Choanal Polyp Originating from Posterior Middle Turbinate : a Case Report

Nikita Frinadya, Siti Nursiah

INTRODUCTION

Nasal polyps are benign abnormal mucosal protrusions associated with nasal
mucosa or paranasal sinuses. They were first reported 4000 years ago. Hippocrates
reffered to these nasal masses as ‘polypus’ due to its resemblance to the sea-polyp.
They appear as fluid flled semitransparent tear drop –like structures. The prevalence
in the adult population is estimated to be around 1-4% (Salaria, 2015)
Solitary, benign soft tissue masses starting at the nasal cavity and extending
to the nasopharynx are termd choanal plyps (CP). CPs of extra-sinusal origin are
rather rare; however, atypical localization sites such as lower concha, middle
concha, and septum have been reported in the literature. (Ertugrul, 2017)
Antrochoanal polyps are the most common choanal polyp and hey arise from
maxillary antrum. Differentiation of true choanal polyp with antrochoanal is made
easy with endoscopic examination and computed tomography. Both modalities help
in confirming the site of origin and the extent of polyp. (Gupta and Singh, 2013)
Four – 6% of all polyps is found to be antrochoanal polyps. CPs may originate
from maxillary, ethmoidal or sphenoidal sinuses. It rarely originated from middle
turbinate. Three types of CPs can be distinguished : antrochoanal, sphenochoanal
and ethmochoanal. (Yariktas, 2006)
The Etiology of CPs, first described by Killian in 1906, remains unclear.
However, chronic inflammation is considered to play a role in the etiology of CPs.
CPs of the middle turbinate are extremely rare and there have been only six reported
in the literature, of which one arose from the inferior, three arose from the posterior
region. (Peric, Jovanovski, and Durdevic, 2017)

CASE REPORT
A 33 years old man came to the Adam Malik General Hospital on August 2nd
2018 with main complaint nasal blockage in both nasal cavity, and he suffered for

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about 6 month. The nasal blockage was experienced every morning and night. He
also complained rhinorrhea, loss of the sense of smell, and intermittent purulent post
nasal discharge, pain in his left cheeks and headache. The history of sneezing
especially in the morning or exposed to the dust.
Based on the ENT routine examination the ear was normal, anterior
rhinoscopy in the right nasal cavity was narrow, with inferior turbinate oedema and
livid. In the left nasal cavity was narrow revealed with white-grayish mass and
smooth surface. We also found secret in the both of nasal cavity. Posterior
rhinoscopy there were post nasal drip (PND). Physical examination the vital sign was
normal, face was symmetric and there were no mass in neck region.
On nasoendoscopy examination we found, in right nasal cavity inferior
turbinate was eutrofi, media turbinate was oedema and livid, there were polypoid
mass revealed choana, it makes nasopharyng were unclear. In left nasal cavity we
found polypoid mass with white-grayish and smooth surface revealed until choana,
septal deviation, inferior turbinate hipertrofi, and chonca bullosa.

Fig 1. Nasoendoscopy in left nasal cavity

Patient underwent several examinations, chest X-ray was normal, ECG was
normal, blood laboratory tests (complete blood count, blood glucose, LFT, RFT, HST,
electrolytes) and the result was normal. The paranasal sinus scanning coronal
cutting without contrast showed mucosal thickening of left ethmoid and sphenoid
sinuses, septal deviation to right nasal cavity, and left concha bullosa.

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 Fig 2. Paranasal Sinus CT Scann

The patient was diagnosed with chronic rhinosinusitis with choanal polyp and
prepared for Functional Endoscopic Sinus Surgery (FESS) under general
anesthesia on August 15th 2018.
Patient was anasthesized with ETT and IVFD well attached, then the
operation area was desinfected using povidone iodine and alcohol 70%, then the
area around the operated area was covered with sterile doek. The eye wasn't
covered, so that we can monitor if there's any eye complication during the operation.
After that, adrenalin tamponade (1:4) applied to the nasal cavities with a 0⁰ telescope
guidance and were left there for 15 minutes, then tampons were taken out from both
nostril and both nostrils were monitored using 00 telescope.

Fig3. Adrenalin tamponade applied to the nasal cavities

First we did the resection of middle turbinate. Middle turbinate resection may
allow for better intra-operative and post operative visualization. The sinus ostium

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was identified and enlarged with an upturned Blakesley forceps at an anterior-inferior
direction. Next, the left maxillary sinus cavity was evaluated with a 30 o telescope and
drained, followed by irrigation of the left maxillary sinus using a bent suction. [Fig. 4].

