Choanal Polyp Research Articles

The Dawn of Bronchoscopy

The Dawn of Bronchoscopy

Intractable pediatric chronic sinusitis with antrochoanal polyp

It has been reported that pediatric chronic sinusitis with antrochoanal polyp is difficult to cure because it tends to recur easily even with surgery. Therefore, in order to improve its cure rate, aggressive treatment combining polypectomy, intra-maxillary intubation through the inferior meatus, macrolide administration, etc., was attempted. Thirty-seven sides of pediatric chronic sinusitis with antrochoanal polyp and 44 sides of chronic sinusitis without polyp were evaluated after the same treatments. The mean age of patients was 9.7 years, and the mean intubation period was 20 months. Since subjective improvements in children are questionable, the efficacy was evaluated strictly on the basis of X-ray alone focusing on the maxillary sinus. Twenty-four percent of the group with antrochoanal polyp showed ‘excellent’ effect, i.e. almost complete resolution of the sinus findings, while 45% of the group without polyp showed ‘excellent’ effect, with a mean follow-up period of 3 years and 6 months. This difference was significant ( P<0.01, χ 2-test). These results further document the intractableness of chronic sinusitis with choanal polyp in children.

Case Report of a Mass that Mimicked an Antrochoanal Polyp

We describe the case of a patient who was originally diagnosed with an antrochoanal polyp. During avulsion of the mass by endoscopic polypectomy, it was discovered that the stalk of the polyp actually arose from the mucosa of the right superior turbinate rather than from the mucosa of the maxillary antrum. A diagnosis of choanal polyp was made.

ETHMOCHOANAL POLYPS

Choanal polyps are conventionally divided into two groups, antrochoanal and sphenochoanal. The paper presents a series of 5 choanal polyps originating from posterior ethmoidal cells and protruding into the nasopharynx through the natural ostium of the posterior ethmoids in the superior nasal meatus. In two of these cases the polyps were bilateral, in three-unilateral. Two cases presented solitary ethmochoanal polyps (ECP) and posterior ethmoids as the only diseased sinuses. In the other three patients ECP was associated with polyps in the middle meatus, anterior ethmoids and maxillary sinuses.Computerized tomography and nasal endoscopy allow correct diagnosis of ECP as well as differentiation between ECP and other types of choanal polyps in most but not in all the cases. Endoscopic sinus surgery through the superior nasal meatus with the use of a microdebrider is the method of choice in treatment of ECP.

Removal of a choanal polyp with the wire loop of an aural snare after microwave coagulation

A 59-year-old man with chronic sinusitis of many years' duration complained of obstruction of the right nostril, particularly on expiration. Rhinoscopic examination revealed a globular tumor, measuring about 1 cm in diameter, behind the right middle meatus. Because the polyp could not be encircled by the loop of a nasal snare, a double-needle electrode (width, 1 mm) was inserted into the polyp three times. Each time a microwave current of 40 watts was applied for 3 seconds to cause coagulation. The polyp became smaller and could be removed with the wire loop (thickness, 0.3 mm) of an aural snare. We consider microwave coagulation therapy useful in the management of selected cases of choanal polyps.

CT and MR evaluation of Choanal Polyps

CT and MR evaluation of Choanal Polyps

Immunohistochemical Analysis of Mononuclear Inflammatory Cells in Nasal and Sinus Epithelium in Children with Sinusitis

The etiology and pathophysiology of both recurrent acute and chronic sinusitis in children are not well understood. To investigate this problem, the nature and magnitude of the local cellular inflammatory response was evaluated in the sinus mucosa of 34 children (25 with chronic sinusitis and 9 with recurrent acute sinusitis), of which 27 are atopic and 7 are nonatopic. In addition, sinus mucosa from three patients who underwent sinus surgery for noninfectious sinus disease (two with antral choanal polyp and one with facial pain syndrome) was studied for comparison and “controls. “ Immunohistochemical methods were used to identify phenotypically distinct mononuclear cells subpopulations (B cells, T cells, macrophages, and MHC class II antigen presenting cells) in the epithelium, stroma, and periglandular compartments of the uncinate and ethmoid mucosal tissue layers. Eosinophils were assessed in the same sinus mucosal tissue compartments and in nasal secretions. For all patients, most of the inflammatory cells were found in the stroma. MHC class II positive cells and T cells were found in the epithelium of greater than 50%, and in the stroma of almost 100% of either the uncinate or ethmoid mucosa. Of interest, the local accumulation of tissue eosinophils and/or their presence in nasal smears was not closely linked to the presence of atopy. In three patients with noninfectious sinusitis, the majority of inflammatory cells had also accumulated in the stroma; the mononuclear cell subset composition in those controls was indistinguishable from the sinusitis population. No difference in the number and distribution of any inflammatory cell subset was noted with respect to clinical classification, atopy or immunocompetency profile in our patient population. These observations indicate that the mucosal surfaces studied were likely to have been immunocompetent. Taken together, the uniformly modest local inflammation and the similarity of cell subpopulations in patients with different clinical profiles suggest that local inflammatory mechanisms may not account for clinical differences in the pathophysiology of sinusitis.

