Antral Choanal Polyp Presenting as Obstructive Sleep Apnea Syndrome Grayson
K.
Rodgers, MD; Kenny H. Chan, MD; Ronald
\s=b\ Obstructive sleep apnea syndrome (OSAS) in children is commonly caused by adenotonsillar hypertrophy. The diagnos-
tic criteria of OSAS in children are not so well delineated as in adults. We report the first case of antral choanal polyp presenting as OSAS in a 10-year-old boy that initially presented to the child psychiatry service for behavior disturbance, enuresis, and daytime somnolence. Overnight
electroencephalogram sleep study
re-
vealed events consistent with OSAS. Multiple inhalant allergies, chronic maxillary sinusitis, and obstructive adenoid hypertrophy were diagnosed by the allergy and otolaryngology services. The child was scheduled for adenoidectomy when his sleep apnea symptoms persisted following antimicrobial therapy. Examination under anesthesia revealed a normal adenoid bed and a large left antral choanal polyp.
Polypectomy was performed as dictated by parental consent. Postoperatively intranasal steroid was nasal mucosa recurred in 2 months and a Caldwell-Luc
treatment with
an
begun. However, polypoid
procedure was performed. Subjective reports following surgery indicated improvement in daytime irritability, attention, and mood. A follow-up overnight electroencephalogram sleep study confirmed resolution of OSAS.
(Arch Otolaryngol Head Neck Surg. 1991;117:914-916)
Accepted for publication October 15, 1990. From the Departments of Otolaryngology (Drs Rodgers and Chan) and Psychiatry (Dr Dahl), University of Pittsburgh (Pa) School of Medicine. Reprint requests to Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, 1 Children's Plaza, 3705 Fifth Ave at DeSoto street, Pittsburgh, Pa 15213 (Dr Chan).
E.
Dahl, MD
syndrome Obstructi ve sleep (OSAS) commonly is
apnea
seen
in
a
pediatrie otolaryngology practice. Generally, OSAS in children presents as chronic mouth breathing, snoring, disrupted sleep patterns, and behav¬ ioral disturbances consistent with dis¬
rupted sleep (such as daytime somno¬ lence, irritability, inattentiveness). In the adult population, apneic periods
with duration greater than 10 seconds are the hallmark of sleep apnea. In children, shorter apneas may be sig¬ nificant. There is also evidence that increased resistive load to breathing (without frank apneas) can result in chronically disrupted sleep and a clin¬ ical picture of OSAS in some children.1-2 The pattern of sleep disrup¬
tion, with increased short arousals,
fragmented sleep, decreased rapid eye movement
sleep and, in
some
cases,
increased delta, can be as important in diagnosis as the measurement of ap¬ neic episodes.1·3 Adenotonsillar hypertrophy causes the majority of cases of OSAS in chil¬ dren. The diagnosis is generally made through a history and physical exam¬ ination and can be further confirmed by lateral neck radiography. Chronic infection is a common cause of the hypertrophied lymphoid tissue and a course of antibiotic therapy is an ac¬ ceptable treatment. If no response is obtained, adenotonsillectomy is un¬ dertaken. Although uncommon, other causes of upper airway obstruction
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/21/2015
need to be considered. The purpose of this article is to present the first doc¬ umented case of OSAS caused by an antral choanal polyp. REPORT OF A CASE A 10-year-old boy presented initially to the psychiatry service for evaluation of be¬ havior disturbances, snoring with restless sleep, daytime hypersomnolence, and enuresis. His medical history was significant for seizure disorder treated with carbamazepine and attention deficit disorder in¬ termittently treated with methylphenidate. Additionally, he complained of chronic rhinorrhea and nasal obstruction for which he was seen by the allergy service. Multiple inhalant allergies were diagnosed by skin-testing, and bilateral maxillary si¬ nusitis (Fig 1) and adenoidal hypertrophy
(Fig 2) were diagnosed by roentgenography. Concurrently, an overnight electroen¬ cephalogram sleep study was performed revealing frequent obstructive apneic epi¬ sodes documented by patterns of paradox¬
ical chest movements combined with de¬ creased air flow, mild desaturation, and bradycardia, but only a few apneic episodes lasting 10 seconds or greater (Fig 3). Many of the shorter duration events (5 to 9 seconds) resulted in brief arousal from sleep and increased muscle tone (as mea¬ sured by electromyogram) before resump¬ tion of normal breathing. Almost all events occurred during rapid eye movement sleep (when muscle tone is at a minimum). Fur¬ thermore, the overall percentage of rapid eye movement sleep was found to be ap¬ proximately 7% (normal for age, 20% ), and the proportion of delta sleep was found to be markedly increased.
