Endoscopic polipectomy with middle meatal antrostomy for antrochoanal polyp treatment

Rev Bras Otorrinolaringol 2007;73(5):689-92. ORIGINAL ARTICLE Endoscopic Polipectomy with Middle Meatal Antrostomy for Antrochoanal Polyp Treatment Guilherme Luis da Silva Franche 1, Eduardo Homrich Granzotto 2, Andresa Thier de Borba 3, Fernando Hermes 4, Cátia de Souza Saleh 5, Person Antunes de Souza 6 Keywords: endoscopic surgery, nasal polyposis, antrochoanal polyp. Summary A ntrochoanal polyp (ACP) or Killian polyp is a benign nonatopic lesion of the maxillary sinus. Patients usually present nasal obstruction. Many surgical options for the treatment of ACPs have been suggested to minimize postoperative recurrence. The endoscopic nasal approach is a surgical option for maxillary intrasinusal resection of the polyp implantation through the maxillary ostium or middle meatal antrostomy, with lower morbidity when compared to other surgical approaches. Aim: To evaluate the rate of endoscopic antrochoanal polypectomy with middle meatotomy in the treatment of ACP. Materials and Methods: Were evaluated by means of a retrospective study, 29 patients, who were diagnosed based on history, physical examination, computed tomography, and histological findings, treated between 1997 and 2004. The surgical approach was endoscopic polypectomy with middle meatotomy. Results: Twenty-nine patients with ACP, 17(58.6%) were females and 12(41.4%) males, age range, 7-75 years (average of 27.55years) were included in this study. The main symptom were nasal obstruction 24(82%), oral breathing 11(37.9%), snoring nine (31%), rhinorrhea 5(17%), epistaxis 2(6.9%), headache 2(6.9%), and drip one (3.4%). The association with atopy was found in nine (31%). The mean follow-up period was 17 months (3-63 months). Only two patients (6.9%) presented recurrence. Conclusion: The rate of recurrence obtained in our study is no different from literature data, even when compared with former and gold standard procedures. M.S. in Medicine. Head of the Rhinology ward - Santa Casa de Porto Alegre. 2 3rd year resident in Otorhinolaryngology - Santa Casa de Porto Alegre. 3 2nd year resident in Otorhinolaryngology - Santa Casa de Porto Alegre. 4 1st year resident in Otorhinolaryngology - Santa Casa de Porto Alegre. 5 Medical student - Fundação Faculdade Federal de Ciências Médicas de Porto Alegre. 6 MD. Graduated by the Universidade Federal de Pelotas. Otorhinolaryngology Department of the Santa Casa de Porto Alegre teaching hospital. Send correspondence to: Guilherme Luís da Silva Franche -Rua Mostardeiro 333/508 Bairro Moinhos de Vento Porto Alegre RS 90430-001. Tel/Fax: (0xx51) 3343-1415 - E-mail: Paper submitted to the ABORL-CCF SGP (Management Publications System) on October 8th, 2006 and accepted for publication on March 24th, 2007. cod. 3445. 1 BRAZILIAN JOURNAL OF OTORHINOLARYNGOLOGY 73 (5) SEPTEMBER/OCTOBER 2007 http://www.rborl.org.br / e-mail: 689 INTRODUCTION RESULTS Antrochoanal polyps (ACP), also known as Killian’s polyps, are a non-atopic1, benign lesions, which stem from the maxillary sinus, go through its ostium (can be the true ostium or the accessory ostium) and extends all the way to the choanas.2 It is more frequent in men than women, and more prevalent in children and young adults3, however it may manifest at any age. The distal antral origin is the most common, although ethmoid-choanal, sphenoid-choanal and choanal manifestations are occasionally seen4. Presentation at physical exam is a nasal and/or rhino-pharyngeal polypoid tumoral mass, usually unilateral. Paranasal sinuses x-ray exams show a unilateral veiling of the maxillary sinus, often times with the ethmoid opaque and, depending on the size of the polypoid tumor, a mass that fills up the nasal cavity, all the way to the rhinopharynx5. It is clinically manifested by unilateral nasal obstruction; there may also be epistaxis, sleep disorders, postnasal drip, headaches, rhinorrhea, oral breathing and hyposmia3,5. Since 1906, when Killian described the maxillary sinus as the site of origin for the polyp, many surgical techniques have been proposed5. In order to reduce post-operative recurrence, it is paramount to completely remove the antral portion of the polyp, close to its base of origin2. The main techniques developed to reach this goal are the Caldwell-Luc procedure, endoscopic polypectomy with middle meatotomy, endoscopic polypectomy with antrostomy through the inferior meatus and endoscopic polypectomy with middle meatotomy and the use of microshaver with or without transcanine access. The goal of the present investigation is to assess the rate of recurrence in endoscopic meatotomy with middle meatotomy in the treatment of ACP. As for secondary goals, we assessed symptoms, age, gender, time of follow up, association with asthma or rhinitis and post-operative complications in the patients. We included 29 patients with antrochoanal polyps in this study, 17 (58.6%) women and 12 (41.4%) men, with ages varying between 7 and 75 years (mean age = 27.55 years). All the patients presented unilateral Killian polyps, 17 (58.6%) on the left side and 12 (41.4%) on the right. Follow up varied between 3 and 63 months, and the mean value was 17 months. The major symptoms reported by the patients are summarized on Table 1. In assessing comorbidities, we observed 2 cases (6.9%) associated with asthma, 9 (31%) with rhinitis and 2 (6.9%) with septal deviation. Table 1. Preoperative symptoms. Symptoms Franche G et al. Balwant SG et al. Hong SK et al. Nasal obstruction 24 (83%) 17 (94%) 28 (100%) Epistaxis 2 (7%) 6 (33%) 0 Snoring 9 (31%) 4 (22%) - Oral Breathing 11 (38%) 6 (33%) - Postnasal drip 1 (4%) 5 (28%) - Headache 2 (7%) 2 (11%) - Rhinorrhea 5 (17%) 8 (44%) 19 (67%) Only 1 patient evolved with purulent secretion and fever in the postoperative, with a good response to clinical treatment. No patient had transoperative complications. Recurrence rate in our study was of 6.9% (2 cases). Both patients were 8 years old and the diagnosis was made after 24 and 30 months of follow up. DISCUSSION Palfyn was the first author to describe ACP among nasopharyngeal polyps in 1753; however, it was Killian in 1906, who documented the exact place of origin in the mucosa of the maxillary sinus wall.1 The antrochoanal polyp suffers the anatomical limitation of the lateral nasal wall, especially the middle meatus and the antrum, looking like a dumbbell. It usually stems from the postero-lateral wall of the maxillary sinus and it passes, without bone destruction, through the maxillary ostium, or occasionally through the accessory ostium (anterior or posterior to nasal fontanels), to inside the middle meatus. Usually the polyp takes up the space between the lateral wall conchae and grows posteriorly to reach the choana.1 ACPs are usually unilateral and occur in children. About 4% to 6% of nasal polyps are ACPs, and they are more common in men than in women. In our series we had a broad age range 7-75 years (mean age of 2 (...truncated)