International Journal of Pediatric Otorhinolaryngology 75 (2011) 1372–1375

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Endoscopic surgery in pediatric recurrent antrochoanal polyp, rule of wide ostium

Hesham Mohammad Eladl *, Shawky M. Elmorsy
ORL Department Mansoura University, Elgomhoria Rode, Mansoura, Egypt

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To evaluate the use of wide middle meatal antrostomy in recurrent antrochoanal polyp (ACP)
Received 1 April 2011 in children as regard technical difficulty, efficacy, and safety in children.
Received in revised form 25 July 2011 Study design: Retrospective study.
Accepted 27 July 2011
Patients and methods: In a retrospective study, 12 children with unilateral recurrent ACP (5 left-sided, 7
Available online 3 September 2011
right-sided). All the ACPs were documented by preoperative endoscopy and computer tomographic (CT)
scans. All cases were treated using endoscopic wide middle meatal antrostomy. The average age at the
Keywords:
onset of symptoms was 9.3 years (median age: 10 years; range: 6–15 years).
Endoscopic surgery
Pediatric polyps
Results: Postoperative improvement in all cases was achieved using both subjective measures
Antrochoanal polyp (symptoms improvement) and objective measures (radiological and endoscopical). No postoperative
Sinus complications or recurrence during the follow up period.
Pediatric endoscopic surgery Conclusions: Endoscopic wide middle meatal antrostomy is a useful and easily applicable technique to
manage recurrent antrochoanal 3 polyp in children. Managing associated pathology as turbinate
hypertrophy, associated adenoids, anterior ethmoidectomy, uncinectomy and endoscopic limited
septoplasty should be put in mind in order to improve ventilations. Powered instrumentations, angled
endoscopes (45 and 708) and angled instrumentations can assure complete clearance of the polyp by
identifying the origin of polyp in maxillary antrum.
ß 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction The treatment of this disease is essentially surgical and

Antrochoanal polyp (ACP) is a soft tissue mass originating from
the maxillary antrum, emerging from the ostium and extending to
the choana through the nasal cavity [1]. ACPs were first reported by
Killian in 1906, it is also called Killian polyp. It is an infrequent
benign neoplasm; most commonly arise in children and young
adults [2]. Moreover, they represent one of the most common types
of nasal polyps in children without cystic fibrosis [3].
Various pathogenic mechanisms have been proposed to explain
the development of ACPs, however, the cause is still largely
unknown and a topic of major debate [1]. A study found the
association of allergy with ACPs to be statistically significant [4].
However, other study found that allergy has no role in the etiology
of ACPs [5] and the etiology of ACP might be chronic inflammatory
processes rather than allergy [6,7].
Interestingly, familial type was reported [8]. Children have
unique clinical and pathological features as compared to adults [5],
as allergic ACP was more common than inflammatory ACP in
children (2.8:1) as compared to adults [9].
endoscopic sinus surgery has become widely accepted modality
for the treatment of ACP. As compared to conventional technique,
the endoscopic approach proves to be superior [10,11]. Moreover,
it can be done as an outpatient procedure, and is safe and reliable
[12]. However, some authors preferred external approach
(Caldwell-Luc) in cases of recurrence or incomplete resection
[13]. Other recommended endoscopic surgery to be combined
with transcanine sinuscopy to ensure complete removal of ACPs
[14]. The maxillary sinus at birth is a small sinus cavity with its
lower border 4 mm above the nasal floor. Expansion continues
until 8–9 years of age when the floor of the sinus and nasal cavity
are roughly equal, the sinus is 2 cm  2 cm  3 cm in diameter.
Growth continues at rate of 2–3 mm/year until the adult age is
reached when sinus floor is usually lower than the nasal cavity by
0.5–10 mm [15]. The surgery of recurrent polyps in children needs
good experience to remove the origin of the polyp from the
growing maxillary sinus [6].
2. Materials and methods

Ethical approval for this work was obtained (by ethical

committee board in our ORL department) in a tertiary care
* Corresponding author. Tel.: +20 148182440; fax: +20 502267016. hospital. Between January 2000 and September 2008, we enrolled
E-mail address: heshameladl@mans.edu.eg (H.M. Eladl). 12 children with unilateral recurrent ACPs. All the ACPs were