Fig 1.—Water's view revealing bilateral maxillary sinusitis.
Fig 2.—Lateral soft-tissue radiograph showing adenoid hypertrophy with adenoid/nasopharynx ratio of .80 (97th percentile for a 10-year-old child).
The patient was referred to the pediatrie otolaryngology service and received a full course of antibiotics that failed to improve his obstructive symptoms. The patient was scheduled for adenoidectomy. Examination under anesthesia revealed a large polyp filling the entire nasopharynx with a stalk based in the left middle meatus. Because of the lack of parental consent for a sinusectomy procedure, the polyp was avulsed and a nasal antral window was created. He was placed on an intranasal steroid spray fol¬
lowing surgery. Polypoid mucosa was again
noted in his left nostril 2 months after polypectomy and he subsequently under¬ went a Caldwell-Luc procedure. Postoperatively the previous signs and symptoms of disrupted sleep resolved com¬ pletely with no further complaints of day¬ time somnolence. Subjective reports also indicated significant improvement in day¬ time irritability, attention, and mood. A follow-up sleep study revealed complete resolution of sleep-disordered breathing with no further sign of disrupted sleep. Al¬ though he continued to have low rapid eye movements and high delta for his age, his follow-up sleep study showed a high sleep efficiency, a more normal sleep architec¬ ture, and normal respiratory patterns dur¬
ing rapid eye
movement
IIV/µ ' ^
eeg
H·-1».—
. ·'' -"·.'4pH1(l1.>"".Chin EMG (^V^^V^^^fAfV,
--^Vr^MvfA^W.WY^^iWW^-^V'''^^
LU4-U-UJJ.-i-tUJJ--l^^ rff-M-K-l I
ROC/LOC ecg
."
·
WA"1'.-W-d ·
Tibialis EMG
Thermistor
Respiration Abdominal Respiration Thoracic
A
Summation
Oximetry
(Fig 4).
COMMENT
Although the diagnostic criteria for OSAS has moderate consensus in
Fig 3.—Sample polysomnography strip during rapid eye movement sleep from preoperative over¬ night electroencephalogram sleep study indicating (1) paradoxical chest movements (thorax and abdomen out of phase), (2) 15-second cessation of air flow at thermistor despite respiratory ef¬ fort, (3) arousal following apnea, and (4) movement following apnea. EEG indicates electroen¬ cephalogram; ROC, right outer canthi; LOC, left outer canthi; EMG, electromyogram; and ECG, electrocardiogram.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/21/2015
EEG
(C3)
ROC
LOC Chin EMG *
"
IT')
«
EEG
(Occipital)
ROC/LOC ECG Tibialis EMG AC Thermistor Thoracic
Respiration
Abdominal
Respiration
Summation
DC Thermistor
Oximetry Fig 4. Sample polysomnography strip during rapid eye movement sleep from postoperative overnight electroencephalogram showing resolution of preoperative abnormalities. Note the very low activity in the muscle (electromyogram) channels, and steady, in-phase movement in respi¬ ratory and thermistor channels. EEG indicates electroencephalogram; ROC, right outer canthi; LOC, left outer canthi; EMG, electromyogram; DC, direct current; AC, alternating current; and ECG, electrocardiogram.
have found a low incidence of allergy and high incidence of chronic infec¬ tion.4·7 The established treatment of antral choanal polyps is removal of the mucosa of the maxillary sinus via the Caldwell-Luc approach. The role of in¬ tranasal polypectomy is limited to spe¬ cial situations in children where injury to unerupted teeth is of concern. Re¬ currence of these polyps after polypec¬ tomy is common. Other mass lesions of the nasophar¬ ynx such as nasopharyngeal cysts and encephalocele have been reported to cause sleep apnea.8 Antral choanal pol¬ yps commonly present with nasal ob¬ struction, mouth breathing, and only rarely have been reported to cause dysphagia and dyspnea.9 This is the first documented case to present with OSAS. In summary, the otolaryngolo¬ gist needs to add antral choanal polyp to the differential diagnosis of naso¬ pharyngeal obstruction producing OSAS.
