superiorly to just below the orbital floor, posteriorly to the posterior wall of the maxillary sinus, and inferiorly to the floor of the nose thus creating a wide antrostomy (Fig. 2). A through-cutting straight and angled forceps or angled shavers were placed through the maxillary ostium to carefully dissect and transect the origin of the polyp. Then, the antral portion of the polyp was removed through the widened maxillary ostium. Associated pathology as turbinate hypertrophy, associated adenoids, anterior ethmoidectomy, uncinectomy and limited
[(Fig._2)TD$IG]
septoplasty were managed endoscopically. We were conservative when dealing with the inferior turbinate hypertrophy by only partially resecting a small part of the posterior half of the turbinate to avoid crustations. The maxillary sinus was thoroughly irrigated with warm normal saline solution through maxillary ostium. All surgical specimens were sent for pathologic examinations. Merocele nasal packings were left in the middle meatus for 24–48 h. Oral antibiotics were given for one week. Regular follow-up with meticulous clearing of crusts was done weekly. Postoperative evaluation was done using both subjective measures (symptoms improvement) and objective measures (endoscopical and radiological). Endoscopic examination was done 3 months, 6 months, 12 months, and up to 24 months postoperatively. 3. Results Twelve patients with 5 left-sided lesions and 7 right-sided lesions: were treated using endoscopic wide middle meatal antrostomy. Patients’ demographic data, the origins of ACPs, time of recurrence after previous surgical approaches listed in Table 1. The average age at the onset of symptoms was 9.3 years (median age: 10 years; range: 6–15 years). Postoperative follow-up duration ranged from 30 to 120 months (average 68.3 months). The origins and attachments of the pedicle in the antrum were as follows: posterior and lateral walls (3 patients); posterior wall (3 patients); and lateral wall (2 patients). In 4 patients the exact Table 1 Patients demographic data (age in years, F = female and M = male), the origin of antrochoanal polyps (P = posterior wall, L = lateral wall, PL = posterior lateral wall, * = origin could not detected), the duration between the first surgery and the recurrence in months and the postoperative follow up period in months.
Fig. 2. Wide middle meatal antrostomy with complete removal of the polyp.
1 2 3 4 5 6 7 8 9 10 11 12
Age
Sex
Side
Origin
Duration
Follow up
11 10 7 8 10 9 8 11 6 8 7 8
M M M F M M F M F M F M
L L R L L R L R L R L L
L P * P PL PL * PL * P * L
7 12 14 16 16 11 13 5 7 32 14 21
120 103 95 77 75 65 60 54 52 47 42 30
H.M. Eladl, S.M. Elmorsy / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1372–1375
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Table 2 Percentage of symptoms in patients with recurrent antrochoanal polyp. Patients
Nasal obstruction Rhinorrhea Snoring Mouth breathing Recurrent sinusitis
Numbers
Percentage
12 6 3 7 6
100% 50% 25% 58% 50%
origin was not detected and the antrum was filled with diffuse polypoid mucosa. The time between the primary surgery and the revision was ranging from 5 months up to 32 months (average 14 months) (Table 1). The common preoperative complaints were nasal obstruction, followed by rhinorrhea and mouth breathing. The duration between the onset of symptoms and referral to hospital varied from 3 months to 2 years (Table 2). In our case series postoperative improvement in all cases was achieved using both subjective measures (symptoms improvement) and objective measures (radiological and endoscopical). No postoperative complications were detected, and no recurrence was detected in all patients during the follow up period. As regard to the primary surgery, simple polypectomy was done for 3 patients, endoscopic surgery with middle meatal antrostomy in 8 patients, and combined endoscopic with transcanine approach in one patient. All surgeries were done in our centre, endoscopic middle meatal antrostomies were found to be contracted to small openings as the surgeons were conservative when dealing with young ages. 3.1. Associated pathology Six patients had associated sinusitis, 4 had adenoids enlargement, 2 had inferior turbinate hypertrophy, deviated septum to the same side in one patient, and concha bullosa in one patient. These lesions were managed endoscopically with managing the antrochoanal polyps (Table 3). 