0165-5876/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2011.07.029

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[(Fig._1)TD$IG] H.M. Eladl, S.M. Elmorsy / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1372–1375 1373

Fig. 1. Coronal computed tomography scans showing antrochoanal polyps.

documented by preoperative endoscopy and computer tomo-
graphic (CT) scans (Fig. 1). All the patients and their families were
well informed before surgeries and had provided informed
consent for endoscopic treatment of ACPs. During operation,
decongestion of the inferior turbinate and middle turbinate was
achieved by using 2% oxymetazoline-soaked cotton pledgets and
injection of diluted adrenaline in a concentration 1/100,000 The
inferior portion of the uncinate process was uniformly excised to
increase the space for endoscopic manipulation. If the polyp was
too large for en bloc removal, the intranasal portion of the ACP was
transected along the insertion line of the uncinate process by
scissors. A zero, 458 and 708 endoscopes were used to inspect the
intramaxillary extent of the ACP and to identify its origin and
attachment and they were used in surgeries. Wide middle meatal
antrostomy was done by enlarging the ostium anteriorly up to the
lacrimal bone, superiorly to just below the orbital floor,
posteriorly to the posterior wall of the maxillary sinus, and
inferiorly to the floor of the nose thus creating a wide antrostomy
(Fig. 2). A through-cutting straight and angled forceps or angled
shavers were placed through the maxillary ostium to carefully
dissect and transect the origin of the polyp. Then, the antral
portion of the polyp was removed through the widened maxillary
ostium. Associated pathology as turbinate hypertrophy, associat-
ed adenoids, anterior ethmoidectomy, uncinectomy and limited
[(Fig._2)TD$IG]
septoplasty were managed endoscopically. We were conservative
when dealing with the inferior turbinate hypertrophy by only
partially resecting a small part of the posterior half of the
turbinate to avoid crustations.
The maxillary sinus was thoroughly irrigated with warm
normal saline solution through maxillary ostium. All surgical
specimens were sent for pathologic examinations. Merocele nasal
packings were left in the middle meatus for 24–48 h. Oral
antibiotics were given for one week. Regular follow-up with
meticulous clearing of crusts was done weekly. Postoperative
evaluation was done using both subjective measures (symptoms
improvement) and objective measures (endoscopical and radio-
logical). Endoscopic examination was done 3 months, 6 months, 12
months, and up to 24 months postoperatively.
3. Results
Twelve patients with 5 left-sided lesions and 7 right-sided
lesions: were treated using endoscopic wide middle meatal
antrostomy. Patients’ demographic data, the origins of ACPs, time
of recurrence after previous surgical approaches listed in Table 1.
The average age at the onset of symptoms was 9.3 years (median
age: 10 years; range: 6–15 years). Postoperative follow-up
duration ranged from 30 to 120 months (average 68.3 months).
The origins and attachments of the pedicle in the antrum were as
follows: posterior and lateral walls (3 patients); posterior wall (3
patients); and lateral wall (2 patients). In 4 patients the exact

Table 1
Patients demographic data (age in years, F = female and M = male), the origin of
antrochoanal polyps (P = posterior wall, L = lateral wall, PL = posterior lateral wall,
* = origin could not detected), the duration between the first surgery and the
recurrence in months and the postoperative follow up period in months.

Age Sex Side Origin Duration Follow up

1 11 M L L 7 120
2 10 M L P 12 103
3 7 M R * 14 95
4 8 F L P 16 77
5 10 M L PL 16 75
6 9 M R PL 11 65
7 8 F L * 13 60
8 11 M R PL 5 54
9 6 F L * 7 52
10 8 M R P 32 47
11 7 F L * 14 42
12 8 M L L 21 30
Fig. 2. Wide middle meatal antrostomy with complete removal of the polyp.