—
adults, there is controversy about de¬
lineating similar criteria in children. Some children seem to present more in the way of disrupted sleep than with frequent prolonged apneic events. The usual cutoff (apnea index of 5 or greater) would have failed to diagnose this case (the patient's apnea index was 3.5). On the other hand, the pat¬ tern of his sleep measurements with frequent brief arousals, decreased rapid eye movement, and daytime symptoms of inadequate sleep were strongly indicative of OSAS. In this case the electroencephalographic mea-
sleep (in addition to the overnight pulmonary studies) were es¬ surements of
sential for the diagnosis. Inflammatory nasal polyps
are
the
nasal mass seen in chil¬ dren. Schramm and Effron4 reviewed nasal polyps in children and found that 33% are antral choanal polyps. Of nasal polyps in adults, only 3% to 6% are of the antral choanal variety.5·6 The cause of nasal polyps has been debated. Chronic infection and allergy are gen¬ erally postulated as the cause of nasal most
common
polyposis, however, studies specifi¬ cally reviewing antral choanal polyps
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/21/2015
References 1. Guilleminault C, Winkle R, Korobkin R, Simmons B. Children and nocturnal snoring: evaluation of the effects of sleep related respiratory resistive load and daytime functioning. Eur J Pediatr. 1982;139:165-171. 2. Potsic WP. Comparison of polysomnography and sonography for assessing regularity of respiration during sleep in adenotonsillar hypertro-
phy. Laryngoscope. 1987;97:1430-1437. 3. Guilleminault C, Korobkin R, Winkle R. A review of 50 children with obstructive sleep apnea syndrome. Lung. 1981;159:275-287. 4. Schramm VL, Effron MZ. Nasal polyps in children. Laryngoscope. 1980;90:1488-1495. 5. Heck WE, Hallberg OE, Williams HL. Antro-choanal polyp. Arch Otolaryngol. 1950; 52:538-548. 6. Sirola R. Choanal
polyps. Acta Otolaryngol. 1966;61:42-48. 7. Ryan RE, Neel HB. Antral-choanal polyp. J Otolaryngol. 1979;8:344-346. 8. Kenna MA. Transsphenoidal encephalocele. Ann Otol, Rhinol Laryngol. 1985;94:520-522. 9. Grewal DS, Sharma BK. Dyspnea and dysphagia in a child due to an antro-choanal polyp. Auris Nasus Larynx. 1984;11:25-28.
K.
Rodgers, MD; Kenny H. Chan, MD; Ronald
\s=b\ Obstructive sleep apnea syndrome (OSAS) in children is commonly caused by adenotonsillar hypertrophy. The diagnos-
tic criteria of OSAS in children are not so well delineated as in adults. We report the first case of antral choanal polyp presenting as OSAS in a 10-year-old boy that initially presented to the child psychiatry service for behavior disturbance, enuresis, and daytime somnolence. Overnight
electroencephalogram sleep study
re-
vealed events consistent with OSAS. Multiple inhalant allergies, chronic maxillary sinusitis, and obstructive adenoid hypertrophy were diagnosed by the allergy and otolaryngology services. The child was scheduled for adenoidectomy when his sleep apnea symptoms persisted following antimicrobial therapy. Examination under anesthesia revealed a normal adenoid bed and a large left antral choanal polyp.
Polypectomy was performed as dictated by parental consent. Postoperatively intranasal steroid was nasal mucosa recurred in 2 months and a Caldwell-Luc
treatment with
an
begun. However, polypoid
procedure was performed. Subjective reports following surgery indicated improvement in daytime irritability, attention, and mood. A follow-up overnight electroencephalogram sleep study confirmed resolution of OSAS.
(Arch Otolaryngol Head Neck Surg. 1991;117:914-916)
Accepted for publication October 15, 1990. From the Departments of Otolaryngology (Drs Rodgers and Chan) and Psychiatry (Dr Dahl), University of Pittsburgh (Pa) School of Medicine. Reprint requests to Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, 1 Children's Plaza, 3705 Fifth Ave at DeSoto street, Pittsburgh, Pa 15213 (Dr Chan).
E.
