CLINICAL STUDY
Antrochoanal Polyp: Clinical Presentation and Retrospective Comparison of Endoscopic Sinus Surgery and Endoscopic Sinus Surgery Plus Mini-Caldwell Surgical Procedures Mehmet Kelles, MD,* Yuksel Toplu, MD,† Ilhami Yildirim, MD,* and Erdogan Okur, MD‡ Abstract: Antrochoanal polyp is a benign polypoid lesion orginating from the maxillary sinus antrum and extending to the choana. Our aim was to assess the clinical presentation and associated rhinological findings of antrochoanal polyp patients and to evaluate results of 2 surgical treatments termed endoscopic sinus surgery (ESS) and ESS plus mini-Caldwell operation. The study included 46 patients. Factors such as patient age, sex, history of chronic sinusitis, allergic rhinitis, septal deviations, chonca bullosa, turbinate hypertrophy, and the origin of the polyp were assessed. We also evaluated ESS and ESS plus mini-Caldwell surgical procedures for recurrences, synechia, bleeding, and ostium stenosis. Overall, there were 27 men and 19 women. The ESS approach was used in 26 cases, and 20 cases had combined ESS and mini-Caldwell procedures. The statistical significant difference between the 2 groups was only recurrence (P < 0.05). In the ESS group, bleeding, synechia, and ostium stenosis were seen more than in the ESS + mini-Caldwell group, but there was no significant difference between the 2 groups in bleeding, synechia, and ostium stenosis (P > 0.05). We thought that lower rate of recurrence found in ESS + Caldwell group in this study was associated with better visualization of the maxillary sinus walls and, therefore, easier resection of the remnant polyp. We concluded that higher incidences of bleeding and synechia were related to the mucosal damage occurring in the septum and the inferior concha due to excessive manipulation of endoscope and surgical instruments. Key Words: Antrochoanal polyp, recurrence, maxillary sinus, endoscopic sinus surgery, mini-Caldwell (J Craniofac Surg 2014;25: 1779–1781)
A
ntrochoanal polyp (ACP) is a soft tissue mass orginating from the maxillary antrum, passes through a sinus ostium, and extends into the choana.1 Approximately 4% to 6% of all nasal polyps From the *Department of Otorhinolaryngology, Sutcu Imam University, Kahramanmaras, Turkey; †Department of Otorhinolaryngology, Inonu University, Malatya, Turkey; and ‡Department of Otorhinolaryngology, Afyon Kocatepe University, Afyon, Turkey. Received May 10, 2013. Accepted for publication February 14, 2014. Address correspondence and reprint requests to Mehmet Kelles, MD, Department of Otorhinolaryngology, Kahramanmaraş Sütçüimam Üniversitesi, Kulak Burun Boğaz Hastaliklari Anabilim dali, Yörük Selim Mah. Gazi Mustafa Kuşçu Cad. 46050, Kahramanmaraş, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000901
in the general population are ACPs.2 Although extreme rare bilateral ACP cases are presented in the literature, ACP is almost always unilateral and occurs most commonly in children and young adults.3 The ACPs are macroscopically the same as typical polyps but are not associated with allergic etiology.4 Radiologically, the sinus looks opaque and is filled by polyps. However, ACP does not involve soft tissue and erode the adjacent bone.5 Although nasal obstruction and nasal drainage are the most common presenting symptoms, in severe cases, the presentation may be with symptoms of snoring, epistaxis, hyposmia, dysphagia, headache, and weight loss.4,6 We retrospectively reviewed the patients treated in 2 different otorhinolaryngology departments during a 7-year period to observe the clinical presentation and associated rhinological findings and to evaluate results of 2 surgical treatments termed endoscopic sinus surgery (ESS) and ESS + mini-Caldwell operation.