副鼻腔筋上皮腫例

Myoepithelioma is a rare lesion which has been reported mainly in the salivary glands. In the nasal cavity and paranasal sinuses, its occurrence is exceedingly rare and, to our knowledge, only 5 cases have been reported. We recently treated a 31-year-old female with myoepithelioma of the ethmoid sinus who presented with swallowing disturbance because of a rapidly expanding choanal polyp. We performed a Caldwell-Luc operation and found the tumor expanding into the ethmoid sinus. For diagnosis, immunohistochemical examination was effective in addition to H-E staining.

Antral choanal polyp--cause of nasal obstruction in children: report of 12 cases

Nasal obstruction is a common pediatric clinical complaint that involves a great number of pathologies (allergic rhinopathy,adenoid hypertrophy, septal deformities, infectious sinusitis, tumours, choanal atresia, nasal foreign bodies, etc.). Not only the history, and a through physical examination but also, the subsidiary exams are of great value in the etiologic diagnostic. Antro-choanal polyp (Killian's polyp) must be remembered in the differential diagnosis of nasal obstruction, when a sinus roentgenogram with unilateral maxillary opacification is seen. Clinically, the lesion often protrudes into the nasopharynx and in some cases it may even be seen extending into the oropharynx. The surgical procedure usually employed is a unilateral Caldwell-Luc antrostomy, with oropharyngeal remotion. We present 12 pediatric patients with antral-choanal polyps,and discuss history, radiology, nasal/nasopharyngeal endoscopic evaluation, considerations about the origin and surgical treatment of choice.

Conventional sinus surgery in the pediatric population

Nasosinus disease in pediatrics has long been overlooked. Some have thought that frequent rhinitis was a natural plight of normal childhood and others have felt that the sinuses in children are too small to cause significant disease. However, the impact of chronic rhinitis in children can be important. The aesthetics of mucopurulent nasal drainage, the annoyance of repetitive coughing, and the disruption and behavioral changes should not be minimized. The heightened general interest in adult sinus disease has spread to the pediatric population. This is most likely secondary to improvements in the ability to examine the sinuses using fiberoptic illumination and advances in diagnostic imaging and endoscopic surgical techniques. These technical innovations in conjunction with a more detailed understanding of nasal and sinus anatomy and physiology have improved the physician’s ability to understand and treat these problems in adults, as well as in children. Although this relatively new interest in pediatric nasal sinusitis has enthusiastically embraced endoscopic sinus surgery, traditional surgical approaches should not be abandoned. Many have begun to think of the antral lavage, naso-antral windows, the Caldwell-Luc procedure, and external ethmoidectomy techniques as archaic; however, it is important to remember that they continue to play a role as the primary surgical modality in certain cases as well as a backup in cases that have proved refractory to endoscopic surgery. Cases such as antral choanal polyps or inverting papilloma may be best served with an open approach. Additionally, patients with complications of sinus disease, such as orbital cellulitis, mucopyocele, and fungal infection, may be more safely treated by open techniques that provide better exposure. Revision surgery where anatomic landmarks may be altered or missing may also be approached using the more traditional techniques in a safer manner, particularly for the less experienced surgeon. Traditional sinus surgery is easily taught and learned, safe, tried and true, and familiar to most currently practicing surgeons. It has withstood the test of time and most surgeons and patients are satisfied with the results. The specific traditional sinus procedures discussed

The nasopharynx, eustachian tube and otitis media

It has been classically hypothesized that a mass in the nasopharynx causes an obstacle to air flow through the eustachian tube, thereby creating a negative pressure in the middle ear followed by an effusion. However, examination of the relevant data concerning the supposed obstruction of the eustachian tube by nasopharyngeal carcinomas, choanal polyps and adenoids does not seem to support this cause and effect relationship. Evidence points to other more sophisticated mechanisms which cause negative pressure and an effusion in pathological middle ear conditions. While the hypothesis of a nasopharyngeal mass as the usual obstructive cause of middle ear effusion is hard to maintain, evidence does exist to support the origin of middle ear infection, as seen in acute and secretory otitis media, as being associated, at times, with an ascending infection from the nasopharynx.

後鼻孔ポリープ摘出後の開鼻声例

A 20-year-old female developed hypernasal speech and nasal regurgitation of food following removal of a choanal polyp. The cause of these complications was found to be congenital velopharyngeal incompetence, which had escaped detection due to the compensatory valving effect of the polyp. Procedures helpful for the pre-operative detection of velopharyngeal incompetence are discussed.

Choanal and angiomatous polyps of the sinonasal tract.

Choanal and angiomatous polyps can be distinguished from ordinary sinonasal polyps by either a distinctive clinical presentation (choanal) or the histopathologic appearance (angiomatous). Nearly all choanal polyps arise within paranasal sinuses, with the antrochoanal polyp the most common. The angiomatous polyp is most often a secondary change in a choanal polyp and can be mistaken for vascular neoplasms, eg, angiofibroma.