Dahl, MD
syndrome Obstructi ve sleep (OSAS) commonly is
apnea
seen
in
a
pediatrie otolaryngology practice. Generally, OSAS in children presents as chronic mouth breathing, snoring, disrupted sleep patterns, and behav¬ ioral disturbances consistent with dis¬
rupted sleep (such as daytime somno¬ lence, irritability, inattentiveness). In the adult population, apneic periods
with duration greater than 10 seconds are the hallmark of sleep apnea. In children, shorter apneas may be sig¬ nificant. There is also evidence that increased resistive load to breathing (without frank apneas) can result in chronically disrupted sleep and a clin¬ ical picture of OSAS in some children.1-2 The pattern of sleep disrup¬
tion, with increased short arousals,
fragmented sleep, decreased rapid eye movement
sleep and, in
some
cases,
increased delta, can be as important in diagnosis as the measurement of ap¬ neic episodes.1·3 Adenotonsillar hypertrophy causes the majority of cases of OSAS in chil¬ dren. The diagnosis is generally made through a history and physical exam¬ ination and can be further confirmed by lateral neck radiography. Chronic infection is a common cause of the hypertrophied lymphoid tissue and a course of antibiotic therapy is an ac¬ ceptable treatment. If no response is obtained, adenotonsillectomy is un¬ dertaken. Although uncommon, other causes of upper airway obstruction
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/21/2015
need to be considered. The purpose of this article is to present the first doc¬ umented case of OSAS caused by an antral choanal polyp. REPORT OF A CASE A 10-year-old boy presented initially to the psychiatry service for evaluation of be¬ havior disturbances, snoring with restless sleep, daytime hypersomnolence, and enuresis. His medical history was significant for seizure disorder treated with carbamazepine and attention deficit disorder in¬ termittently treated with methylphenidate. Additionally, he complained of chronic rhinorrhea and nasal obstruction for which he was seen by the allergy service. Multiple inhalant allergies were diagnosed by skin-testing, and bilateral maxillary si¬ nusitis (Fig 1) and adenoidal hypertrophy
(Fig 2) were diagnosed by roentgenography. Concurrently, an overnight electroen¬ cephalogram sleep study was performed revealing frequent obstructive apneic epi¬ sodes documented by patterns of paradox¬
ical chest movements combined with de¬ creased air flow, mild desaturation, and bradycardia, but only a few apneic episodes lasting 10 seconds or greater (Fig 3). Many of the shorter duration events (5 to 9 seconds) resulted in brief arousal from sleep and increased muscle tone (as mea¬ sured by electromyogram) before resump¬ tion of normal breathing. Almost all events occurred during rapid eye movement sleep (when muscle tone is at a minimum). Fur¬ thermore, the overall percentage of rapid eye movement sleep was found to be ap¬ proximately 7% (normal for age, 20% ), and the proportion of delta sleep was found to be markedly increased.
Fig 1.—Water's view revealing bilateral maxillary sinusitis.
Fig 2.—Lateral soft-tissue radiograph showing adenoid hypertrophy with adenoid/nasopharynx ratio of .80 (97th percentile for a 10-year-old child).
The patient was referred to the pediatrie otolaryngology service and received a full course of antibiotics that failed to improve his obstructive symptoms. The patient was scheduled for adenoidectomy. Examination under anesthesia revealed a large polyp filling the entire nasopharynx with a stalk based in the left middle meatus. Because of the lack of parental consent for a sinusectomy procedure, the polyp was avulsed and a nasal antral window was created. He was placed on an intranasal steroid spray fol¬
lowing surgery. Polypoid mucosa was again
noted in his left nostril 2 months after polypectomy and he subsequently under¬ went a Caldwell-Luc procedure. Postoperatively the previous signs and symptoms of disrupted sleep resolved com¬ pletely with no further complaints of day¬ time somnolence. Subjective reports also indicated significant improvement in day¬ time irritability, attention, and mood. A follow-up sleep study revealed complete resolution of sleep-disordered breathing with no further sign of disrupted sleep. Al¬ though he continued to have low rapid eye movements and high delta for his age, his follow-up sleep study showed a high sleep efficiency, a more normal sleep architec¬ ture, and normal respiratory patterns dur¬
ing rapid eye
movement
IIV/µ ' ^
eeg
H·-1».—
. ·'' -"·.'4pH1(l1.>"".Chin EMG (^V^^V^^^fAfV,
--^Vr^MvfA^W.WY^^iWW^-^V'''^^
LU4-U-UJJ.-i-tUJJ--l^^ rff-M-K-l I
ROC/LOC ecg
."
·
WA"1'.-W-d ·
Tibialis EMG
Thermistor
Respiration Abdominal Respiration Thoracic
A
Summation
Oximetry
(Fig 4).