PATIENTS AND METHODS The study was approved by the ethics committee of the Sutcu Imam University (March 27, 2013). We studied the clinical presentations and operative records of 46 patients with ACPs treated surgically between June 2005 and January 2012 at the Department of Otorhinolaryngology, Sutcu Imam University, Kahramanmaraş, and Department of Otorhinolaryngology, Hayat Hospital, Malatya in Turkey. Clinical symptoms, associated rhinological findings, and forms of surgical treatment were reviewed and tabulated. In this study, all patients were operated on under general anesthesia. Two surgical techniques were performed to the patients. The first technique was ESS technique accompanying removal of ACP after uncinectomy and antrostomy using 30 and 70 endoscopes and angled forceps. The second technique was a combination of ESS with uncinectomy, antrostomy, and mini-Caldwell (with a window of 0.5–0.6 0.5 cm), in which an endoscope and forceps were introduced into the sinus to remove the entire stalk of the polyp. Preoperatively, all of the patients were examined endoscopically and had computed tomographic (CT) scans (Fig. 1). All patients were operated on by the 4 authors using the same techniques to prevent intersurgeon variability. Patients were followed for a minimum of 12 months with a mean of 26.4 months. Postoperatively, all patients were examined endoscopically and had CT scans if necessary. Complications such as formation of synechia, stenosis, or obstruction of sinus were evaluated, and recurrence of ACPs were assessed. Any residual maxillary or choanal portion during follow-up endoscopic examination was to be considered as recurrence. Patients who did not have follow-up assessments and recurrent cases who had been operated on at different centers were excluded.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Kelles et al
TABLE 2. Associated Rhinological Findings in ACPs Associated Finding
n (%)
Chronic sinusitis
16 29 14 12
Septal deviation Concha bullosa Inferior turbinate hypertophy
FIGURE 1. Coronal CT scans showing ACPs. A, Antral part. B, Nasal part. C, Choanal part of the ACP.
We evaluated the the results of the study using Fischer exact test. Statistical analyses were carried out using SPSS software version 16 (IBM, Armonk, NY), and statistical sigificance was defined as P < 0.05.
ESS group. All bleedings in the 2 groups were controlled by using 0.0125 mg/mL of adrenaline plus 20 mg/mL of lidocaine-soaked cotton pack. All packs were taken out from the nasal cavity between 10 and 15 minutes. Whereas 5 patients had recurrences in the ESS group, only 1 patient had reccurence in the ESS + mini-Caldwell group (Table 3). The only statistically significant difference between the 2 groups was recurrence rates (P < 0.05). In the ESS group, bleeding, synechia, and ostium stenosis were seen more than in the ESS + miniCaldwell group, but there was no significant difference between the 2 groups in bleeding, synechia, and ostium stenosis (P > 0.05).
RESULTS Of the 46 patients, 19 (41.3%) were women, and 27 (58.7%) were men. Ages ranged from 9 to 60 years, with a mean of 25 years. Twelve patients (26%) were younger than 16 years. Right-side involvement was seen in 22 (47.8%); and left side, in 24 (52.2%). Sixteen patients (35%) had chronic sinusitis. Two patients had concomitant bronchial asthma, and 1 patient had symptoms of allergy. The patient symptoms before treatment were nasal obstruction on the affected side (46 patients, 100%), rhinorrhea (26 patients, 56.5%), postnasal drip (14 patients, 30.4%), snoring (17 patients, 36.9%), lump in throat (5 patients, 10.8%), and headache (6 patients, 13%) (Table 1). During oropharynx examination, 5 patients had an oral mass that was visible without retraction of uvula. Twenty-nine patients (59%) had nasal septal deviation. Fourteen patients (18%) had unilateral or bilateral concha bullosa. Twelve patients (26%) had unilateral or bilateral inferior turbinate hypertophy (Table 2). Twenty patients underwent endoscopic endonasal surgery with mini-Caldwell operation, and the other 26 patients underwent endoscopic endonasal surgery for the removal of