Fig 4. Resection of middle turbinate

Then we opened the cannals to left anterior and posterior ethmoid sinuses
with a curette and we found suprabullar cell. Once the sinus is entered safely, the
ostium can be enlarged using cutting forceps and we found the polyps in those
sinuses, then we removed the polyps by using forceps.

Then the choanal polyp in left nasal cavity was extracted by forceps through
clamping its stalk, pulling it out slowly with right-to-left swing and rotational
movement until the whole mass was fully removed. Afterwards, we evaluated the
right nasal cavity using a 0 0 telescope towards the nasopharynx in order to ensure
no remaining mass left detected. Subsequently, the surgical specimen was sent for
histopathologic examination.

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 Fig 5. choanal polyp was extracted

After all the procedures above, we rinsed both nasal cavities with normal
saline solution. Anterior packing were applied for both nasal cavities.

Fig 6. Anterior tamponade

After the surgery, antibiotic, corticosteroid, analgetic, and antihemorrhagic

agents were administered intravenously. Anterior packing were both removed 2 days
after. On day 3, nasal irrigation was performed and we evaluated the nasal cavity by
endoscopic assistance. The outcome was satisfying and the patient was discharged
from the hospital on day 4 and assigned for post-operative follow-up visit on day 6,
but we still detected apparent discharged and crusting in both nasal cavities. Nasal
irrigation and crusting removal were then performed. On day 8, her post-operative
histopathologic finding revealed inflammatory polyp.

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DISCUSSION

Chronic rhinosinusitis is defined as inflammation of the nose and the

paranasal sinuses characterized by two or more symptoms, one of which should be
either nasal blockage or obstruction or congestion or nasal discharge (anterior,
posterior nasal drip), with facial pain or pressure with reduction or loss of smell
sensation and either endoscopic signs of nasal polyps and or mucopurulent
discharge primarily from the middle meatus and/or edema or mucosal obstruction
primarily in middle meatus, and/or CT scan showing mucosal changes within the
osteomeatal complex and/or sinuses. Diagnosis of CRS requires the presence of at
least 2 important symptoms for at least 12 weeks, plus objective documentation of
sinus inflammation with endoscopy or CT scan (Fokkens, et al., 2012).
Some authors have found a statistically significant association of choanal
polyp with allergic diseases. Cook, et al. reported allergic rhinitis in approximately
70% of their patients with antrochoanal polyp. Similarly, Chen, et al. detected that
allergic disease plays a significant role in antrochoanal polyp (Yaman, et al., 2010).
In our case, the patient was a 33 years old man complaining nasal stuffiness for the
past 6 months. Other symptoms like colored-nasal discharge, headache, facial pain,
and the sensation of mucous accumulation dripping downward from the back of nose
to throat were also encountered from this patient. He tended to sneeze repeatedly
during the night and early morning or during cold- and dust-exposures suggesting an
allergic disease.
Septum deviation may be a factor in the localization of CP. Septum Deviation
changes the air flow within the nose. An air current is formed in the concave side of
the deviation, which is stronger as compared to the convex side. This, in turn, may
cause the polyp to be in the concave side of the deviation. Also, in our case, a
deviation with a right-oriented convexity and a CP on the left side were observed.
(Ertugrul and Ensari, 2017)
Differentiation of true choanal polyp with antrochoanal is made easy with
endoscopic examination and computed tomography. Both modalities help in
confirming the site of oriin and the extent of the polyp. On computed tomography
antrochoanal polyps are seen between the middle turbinate and lateral wall of the
nasal cavity, while the choana polyp arising from choncha as in our case choanal

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polyps occuoies the space between the middle turbinate and septum. (Gupta and
Singh, 2013)
Surgery is the only feasible option for treatment of choanal polyp. Several
surgical techniques have been described in the literature. Functional endoscopic
sinus surgery (FESS) is, currently, the gold standard technique. As compared to
conventional technique, the endoscopic approach proves to be superior. (Frosini,
Picarella and De Campora, 2009; Eladl and Elmorsy, 2011; El-Sharkawy, 2013).
Complete removal of the choanal polyp is necessary to decrease recurrence rates
(Al-Mazrou, Bukhari and Al-Fayez, 2009).
In our case, polypectomy with Functional Endoscopic Sinus Surgery (FESS)
under general anesthesia was performed. The choanal polyp was extracted by
forceps through clamping its stalk, pulling it out slowly with right-to-left swing and
rotational movement until the whole mass was fully removed.

CONCLUSION
We report a 33 years old man with antrochoanal polyp and the patient was
treated with a surgical intervention of Functional Endoscopic Sinus Surgery (FESS)
and the outcome was satisfying.

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