COMMENT
Although the diagnostic criteria for OSAS has moderate consensus in
Fig 3.—Sample polysomnography strip during rapid eye movement sleep from preoperative over¬ night electroencephalogram sleep study indicating (1) paradoxical chest movements (thorax and abdomen out of phase), (2) 15-second cessation of air flow at thermistor despite respiratory ef¬ fort, (3) arousal following apnea, and (4) movement following apnea. EEG indicates electroen¬ cephalogram; ROC, right outer canthi; LOC, left outer canthi; EMG, electromyogram; and ECG, electrocardiogram.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/21/2015
EEG
(C3)
ROC
LOC Chin EMG *
"
IT')
«
EEG
(Occipital)
ROC/LOC ECG Tibialis EMG AC Thermistor Thoracic
Respiration
Abdominal
Respiration
Summation
DC Thermistor
Oximetry Fig 4. Sample polysomnography strip during rapid eye movement sleep from postoperative overnight electroencephalogram showing resolution of preoperative abnormalities. Note the very low activity in the muscle (electromyogram) channels, and steady, in-phase movement in respi¬ ratory and thermistor channels. EEG indicates electroencephalogram; ROC, right outer canthi; LOC, left outer canthi; EMG, electromyogram; DC, direct current; AC, alternating current; and ECG, electrocardiogram.
have found a low incidence of allergy and high incidence of chronic infec¬ tion.4·7 The established treatment of antral choanal polyps is removal of the mucosa of the maxillary sinus via the Caldwell-Luc approach. The role of in¬ tranasal polypectomy is limited to spe¬ cial situations in children where injury to unerupted teeth is of concern. Re¬ currence of these polyps after polypec¬ tomy is common. Other mass lesions of the nasophar¬ ynx such as nasopharyngeal cysts and encephalocele have been reported to cause sleep apnea.8 Antral choanal pol¬ yps commonly present with nasal ob¬ struction, mouth breathing, and only rarely have been reported to cause dysphagia and dyspnea.9 This is the first documented case to present with OSAS. In summary, the otolaryngolo¬ gist needs to add antral choanal polyp to the differential diagnosis of naso¬ pharyngeal obstruction producing OSAS.
—
adults, there is controversy about de¬
lineating similar criteria in children. Some children seem to present more in the way of disrupted sleep than with frequent prolonged apneic events. The usual cutoff (apnea index of 5 or greater) would have failed to diagnose this case (the patient's apnea index was 3.5). On the other hand, the pat¬ tern of his sleep measurements with frequent brief arousals, decreased rapid eye movement, and daytime symptoms of inadequate sleep were strongly indicative of OSAS. In this case the electroencephalographic mea-
sleep (in addition to the overnight pulmonary studies) were es¬ surements of
sential for the diagnosis. Inflammatory nasal polyps
are
the
nasal mass seen in chil¬ dren. Schramm and Effron4 reviewed nasal polyps in children and found that 33% are antral choanal polyps. Of nasal polyps in adults, only 3% to 6% are of the antral choanal variety.5·6 The cause of nasal polyps has been debated. Chronic infection and allergy are gen¬ erally postulated as the cause of nasal most
common
polyposis, however, studies specifi¬ cally reviewing antral choanal polyps
Downloaded From: http://archotol.jamanetwork.com/ by a University of Pittsburgh User on 06/21/2015
References 1. Guilleminault C, Winkle R, Korobkin R, Simmons B. Children and nocturnal snoring: evaluation of the effects of sleep related respiratory resistive load and daytime functioning. Eur J Pediatr. 1982;139:165-171. 2. Potsic WP. Comparison of polysomnography and sonography for assessing regularity of respiration during sleep in adenotonsillar hypertro-
phy. Laryngoscope. 1987;97:1430-1437. 3. Guilleminault C, Korobkin R, Winkle R. A review of 50 children with obstructive sleep apnea syndrome. Lung. 1981;159:275-287. 4. Schramm VL, Effron MZ. Nasal polyps in children. Laryngoscope. 1980;90:1488-1495. 5. Heck WE, Hallberg OE, Williams HL. Antro-choanal polyp. Arch Otolaryngol. 1950; 52:538-548. 6. Sirola R. Choanal
polyps. Acta Otolaryngol. 1966;61:42-48. 7. Ryan RE, Neel HB. Antral-choanal polyp. J Otolaryngol. 1979;8:344-346. 8. Kenna MA. Transsphenoidal encephalocele. Ann Otol, Rhinol Laryngol. 1985;94:520-522. 9. Grewal DS, Sharma BK. Dyspnea and dysphagia in a child due to an antro-choanal polyp. Auris Nasus Larynx. 1984;11:25-28.