ACPs. We visualized the maxillary antrum by endoscpic tools to determine where ACPs orginated. The origins of the ACPs’ stalk in the maxillary sinüs were as follows: posterior and inferior walls (15 patients), posterior and lateral walls (12 patients), posterior wall (7 patients), lateral wall (4 patients), inferior wall (5 patients), and medial wall (3 patients). The distributions of origin were as follows: posterior wall (73.9%), lateral wall (34.7%), inferior wall (43.7), and medial wall (6.5%). There were no any ACPs orginating from the anterior wall of the maxillary sinus. Postoperative complications in the ESS + mini-Caldwell group included synechia in 2 patients and bleeding in 3 patients. Ostium stenosis was seen in 2 patients. Synechia in 4 patients, bleeding in 5 patients, and ostium stenosis in 4 patients were observed in the TABLE 1. Clinical Symptoms in 46 Patients With ACPs Symptom Nasal obstruction Rhinorrhea Snoring Postnasal drip Headache Lump in throat
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n (%) 46 (100) 26 (56.5) 17 (36.9) 14 (30.4) 6 (13) 5 (10.8)
(35) (59) (30) (26)
DISCUSSION The ACP originates from the inflamed and edematous mucosa of the antrum of the maxillary sinus, passes through the maxillary sinus ostium, and extends to the nasopharynx and/or oropharynx.1,7 The ACP occurs predominantly in children and young adult men.7,8 In our study, 12 patients were younger than 16 years, 23 patients were aged between 16 and 35 years, and 9 patients were older than 35 years. Of all the patients, 58.7% were men, and 41.3% were women. Although its exact etiopathogenesis is uncertain, chronic sinusitis, allergic rhinitis, and lower respiratory tract disorders stand accused of the etiology.9 In a study, a statistically significant association was found between allergy and ACP10; however, other studies reported that allergy did not play a role in the etiology of ACP.1,4,11 In our study, we identified chronic sinusitis in 16 patients (35%) and bronchial asthma in 2 patients. Only 1 patient had the symptoms of allergic rhinitis. Unfortunately, we could not perform routinely the tests for allergic rhinitis in our patients. Several studies reported that chronic inflammation rather than allergy played a role in the etiology.12,13 In a study, Frosini et al asserted that chronic inflammation caused the formation of mucous retention cyst by creating edema and obstruction in the osteomeatal complex, the medial surface of this mucous retention cyst obstructed fully or partially the natural and accessory ostia of the maxillary sinus, and therefore, the retention cyst herniated toward the middle meatus through the accessory ostium because of increased pressure within the antrum after obstruction. Moreover, in that study, the authors claimed that the anatomic variations such as septal deviation, conchal hypertrophy, and concha bullosa increased the pressure difference between the middle meatus and the maxillary sinus antrum. Frosini et al14 found septal deviation in 56% of their patient series, conchal hypertrophy in 21% of the patients, and concha bullosa in 7% of their patients. When all patients were assessed together, nasal anatomic variations were found in 83% of the patients. In our study, we found septal TABLE 3. Postoperative Compliations in the Two Techniques Postoperative Complication Bleeding Ostium stenosis Synechia Recurrence
ESS, n (%) 5 4 4 5
(19.2) (15.3) (15.3) (19.2)
ESS + Mini-Caldwell, n (%) 3 (15) 2 (10) 2 (10) 1 (5)
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