Antral Choanal Polyp Presenting as Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) in children is commonly caused by adenotonsillar hypertrophy. The diagnostic 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 revealed 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 treatment with an intranasal steroid was begun. However, polypoid nasal mucosa recurred in 2 months and a Caldwell-Luc 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.

Sphenochoanal polyps: evaluation with CT and MR imaging.

A sphenochoanal polyp is a solitary mass of low attenuation on computed tomographic (CT) scans that arises from the sphenoid sinus and extends through the sphenoid ostium, across the sphenoethmoid recess, and into the choana (the boundary between the nasal cavity and nasopharynx). More often, however, a choanal polyp is an antrochoanal polyp, which arises from the maxillary antrum, protrudes through the middle meatus, extends into the nasal cavity, and continues back to the choana. Contiguous axial or coronal magnetic resonance and CT images help clearly differentiate the rare sphenochoanal polyp from the more common antrochoanal polyp. The sinus of origin is important to identify, as the surgical approach depends on the target sinus.

On the diagnosis and pathogenesis of intramural maxillary cysts.

In order to study the etiology of the intramural maxillary cyst, which is the origin of the choanal polyp, an antrotomy was performed on 27 patients with such cysts. The cyst-fluid was analysed with respect to protein distribution and bacterial growth. The findings indicate an inflammatory process characterized by high concentrations of immunoglobulins and by consumption of complement and antiproteases. The growth of bacteria, primarily an oral flora found in the cyst-fluids studied, and the sites of cyst attachment, may indicate an epithelial residue of the dental list as the origin of the intramural cyst. It is further suggested that bacterial substances will provoke an inflammatory response, giving rise to an expansion of the cyst. In all cases studied, the cyst-fluid was capable of gelling after a couple of minutes at room temperature. This observation seems to be a reliable diagnostic procedure at antral aspiration, distinguishing the cyst-fluid from the serous transudate of the serous sinusitis, which according to our results, does not have this capacity to form a gel.

Origin of the choanal polyp.

To study the origin of the choanal polyp, the maxillary sinus was surgically explored using a preservative technique. An antral cyst or a cystic rudiment, usually attached to the inferolateral aspect of the sinus wall, was disclosed in 15 patients with this condition. As a part of the choanal polyp, the antral cyst exhibited a macroarchitecture and microarchitecture identical to the structure of the common intramural cyst of the maxillary sinus as studied in nine patients. It is concluded that the choanal polyp develops from the expanding intramural cyst protruding through the maxillary ostium and into the nasal cavity.

骨形成のみられた孤立性後鼻孔鼻茸の一症例

A 15-year-old female complained of bilateral nasal obstruction. Examination revealed an enormous choanal polyp in her choanal cavity, and its stroma originated in the left middle meatus. X-ray examination showed no inflammatory sign in the paranasal sinuses. Pathologic findings revealed bone formation in polyp tissue.

Nasal polyps in children

The inflammatory nasal polyp is the most common benign or malignant nasal mass seen in children. Nasal polyps in the pediatric population appear to occur as inflammatory responses to bacterial infections. In 33% of the patients with polyps whom we studied, antral choanal polyps were noted, and in 20% of the patients the polyps were unilateral but not antral choanal. In 18% of the patients the polyps were bilateral and in an additional 29% they occurred bilaterally in association with cystic fibrosis. History of an allergy is infrequently associated with nasal polyps; allergies are potentially major contributing factors to nasal polyps only in patients without cystic fibrosis whose nasal polyps are bilateral. Patients with antral choanal polyps are most successfully managed by simultaneous Caldwell-Luc antrostomy and polypectomy. Sixty percent of patients with nasal polyps and cystic fibrosis are adequately managed with a single intranasal polypectomy. Simultaneous sinus surgery and polypectomy should be considered for all patients with recurrent polyps and for all patients with clinical or radiographic evidence of significant sinusitis. Complications, including epistaxis and intranasal synechia, occurred in 3% of the 170 surgical procedures performed.

Immunohistochemistry of local immunoglobulin production in nasopharyngeal carcinoma

Immunohistochemical investigations by the immunoperoxidase method have been carried out on sections of biopsy specimens obtained from the primary tumour sites of patients with nasopharyngeal carcinoma (NPC). It was found that, in many of the sections thus examined, there was an accumulation of plasma cells, particularly of the IgA type, in the connective tissues surrounding nests of NPC cells. Similar accumulation of plasma cells in the subepithelial connective tissues was likewise observed in a case of choanal polyp. Plasma cells were rarely observed in the section of a biopsy specimen of non-neoplastic oropharyngeal mucosa. These results indicated that the nasopharynx may be a site for the local production of IgA, but the antigenic specificity of these molecules is, however, not known. The possibility that the nasopharynx is a site for the local production of antibodies to the Epstein-Barr virus (EBV)-related antigens was discussed.