4. Discussion Antrochoanal polyp (ACP) is not uncommon in our locality. ACP occurs predominantly in children and young adults. It originates from the maxillary sinus antrum, passing through the maxillary sinus ostium into the middle meatus, with extension into the nasopharynx and the oropharynx. Although recurrence of antrochoanal polyp is high especially in children, limited papers had been published. Orvidas et al. [16] recorded up to 25% recurrence after endoscopic approach; Ozdek et al. [17] recorded up to 22% recurrence after middle meatal antrostomy alone but no recurrence after combining MMA with transcanine surgery. To our
Table 3 Associated pathologies with recurrent antrochoanal polyp and their management. Associated pathology
Numbers
Endoscopic surgery
Sinusitis
4
Adenoids Inf. tur. hypertrophy DS Concha bullosa Adenoids + sinusitis
2 2 1 1 2
Uncinectomy + ant ehmoidectomy + wide MMA Adenoidectomy + wide MMA Par. Inf. Turbinectomy + wide MMA Endoscopic septoplasty + wide MMA Chonchoplasty + wide MMA Adenoidectomy + anterior ethmoidectomy + wide MMA
knowledge this is the first paper to discuss the management of recurrent antrochoanal polyp in children. There are many options for managing antrochoanal polyp as simple polypectomy, Caldwell Luc’s operation, endoscopic sinus surgery with middle meatal antrostomy and combined (endoscopic endonasal surgery and mini-Caldwell Luc’s). Endoscopic approach for complete removal of the ACP is an extremely safe and effective procedure. The principle of treatment is to identify and remove the origin of polyp in maxillary antrum along with main bulk of polyp. The origin of ACP is [11] multitudinous. The common site is posterior wall followed by inferior and lateral walls. It should be focused on the detection of the exact origin and the extent of the polyp to prevent recurrence [16,18]. Bozzo et al. [19] observed two recurrences, both in pediatric cases who evidently underwent an incomplete surgical removal of antral mucosa at its inferior aspect, probably due to the fear of damaging the teeth buds. They did not observe any postsurgical complication. Their data indicate the endoscopic middle meatal antrostomy as the optimal approach, also for the revision cases and in children. Endoscopic sinus surgery is the approach of choice; however in pediatric age group there are drawbacks included (a) narrow space in pediatric age and (b) inaccessibility of the lateral wall of maxillary antrum. Combined approach by canine fossa technique with angled endoscope and a straight debrider through trocar proved to be safe and effective. The risk of injury to bone growth centre and permanent tooth by this approach is low compared to Caldwell-Luc operation. It should be done only in developed maxillary sinus after radiographic evaluation [20]. Endoscopic surgery through the middle meatal antrostomy combined with transcanine sinuscopy ensures the complete removal of the antral part of ACP in children [17,21]. In order to prevent incomplete excision and recurrences, combined approaches (endoscopic endonasal surgery and miniCaldwell) were considered, particularly when the attachment site of the antral part of ACP is undetected [22]. The most important factors affecting the choice of surgical approaches are the preference of the surgeon, the age of the patient and the presence of recurrent disease [23]. In our series associated pathologies were present in all cases, sinusitis, adenoids, turbinate hypertrophy, deviated septum, and concha bullosa. These lesions should be addressed and managed whether in primary or revision surgeries. Basak et al. [21] reported the association of sinusitis, concha bullosa, turbinate hypertrophy, and adenoids with their cases but these cases were primary not recurrent. Intractable pediatric chronic sinusitis with antrochoanal polyp had been discussed [24]. Drawbacks for combined approach include the small distance between the developing teeth buds and the infraorbital bundles, which should be exactly studied before opening the anterior maxillary wall. Mini-Caldwell or transcanine surgeries can miss pathology in the anterior wall of the maxillary sinus. Stammberger [25] had suggested that transcanine is rarely indicated in children, except for ACP. Moreover, he also stated that they do not apply transcanine to children under 9 because of immature