deviation, conchal hypertrophy, and concha bullosa in 59%, 26%, and 18% of the patients, respectively; anatomic nasal pathologies were found in 79% of all patients. These results showed that our cases supported the hypothesis established by Frosini et al. Jang et al15 reported that arachidonic acid metabolites played a role in the etiology of ACP. Sunagawa et al16 demonstrated that urokinase-type plasminogen activator and plasminogen inhibitor-1 played a role in the pathogenesis of ACP. The ACPs orginate rarely from the anterior wall of the maxillar sinus. Most of the ACPs are multitudinous or broad based. Lee and Huang17 reported that 92% of ACPs orginate from the posterior wall of the maxillary sinus. We also visualized maxillary sinus antrum by endoscopic tools to assess where ACPs orginated. The origins of the pedicle of the sinus were as follows: posterior and inferior walls (15 patients), posterior and lateral walls (12 patients), posterior wall (7 patients), lateral wall (4 patients), inferior wall (5 patients), and medial wall (3 patients). The distributions of origin were as follows: posterior wall (73.9%), lateral wall (34.7%), inferior wall (43.7), and medial wall (6.5%). There were no any ACPs orginating from the anterior wall of the maxillary sinus. The medical treatment modality is not an option in the treatment of ACP; the surgery is the unique efficacious treatment option. So far, several surgical procedures have been implemented for the treatment of ACP. One of the recent surgery options is ESS. However, sometimes, the stalk or base of the polyp cannot be removed by a forceps with this technique, and therefore, the rate of recurrence may increase. Although it was reported in a study conducted by Kamel18 that no recurrence was observed after the transnasal ESS, many studies reported recurrence in varying rates.8,17,19,20 In some studies, combined approaches, that is, ESS + transcanine sinoscopy and ESS + Caldwell – Luc, were proposed for the treatment of ACP to identify and exactly resect the antral part of the polyp and, therefore, to reduce the rate of recurrence.21–23 Recently, in addition to these combined surgery approaches, ESS + miniCaldwell procedure has also been used. With this approach, the maxillary sinus ostium is enlarged by performing uncinectomy and antrostomy, and a supplementary window sized 0.5 to 0.7 0.5 cm was created in the canine fossa. Using the endoscopes introduced through this window, the walls of the maxillary sinus are exposed better, and the remnant polyp is resected with the help of forceps or a curette entered with lesser damage to the sinus mucosa.24 As a result, the only statistically significant difference between the 2 groups was recurrence rates. In the ESS group, bleeding, synechia, and ostium stenosis were seen more than in the ESS + Caldwell group, but there was no significant difference between the 2 groups in bleeding, synechia, and ostium stenosis. We thought that the lower rate of recurrence found in the ESS + Caldwell group in this study was associated with better visualization of the maxillary sinus walls and, therefore, easier resection of the remnant polyp. We concluded that higher incidences of bleeding and synechia were related to the mucosal damage occurring in the septum and the inferior concha due to excessive manipulation of endoscope and surgical instruments.
REFERENCES 1. Min YG, Chung JW, Shin JS, et al. Histologic structure of antrochoanal polyps. Acta Otolaryngol 1995;115:543–547
Antrochoanal Polyp Surgery
2. Başak S, Karaman CZ, Akdilli A, et al. Surgical approaches to antrochoanal polyps in children. Int J Pediatr Otorhinolaryngol 1998;46:197–205 3. Al-Qudah M. Bilateral antrochoanal polyps: possible pathogenesis. J Craniofac Surg 2011;22:1116–1118 4. Gendeh BS, Long YT, Misiran K. Antrochoanal polyps: clinical presentation and the role of powered endoscopic polypectomy. Asian J Surg 2004;27:22–25 5. Aydin O, Keskin G, Ustündağ E, et al. Choanal polyps: an evaluation of 53 cases. Am J Rhinol 2007;21:164–168 6. Salib RJ, Sadek SA, Dutt SN, et al. Antrochoanal polyp presenting with obstructive sleep apnoea and cachexia. Int J Pediatr Otorhinolaryngol 2000;54:163–166 7. Yuca K, Bayram I, Kiroğlu AF, et al. Evaluation and treatment of antrochoanal polyps. J Otolaryngol 2006;35:420–423 8. Bozzo C, Garrel R, Meloni F, et al. Endoscopic treatment of antrochoanal polyps. Eur Arch Otorhinolaryngol 2007;264:145–150 9. Maldonado M, Martínez A, Alobid I, et al. The antrochoanal polyp. Rhinology 2004;42:178–182 10. Cook PR, Davis WE, McDonald R, et al. Antrochoanal polyposis: a review of 33 cases. Ear Nose Throat J 1993;72:404–410 11. Aktaş D, Yetişer S, Gerek M, et al. Antrochoanal polyps: analysis of 16 cases. Rhinology 