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1374 H.M. Eladl, S.M. Elmorsy / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1372–1375

Table 2 knowledge this is the first paper to discuss the management of

Percentage of symptoms in patients with recurrent antrochoanal polyp.
recurrent antrochoanal polyp in children.
Patients There are many options for managing antrochoanal polyp as
Numbers Percentage simple polypectomy, Caldwell Luc’s operation, endoscopic sinus
surgery with middle meatal antrostomy and combined (endo-
Nasal obstruction 12 100%
Rhinorrhea 6 50%
scopic endonasal surgery and mini-Caldwell Luc’s). Endoscopic
Snoring 3 25% approach for complete removal of the ACP is an extremely safe and
Mouth breathing 7 58% effective procedure. The principle of treatment is to identify and
Recurrent sinusitis 6 50% remove the origin of polyp in maxillary antrum along with main
bulk of polyp. The origin of ACP is [11] multitudinous. The common
site is posterior wall followed by inferior and lateral walls. It should
origin was not detected and the antrum was filled with diffuse be focused on the detection of the exact origin and the extent of the
polypoid mucosa. The time between the primary surgery and the polyp to prevent recurrence [16,18]. Bozzo et al. [19] observed two
revision was ranging from 5 months up to 32 months (average 14 recurrences, both in pediatric cases who evidently underwent an
months) (Table 1). incomplete surgical removal of antral mucosa at its inferior aspect,
The common preoperative complaints were nasal obstruction, probably due to the fear of damaging the teeth buds. They did not
followed by rhinorrhea and mouth breathing. The duration observe any postsurgical complication. Their data indicate the
between the onset of symptoms and referral to hospital varied endoscopic middle meatal antrostomy as the optimal approach,
from 3 months to 2 years (Table 2). In our case series postoperative also for the revision cases and in children.
improvement in all cases was achieved using both subjective Endoscopic sinus surgery is the approach of choice; however in
measures (symptoms improvement) and objective measures pediatric age group there are drawbacks included (a) narrow space
(radiological and endoscopical). No postoperative complications in pediatric age and (b) inaccessibility of the lateral wall of
were detected, and no recurrence was detected in all patients maxillary antrum. Combined approach by canine fossa technique
during the follow up period. with angled endoscope and a straight debrider through trocar
As regard to the primary surgery, simple polypectomy was done proved to be safe and effective. The risk of injury to bone growth
for 3 patients, endoscopic surgery with middle meatal antrostomy centre and permanent tooth by this approach is low compared to
in 8 patients, and combined endoscopic with transcanine approach Caldwell-Luc operation. It should be done only in developed
in one patient. All surgeries were done in our centre, endoscopic maxillary sinus after radiographic evaluation [20]. Endoscopic
middle meatal antrostomies were found to be contracted to small surgery through the middle meatal antrostomy combined with
openings as the surgeons were conservative when dealing with transcanine sinuscopy ensures the complete removal of the antral
young ages. part of ACP in children [17,21].
In order to prevent incomplete excision and recurrences,
3.1. Associated pathology combined approaches (endoscopic endonasal surgery and mini-
Caldwell) were considered, particularly when the attachment site
Six patients had associated sinusitis, 4 had adenoids enlarge- of the antral part of ACP is undetected [22]. The most important
ment, 2 had inferior turbinate hypertrophy, deviated septum to the factors affecting the choice of surgical approaches are the
same side in one patient, and concha bullosa in one patient. These preference of the surgeon, the age of the patient and the presence
lesions were managed endoscopically with managing the antro- of recurrent disease [23].
choanal polyps (Table 3). In our series associated pathologies were present in all cases,
sinusitis, adenoids, turbinate hypertrophy, deviated septum, and
4. Discussion concha bullosa. These lesions should be addressed and managed
whether in primary or revision surgeries. Basak et al. [21] reported
Antrochoanal polyp (ACP) is not uncommon in our locality. ACP the association of sinusitis, concha bullosa, turbinate hypertrophy,
occurs predominantly in children and young adults. It originates and adenoids with their cases but these cases were primary not
from the maxillary sinus antrum, passing through the maxillary recurrent. Intractable pediatric chronic sinusitis with antrochoanal
sinus ostium into the middle meatus, with extension into the polyp had been discussed [24].
nasopharynx and the oropharynx. Although recurrence of Drawbacks for combined approach include the small distance
antrochoanal polyp is high especially in children, limited papers between the developing teeth buds and the infraorbital bundles,
had been published. Orvidas et al. [16] recorded up to 25% which should be exactly studied before opening the anterior
recurrence after endoscopic approach; Ozdek et al. [17] recorded maxillary wall. Mini-Caldwell or transcanine surgeries can miss
up to 22% recurrence after middle meatal antrostomy alone but no pathology in the anterior wall of the maxillary sinus. Stammberger
recurrence after combining MMA with transcanine surgery. To our [25] had suggested that transcanine is rarely indicated in children,
except for ACP. Moreover, he also stated that they do not apply
transcanine to children under 9 because of immature dental
development and maxillary sinus pneumatisation. Although,
Table 3
Associated pathologies with recurrent antrochoanal polyp and their management. another study found that the maxillary sinus volume in pediatric
patients was not affected after the canine fossa puncture approach
Associated Numbers Endoscopic surgery in pediatric patients with ACP [26]. In our study, endoscopic wide
pathology
middle meatal antrostomy in recurrent ACP, with the help of
Sinusitis 4 Uncinectomy + ant angled endoscopes, give good exploration of the maxillary sinus
ehmoidectomy + wide MMA
walls to completely remove the antral part of the polyp without the
Adenoids 2 Adenoidectomy + wide MMA
Inf. tur. hypertrophy 2 Par. Inf. Turbinectomy + wide MMA need for the combined approaches and their drawbacks. In this
DS 1 Endoscopic septoplasty + wide MMA study, no postoperative complications were detected, and no
Concha bullosa 1 Chonchoplasty + wide MMA recurrence was detected in all patients during the follow up period.
Adenoids + sinusitis 2 Adenoidectomy + anterior
In 50 pediatric patients, Parsons and Phillips [27] found the
ethmoidectomy + wide MMA
maxillary ostia 1–2 mm from the attachment of the uncinate