dental development and maxillary sinus pneumatisation. Although, another study found that the maxillary sinus volume in pediatric patients was not affected after the canine fossa puncture approach in pediatric patients with ACP [26]. In our study, endoscopic wide middle meatal antrostomy in recurrent ACP, with the help of angled endoscopes, give good exploration of the maxillary sinus walls to completely remove the antral part of the polyp without the need for the combined approaches and their drawbacks. In this study, no postoperative complications were detected, and no recurrence was detected in all patients during the follow up period. In 50 pediatric patients, Parsons and Phillips [27] found the maxillary ostia 1–2 mm from the attachment of the uncinate
H.M. Eladl, S.M. Elmorsy / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1372–1375
process to the lateral nasal wall. Mendelson and Gross [28] advocated widening the ostia to 3–5 times its normal size, as well as creating even larger mega-ostia for patients with ciliary abnormalities. On the other hand, many surgeons prefer limited surgical technique (mini FESS) in pediatric age group, this operation is conservative and directed to the originating site of the disease. If ostial dilation is indicated, dilation in the anterior direction after the excision of the uncinate process is the principal management [29]. This approach is only suitable for early and mild disease [30]. In this study, wide middle meatal antrostomy was done by enlarging the ostium anteriorly, superiorly, posteriorly, and inferiorly to create a wide antrostomy to ensure complete removal of the polyps’ tissue. Incidence of middle meatal antrostomy stenosis is not known. Stankiewicz [31] reported nearly a 50% incidence of antrostomy closure. However, Lazar et al. [32] found only a 2% incidence of stenosis. Stenosis may occur secondary to extensive scarring in the middle meatus, recurrent polyposis, or insufficient widening of the antrostomy during the initial surgery. Effects of early ESS on facial growth are controversial issue. Although Van Peteghem [33] was not able to see any influence of previous endoscopic sinus surgery on the anthropomorphic data of the face. However, other study suggests that ESS affect the midfacial growth [34]. In our study, no effect on facial growth could be detected. Nevertheless, the ESS even with wide middle meatal antrostomy appears more conservative than Caldwell Luc’s operation or even combined ESS with transcanine sinuscopy. In this research the use of wide middle meatal osteotomy is indicated for recurrent antrochoanal polyps to complete the removal of polyps tissues, allow good ventilation to the sinus and avoid ostial stenosis. However, the mini endoscopic technique is still the most recommended approach in our opinion in pediatric endoscopic sinus surgery in mild and non-recurrent cases to avoid unnecessary tissue injury and complications. In this study, no postoperative complications were detected, and no recurrence was detected in all patients during the follow up period. In our case series, wide middle meatal antrostomies with the help of angled endoscopes allow us to examine the whole walls, curved instruments and curettes allow us to remove any pathology in the maxillary sinus and to leave healthy mucosa. Transnasal endoscopic technique was favored by parents as it is less invasive with mild or no complications. Associated pathologies were managed safely. Endoscopic follow up was easily applicable, without recurrence in all cases. 5. Conclusion Endoscopic wide middle meatal antrostomy is a useful and easily applicable technique to manage recurrent antrochoanal polyp in children. Managing associated pathology as turbinate hypertrophy, associated adenoids, anterior ethmoidectomy, uncinectomy and endoscopic limited septoplasty should be put in mind in order to improve ventilations. Powered instrumentations, angled endoscopes (45 and 708) and angled instrumentations can assure complete clearance of the polyp by identifying the origin of polyp in maxillary antrum. References [1] M.E. Mahfouz, M.N. Elsheikh, N.F. Ghoname, Molecular profile of the antrochoanal polyp: upregulation of basic fibroblast growth factor and transforming growth factor beta in maxillary sinus mucosa, Am. J. Rhinol. 20 (4) (2006) 466–470.
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