1998;36:81–85 12. Ozcan C, Zeren H, Talas DU, et al. Antrochoanal polyp: a transmission electron and light microscopic study. Eur Arch Otorhinolaryngol 2005;262:55–60 13. Składzień J, Litwin JA, Nowogrodzka-Zagórska M, et al. Morphological and clinical characteristics of antrochoanal polyps: comparison with chronic inflammation-associated polyps of the maxillary sinus. Auris Nasus Larynx 2001;28:137–141 14. Frosini P, Picarella G, De Campora E. Antrochoanal polyp: analysis of 200 cases. Acta Otorhinolaryngol Ital 2009;29:21–26 15. Jang YJ, Rhee CK, Oh CH, et al. Arachidonic acid metabolites in antrochoanal polyp and nasal polyp associated with chronic paranasal sinusitis. Acta Otolaryngol 2000;120:531–534 16. Sunagawa M, Kinjoh K, Nakamura M, et al. Urokinase-type plasminogen activator and plasminogen activator inhibitor antigen in tissue extracts of paranasal sinus mucous membranes affected by chronic sinusitis and antrochoanal polyps. Eur Arch Otorhinolaryngol 1999;256:237–241 17. Lee TJ, Huang SF. Endoscopic sinus surgery for antrochoanal polyps in children. Otolaryngol Head Neck Surg 2006;135:688–692 18. Kamel R. Endoscopic transnasal surgery in antrochoanal polyp. Arch Otolaryngol Head Neck Surg 1990;116:841–843 19. Ozcan C, Unal M, Görür K, et al. A review of antrochoanal polyps in 14 cases. Kulak Burun Bogaz Ihtis Derg 2002;9:188–192 20. Franche GL, Granzotto EH, de Borba AT, et al. Endoscopic polipectomy with middle meatal antrostomy for antrochoanal polyp treatment. Braz J Otorhinolaryngol 2007;73:689–692 21. Hong SK, Min YG, Kim CN, et al. Endoscopic removal of the antral portion of antrochoanal polyp by powered instrumentation. Laryngoscope 2001;111:1774–1778 22. Altun H, Teker AM, Ceran M, et al. Endoscopic approach in patients with choanal polyps. Kulak Burun Bogaz Ihtis Derg 2008;18:74–78 23. Ozer F, Ozer C, Cagici CA, et al. Surgical approaches for antrochoanal polyp: a comparative analysis. B-ENT 2008;4:93–99 24. Atighechi S, Baradaranfar MH, Karimi G, et al. Antrochoanal polyp: a comparative study of endoscopic endonasal surgery alone and endoscopic endonasal plus mini-Caldwell technique. Eur Arch Otorhinolaryngol 2009;266:1245–1248
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Antrochoanal Polyp: Clinical Presentation and Retrospective Comparison of Endoscopic Sinus Surgery and Endoscopic Sinus Surgery Plus Mini-Caldwell Surgical Procedures Mehmet Kelles, MD,* Yuksel Toplu, MD,† Ilhami Yildirim, MD,* and Erdogan Okur, MD‡ Abstract: Antrochoanal polyp is a benign polypoid lesion orginating from the maxillary sinus antrum and extending to the choana. Our aim was to assess the clinical presentation and associated rhinological findings of antrochoanal polyp patients and to evaluate results of 2 surgical treatments termed endoscopic sinus surgery (ESS) and ESS plus mini-Caldwell operation. The study included 46 patients. Factors such as patient age, sex, history of chronic sinusitis, allergic rhinitis, septal deviations, chonca bullosa, turbinate hypertrophy, and the origin of the polyp were assessed. We also evaluated ESS and ESS plus mini-Caldwell surgical procedures for recurrences, synechia, bleeding, and ostium stenosis. Overall, there were 27 men and 19 women. The ESS approach was used in 26 cases, and 20 cases had combined ESS and mini-Caldwell procedures. The statistical significant difference between the 2 groups was only recurrence (P < 0.05). In the ESS group, bleeding, synechia, and ostium stenosis were seen more than in the ESS + mini-Caldwell group, but there was no significant difference between the 2 groups in bleeding, synechia, and ostium stenosis (P > 0.05). We thought that lower rate of recurrence found in ESS + Caldwell group in this study was associated with better visualization of the maxillary sinus walls and, therefore, easier resection of the remnant polyp. We concluded that higher incidences of bleeding and synechia were related to the mucosal damage occurring in the septum and the inferior concha due to excessive manipulation of endoscope and surgical instruments. Key Words: Antrochoanal polyp, recurrence, maxillary sinus, endoscopic sinus surgery, mini-Caldwell (J Craniofac Surg 2014;25: 1779–1781)
