Verma P 1, Jain N ,1 Arya M2 , Vaid L 3, Singh PP3

1. Senior Resident, Department of Otorhinolaryngology, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi , India.
2. Junior Resident, Department of Otorhinolaryngology, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi , India.
3. Professor, Department of Otorhinolaryngology, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi , India.

ABSTRACT

Antrochoanal polyp are usually single, unilateral and more frequent in children and adolescents. We report a bilateral antrochoanal polyp in an adult female which is a rare presentation.

Keyword

Bilateral antrochoanal polyp , Functional endoscopic sinus surgery.

Introduction

Antrochoanal polyp are more frequent in children and young adults . They are usually unilateral and of infective in origin. It is a benign, solitary , polypoidal lesion which arises from maxillary sinus and grows by extension , more commonly through the antral accessory ostium into middle meatus and then to the choana and nasopharynx. It is dumbbell shaped and having three parts nasal, antral and choanal. It represents 3 to 6% among nasal polyposis in the general population. In this paper we report a rare case of bilateral antrochoanal polyp in an adult female and discuss the aetiology and management.

Case report

A 25 year female patient presented to ENT OPD complaining of gradually increasing nasal obstruction in both nostrils for 1 year. Snoring , anosmia & feeling of lump in throat for last 2 months. Patient was treated by her general practitioner but showed no improvement. She starts worsening of symptom.

On clinical examination there was complete bilateral nasal obstruction by soft tissue with muco-purulent discharge . The polyps were seen on both side nasal cavity arising from middle meatus area. On posterior rhinoscopy a polypoidal mass present in nasophrynx coming through left choana.

General physical examination of patient was within normal limit . There was no personal or family history of allergy, asthma, diabetes and tuberculosis. Routine blood and urine examination was within normal limit. Xray paranasal sinus, waters view showing opacity in the both maxillary antrum and nasal cavities.

Computed tomography of the nose and paranasal sinus both axial and coronal cuts showed soft tissue opacification of bilateral maxillary sinus extending into bilateral nasal cavities and nasopharynx. Osteomeatal complex of both nasal cavities was widened and blocked.

Fig 1- CT Scan paranasal sinus (coronal & axial section) – soft tissue density in both nasal cavity and maxillary sinus . Polyp of left nasal cavity extending into nasopharynx. Both side osteomeatal complex were widened and blocked.

The polyps were removed under general anaesthesia by functional endoscopic sinus surgery(FESS). The polyps were pale white in colour and had smooth glossy surface. They were soft in consistency. The gross appearance showed that both polyps had three parts antral, nasal and choanal. All the three parts were removed transnasally. The patient had an uneventful post-operative course and was discharged from hospital after removal of bilateral anterior nasal pack on second post-operative day with no specific medication. Histological examination of the polyp showed them to be of inflammatory nature. Review of the patient at six months revealed no recurrence.

Discussion

antrochoanal polyp is a large, fleshy, polyp, stalked, arises from maxillary sinus, pass through the ostium into the nasal cavity, choana and from there into the nasopharynx. Histologicaly, it is an inflammatory polyp with a ciliated columnar epithelial lining. The stroma is usually edematous and highly vascular, composed of loose connective tissue infiltrated with plasma cells. The antrochoanal polyp commonly occuring under 40 year age group with male to female ratio is about 2.3:1 .

They are usually unilateral .Prevalence of bilateral antrochoanal polyposis is very rare. On search of literature we found only four reported cases (Myatt et al,1996 ; Basu et al,2001 ; Sami et al,2006 ; Yilmaz et al,2007) . Here we represent a case of bilateral antrochoanal polyp in 25 year old female with negative history of allergy and asthma.