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 H.M. Eladl, S.M. Elmorsy / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1372–1375
process to the lateral nasal wall. Mendelson and Gross [28]
advocated widening the ostia to 3–5 times its normal size, as well
as creating even larger mega-ostia for patients with ciliary
abnormalities. On the other hand, many surgeons prefer limited
surgical technique (mini FESS) in pediatric age group, this
operation is conservative and directed to the originating site of
the disease. If ostial dilation is indicated, dilation in the anterior
direction after the excision of the uncinate process is the principal
management [29]. This approach is only suitable for early and mild
disease [30]. In this study, wide middle meatal antrostomy was
done by enlarging the ostium anteriorly, superiorly, posteriorly,
and inferiorly to create a wide antrostomy to ensure complete
removal of the polyps’ tissue. Incidence of middle meatal
antrostomy stenosis is not known. Stankiewicz [31] reported
nearly a 50% incidence of antrostomy closure. However, Lazar et al.
[32] found only a 2% incidence of stenosis. Stenosis may occur
secondary to extensive scarring in the middle meatus, recurrent
polyposis, or insufficient widening of the antrostomy during the
initial surgery.
Effects of early ESS on facial growth are controversial issue.
Although Van Peteghem [33] was not able to see any influence of
previous endoscopic sinus surgery on the anthropomorphic data of
the face. However, other study suggests that ESS affect the
midfacial growth [34]. In our study, no effect on facial growth could
be detected. Nevertheless, the ESS even with wide middle meatal
antrostomy appears more conservative than Caldwell Luc’s
operation or even combined ESS with transcanine sinuscopy.
In this research the use of wide middle meatal osteotomy is
indicated for recurrent antrochoanal polyps to complete the
removal of polyps tissues, allow good ventilation to the sinus and
avoid ostial stenosis. However, the mini endoscopic technique is
still the most recommended approach in our opinion in pediatric
endoscopic sinus surgery in mild and non-recurrent cases to avoid
unnecessary tissue injury and complications. In this study, no
postoperative complications were detected, and no recurrence was
detected in all patients during the follow up period. In our case
series, wide middle meatal antrostomies with the help of angled
endoscopes allow us to examine the whole walls, curved
instruments and curettes allow us to remove any pathology in
the maxillary sinus and to leave healthy mucosa. Transnasal
endoscopic technique was favored by parents as it is less invasive
with mild or no complications. Associated pathologies were
managed safely. Endoscopic follow up was easily applicable,
without recurrence in all cases.
5. Conclusion
Endoscopic wide middle meatal antrostomy is a useful and
easily applicable technique to manage recurrent antrochoanal
polyp in children. Managing associated pathology as turbinate
hypertrophy, associated adenoids, anterior ethmoidectomy, unci-
nectomy and endoscopic limited septoplasty should be put in mind
in order to improve ventilations. Powered instrumentations,
angled endoscopes (45 and 708) and angled instrumentations
can assure complete clearance of the polyp by identifying the
origin of polyp in maxillary antrum.
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