A
ntrochoanal polyp (ACP) is a soft tissue mass orginating from the maxillary antrum, passes through a sinus ostium, and extends into the choana.1 Approximately 4% to 6% of all nasal polyps From the *Department of Otorhinolaryngology, Sutcu Imam University, Kahramanmaras, Turkey; †Department of Otorhinolaryngology, Inonu University, Malatya, Turkey; and ‡Department of Otorhinolaryngology, Afyon Kocatepe University, Afyon, Turkey. Received May 10, 2013. Accepted for publication February 14, 2014. Address correspondence and reprint requests to Mehmet Kelles, MD, Department of Otorhinolaryngology, Kahramanmaraş Sütçüimam Üniversitesi, Kulak Burun Boğaz Hastaliklari Anabilim dali, Yörük Selim Mah. Gazi Mustafa Kuşçu Cad. 46050, Kahramanmaraş, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000901
in the general population are ACPs.2 Although extreme rare bilateral ACP cases are presented in the literature, ACP is almost always unilateral and occurs most commonly in children and young adults.3 The ACPs are macroscopically the same as typical polyps but are not associated with allergic etiology.4 Radiologically, the sinus looks opaque and is filled by polyps. However, ACP does not involve soft tissue and erode the adjacent bone.5 Although nasal obstruction and nasal drainage are the most common presenting symptoms, in severe cases, the presentation may be with symptoms of snoring, epistaxis, hyposmia, dysphagia, headache, and weight loss.4,6 We retrospectively reviewed the patients treated in 2 different otorhinolaryngology departments during a 7-year period to observe the clinical presentation and associated rhinological findings and to evaluate results of 2 surgical treatments termed endoscopic sinus surgery (ESS) and ESS + mini-Caldwell operation.
PATIENTS AND METHODS The study was approved by the ethics committee of the Sutcu Imam University (March 27, 2013). We studied the clinical presentations and operative records of 46 patients with ACPs treated surgically between June 2005 and January 2012 at the Department of Otorhinolaryngology, Sutcu Imam University, Kahramanmaraş, and Department of Otorhinolaryngology, Hayat Hospital, Malatya in Turkey. Clinical symptoms, associated rhinological findings, and forms of surgical treatment were reviewed and tabulated. In this study, all patients were operated on under general anesthesia. Two surgical techniques were performed to the patients. The first technique was ESS technique accompanying removal of ACP after uncinectomy and antrostomy using 30 and 70 endoscopes and angled forceps. The second technique was a combination of ESS with uncinectomy, antrostomy, and mini-Caldwell (with a window of 0.5–0.6 0.5 cm), in which an endoscope and forceps were introduced into the sinus to remove the entire stalk of the polyp. Preoperatively, all of the patients were examined endoscopically and had computed tomographic (CT) scans (Fig. 1). All patients were operated on by the 4 authors using the same techniques to prevent intersurgeon variability. Patients were followed for a minimum of 12 months with a mean of 26.4 months. Postoperatively, all patients were examined endoscopically and had CT scans if necessary. Complications such as formation of synechia, stenosis, or obstruction of sinus were evaluated, and recurrence of ACPs were assessed. Any residual maxillary or choanal portion during follow-up endoscopic examination was to be considered as recurrence. Patients who did not have follow-up assessments and recurrent cases who had been operated on at different centers were excluded.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Kelles et al
TABLE 2. Associated Rhinological Findings in ACPs Associated Finding
n (%)
Chronic sinusitis
16 29 14 12
Septal deviation Concha bullosa Inferior turbinate hypertophy
FIGURE 1. Coronal CT scans showing ACPs. A, Antral part. B, Nasal part. C, Choanal part of the ACP.
We evaluated the the results of the study using Fischer exact test. Statistical analyses were carried out using SPSS software version 16 (IBM, Armonk, NY), and statistical sigificance was defined as P < 0.05.