The etiology of antrochoanal polyp remains obscure. It can be infectious or allergic. It is believed that an ACP develops as a complication of chronic antral disease, such as chronic sinusitis. The infectious polyp is characterized by nasal neutrophilia and purulent secretion. Other studies have suggested that a derangement in the metabolism of arachidonic acid , prostaglandins, and leukotriens is implicated in the pathogenesis of nasal polyps. . It is also recognized that inflammation associated with an allergic diathesis may lead to polypoid changes of the mucosa. Although nasal polyps are associated with analgesics- induced asthma, such a relationship between nasal polyp and nasal allergy has been reported by some authors. Cook et al1 found that 24% of patient with ACPs had the aspirin sensitive asthma triad (aspirin sensitivity,nasal polyposis and bronchial asthma) . He observed allergy by mean of in vitro test in patient of antrochoanal ployp. Earlier reports have even indicated that the histology of the antrochoanal ployp does not differ significantly from that of nasal polyp. . Heck et al (1950) reported that 23.4% of antrochoanal polyp patients had allergy and he concluded that the formation of an antrochoanal polyp is rarely related to allergy.He noted that the antrochoanal polyp is less likely to contain eosinophils and mucous glands . Such histologic distinction could provide clues to the pathogenesis of the antrochoanal polyp. The antrochoanal polyp is generally accepted as a polyp that arises from the edematous antral mucosa. Numerous authors have reported on the clinical feature and origin of the antrochoanal polyp. As early as in 1906, Killian2 suggested that the antrochoanal polyp arises from the growth of a single antral polyp through the wide accessory ostium. He stated that physical factors such as nose blowing , sinus irrigation, and sinus inhalation could contribute to the propulsion of an antral polyp towards the nasal cavity. Later reports suggested developmental error, rupture of enlarged submucous gland with subsequent cyst formation, and expansion of an intrasinus intramural cyst as the mechanism of antrochoanal polyp formation. Berg et al3 1988 demonstrate that ACPs develop from an expanding intramural cyst within the maxillary sinus that herniated through the maxillary ostium into the middle meatus from which it extends along the floor of the nose into the nasopharynx.Mills4 on the other hand stated that polyp arises from blocked and ruptured acinous mucous glands..

Taylor5 suggested that nasal polyps result from edematous hypertrophy of the respiratory epithelium, rather from distention of glandular structures. Histology shows a respiratory epithelium over a normal basement membrane. The ultrastructure is grossly oedematous and the cellular infiltrate is similar to ordinary polyps except that there is no eosinophelia.There is lots of controversy regarding origin of antrochoanal polyp , the close relationship between antrochoanal polyp and the maxillary sinus was first reported by Killian2 in 1906 when he traced the polyp from the nasopharynx to the region of the maxillary sinus ostium but not into the sinus cavity . Kubo mention that the choanal polyps originated from the maxillary sinus mucosa, just inside the ostium . Van Alyea6 found the antrochoanal polyps, in some patients to be attached to the lateral aspects of maxillary sinus with a fibrous or polypoidal pedicle. How and why this pedicle reached the ostium for further expansion into a choanal polyp, was not explained. Mills4 on the other hand , stated that the choanal polyps arises from blocked and ruptured acinous mucous glands during the healing process of a bacterial sinusitis, thus being the extension of a mucocele. In the study done by El Guindy et al 7 the findings regarding the site of origin of the antrochoanal polyp inside the maxillary antrum were that it arose from the medial wall of the maxillary antrum in 5 cases, from the lateral wall of the maxillary antrum in 14 cases and the site of origin was uncertain in 5 cases. Berg et al3 from his study of 15 cases of antrochoanal ployp is from the inferolateral wall of the maxillary sinus. In our previous study done in 2004 (IJLO) the site of origin was -7 from infrolateral wall,2 from infromedial wall,2 from superomedial wall & 1 was having annular origin,out of 20 cases ,in 8 it was uncertain .Antrochoanal polyp removal by FESS is a safe and effective procedure in recent years .As stated by Kamel R8,1990 : Endoscopic surgery in antrochoanal polyp through the middle meatal antrostomy is advantageous as it insure complete removal of the antral part and diseased mucosa without the need to perform Caldwell-luc antrostomy or inferior meatal antrostomy, It offers preservation of the healthy sinus mucosa for later epithelization.

Here we conclude there were two polyps in both nasal cavities of separate infective origin in an adult female diagnosed as bilateral antrochoanal polyp & was completely removed by functional endoscopic sinus surgery.

References

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5. TaylorM.Histochemichal studies on nasal polypi.J laryngol otol 1973; 77: 326-41
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