ESS group. All bleedings in the 2 groups were controlled by using 0.0125 mg/mL of adrenaline plus 20 mg/mL of lidocaine-soaked cotton pack. All packs were taken out from the nasal cavity between 10 and 15 minutes. Whereas 5 patients had recurrences in the ESS group, only 1 patient had reccurence in the ESS + mini-Caldwell group (Table 3). The only statistically significant difference between the 2 groups was recurrence rates (P < 0.05). In the ESS group, bleeding, synechia, and ostium stenosis were seen more than in the ESS + miniCaldwell group, but there was no significant difference between the 2 groups in bleeding, synechia, and ostium stenosis (P > 0.05).
RESULTS Of the 46 patients, 19 (41.3%) were women, and 27 (58.7%) were men. Ages ranged from 9 to 60 years, with a mean of 25 years. Twelve patients (26%) were younger than 16 years. Right-side involvement was seen in 22 (47.8%); and left side, in 24 (52.2%). Sixteen patients (35%) had chronic sinusitis. Two patients had concomitant bronchial asthma, and 1 patient had symptoms of allergy. The patient symptoms before treatment were nasal obstruction on the affected side (46 patients, 100%), rhinorrhea (26 patients, 56.5%), postnasal drip (14 patients, 30.4%), snoring (17 patients, 36.9%), lump in throat (5 patients, 10.8%), and headache (6 patients, 13%) (Table 1). During oropharynx examination, 5 patients had an oral mass that was visible without retraction of uvula. Twenty-nine patients (59%) had nasal septal deviation. Fourteen patients (18%) had unilateral or bilateral concha bullosa. Twelve patients (26%) had unilateral or bilateral inferior turbinate hypertophy (Table 2). Twenty patients underwent endoscopic endonasal surgery with mini-Caldwell operation, and the other 26 patients underwent endoscopic endonasal surgery for the removal of ACPs. We visualized the maxillary antrum by endoscpic tools to determine where ACPs orginated. The origins of the ACPs’ stalk in the maxillary sinüs were as follows: posterior and inferior walls (15 patients), posterior and lateral walls (12 patients), posterior wall (7 patients), lateral wall (4 patients), inferior wall (5 patients), and medial wall (3 patients). The distributions of origin were as follows: posterior wall (73.9%), lateral wall (34.7%), inferior wall (43.7), and medial wall (6.5%). There were no any ACPs orginating from the anterior wall of the maxillary sinus. Postoperative complications in the ESS + mini-Caldwell group included synechia in 2 patients and bleeding in 3 patients. Ostium stenosis was seen in 2 patients. Synechia in 4 patients, bleeding in 5 patients, and ostium stenosis in 4 patients were observed in the TABLE 1. Clinical Symptoms in 46 Patients With ACPs Symptom Nasal obstruction Rhinorrhea Snoring Postnasal drip Headache Lump in throat
1780
n (%) 46 (100) 26 (56.5) 17 (36.9) 14 (30.4) 6 (13) 5 (10.8)
(35) (59) (30) (26)
DISCUSSION The ACP originates from the inflamed and edematous mucosa of the antrum of the maxillary sinus, passes through the maxillary sinus ostium, and extends to the nasopharynx and/or oropharynx.1,7 The ACP occurs predominantly in children and young adult men.7,8 In our study, 12 patients were younger than 16 years, 23 patients were aged between 16 and 35 years, and 9 patients were older than 35 years. Of all the patients, 58.7% were men, and 41.3% were women. Although its exact etiopathogenesis is uncertain, chronic sinusitis, allergic rhinitis, and lower respiratory tract disorders stand accused of the etiology.9 In a study, a statistically significant association was found between allergy and ACP10; however, other studies reported that allergy did not play a role in the etiology of ACP.1,4,11 In our study, we identified chronic sinusitis in 16 patients (35%) and bronchial asthma in 2 patients. Only 1 patient had the symptoms of allergic rhinitis. Unfortunately, we could not perform routinely the tests for allergic rhinitis in our patients. Several studies reported that chronic inflammation rather than allergy played a role in the etiology.12,13 In a study, Frosini et al asserted that chronic inflammation caused the formation of mucous retention cyst by creating edema and obstruction in the osteomeatal complex, the medial surface of this mucous retention cyst obstructed fully or partially the natural and accessory ostia of the maxillary sinus, and therefore, the retention cyst herniated toward the middle meatus through the accessory ostium because of increased pressure within the antrum after obstruction. Moreover, in that study, the authors claimed that the anatomic variations such as septal deviation, conchal hypertrophy, and concha bullosa increased the pressure difference between the middle meatus and the maxillary sinus antrum. Frosini et al14 found septal deviation in 56% of their patient series, conchal hypertrophy in 21% of the patients, and concha bullosa in 7% of their patients. When all patients were assessed together, nasal anatomic variations were found in 83% of the patients. In our study, we found septal TABLE 3. Postoperative Compliations in the Two Techniques Postoperative Complication Bleeding Ostium stenosis Synechia Recurrence
ESS, n (%) 5 4 4 5
(19.2) (15.3) (15.3) (19.2)
ESS + Mini-Caldwell, n (%) 3 (15) 2 (10) 2 (10) 1 (5)
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
deviation, conchal hypertrophy, and concha bullosa in 59%, 26%, and 18% of the patients, respectively; anatomic nasal pathologies were found in 79% of all patients. These results showed that our cases supported the hypothesis established by Frosini et al. Jang et al15 reported that arachidonic acid metabolites played a role in the etiology of ACP. Sunagawa et al16 demonstrated that urokinase-type plasminogen activator and plasminogen inhibitor-1 played a role in the pathogenesis of ACP. The ACPs orginate rarely from the anterior wall of the maxillar sinus. Most of the ACPs are multitudinous or broad based. Lee and Huang17 reported that 92% of ACPs orginate from the posterior wall of the maxillary sinus. We also visualized maxillary sinus antrum by endoscopic tools to assess where ACPs orginated. The origins of the pedicle of the sinus were as follows: posterior and inferior walls (15 patients), posterior and lateral walls (12 patients), posterior wall (7 patients), lateral wall (4 patients), inferior wall (5 patients), and medial wall (3 patients). The distributions of origin were as follows: posterior wall (73.9%), lateral wall (34.7%), inferior wall (43.7), and medial wall (6.5%). There were no any ACPs orginating from the anterior wall of the maxillary sinus. The medical treatment modality is not an option in the treatment of ACP; the surgery is the unique efficacious treatment option. So far, several surgical procedures have been implemented for the treatment of ACP. One of the recent surgery options is ESS. However, sometimes, the stalk or base of the polyp cannot be removed by a forceps with this technique, and therefore, the rate of recurrence may increase. Although it was reported in a study conducted by Kamel18 that no recurrence was observed after the transnasal ESS, many studies reported recurrence in varying rates.8,17,19,20 In some studies, combined approaches, that is, ESS + transcanine sinoscopy and ESS + Caldwell – Luc, were proposed for the treatment of ACP to identify and exactly resect the antral part of the polyp and, therefore, to reduce the rate of recurrence.21–23 Recently, in addition to these combined surgery approaches, ESS + miniCaldwell procedure has also been used. With this approach, the maxillary sinus ostium is enlarged by performing uncinectomy and antrostomy, and a supplementary window sized 0.5 to 0.7 0.5 cm was created in the canine fossa. Using the endoscopes introduced through this window, the walls of the maxillary sinus are exposed better, and the remnant polyp is resected with the help of forceps or a curette entered with lesser damage to the sinus mucosa.24 As a result, the only statistically significant difference between the 2 groups was recurrence rates. In the ESS group, bleeding, synechia, and ostium stenosis were seen more than in the ESS + Caldwell group, but there was no significant difference between the 2 groups in bleeding, synechia, and ostium stenosis. We thought that the lower rate of recurrence found in the ESS + Caldwell group in this study was associated with better visualization of the maxillary sinus walls and, therefore, easier resection of the remnant polyp. We concluded that higher incidences of bleeding and synechia were related to the mucosal damage occurring in the septum and the inferior concha due to excessive manipulation of endoscope and surgical instruments.
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© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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