Eur J Rhinol Allergy 2020; 3(1): 13-6
Association of Antrochoanal Polyps
Cite this article as: Yazıcı
ZM, Güneş S, Aydın E,
Gülüstan F, Abakay MA,
Sayın İ. Association of
Antrochoanal Polyps with
Contralateral Site Sinus
Obliteration. Eur J Rhinol
Allergy 2020; 3(1): 13-6.
Address for Correspondence:
İbrahim Sayın
E-mail:
dribrahimsayin@yahoo.com
Received: 01.02.2020
Accepted: 27.03.2020
DOI: 10.5152/ejra.2020.257
Copyright@Author(s) - Available
online at www.eurjrhinol.org
Content of this journal is licensed
under a Creative Commons
Attribution-NonCommercial 4.0
International License.
Original Article
with Contralateral Site Sinus
Obliteration
Zahide Mine Yazıcı , Selçuk Güneş , Esra Aydın , Filiz Gülüstan , M. Akif Abakay , İbrahim Sayın
Clinic of Ears, Nose and Throat, Bakırköy Sadi Konuk Training and Research Hospital, İstanbul, Turkey
Abstract
Objective: The present study was performed to investigate the association of antrochoanal polyps (ACP) with cont-
ralateral sinus obliteration and their effect on recurrence.
Material and Methods: This retrospective study was performed by searching the records of 106 patients who un-
derwent surgery with a diagnosis of ACP between January 2010 and January 2018. Determination of the presence of
sinus obliteration in patients and scoring were performed by analyzing the preoperative paranasal sinus tomography.
The Lund–MacKay (LMK) system was used for scoring. Patients were followed up for an average of 25 months (range,
12 to 47 months).
Results: Sinus obliteration was determined by examination of tomography results and the mean preoperative LMK
score of 106 patients was 7.49±3.76. The mean LMK score for the side with the polyp(s) (5.49±2.56) was significantly
higher than that of the contralateral side (2. 00±2.31) (p = 0.0001). Recurrence was detected in eleven patients (10.4%).
The mean preoperative LMK score for the side with the polyp(s) of recurrence (+) patients was significantly higher
than that of recurrence (–) patients (p = 0.039). There was no significant difference between mean LMK scores of the
sides without ACP in recurrence (–) and recurrence (+) patients (p= 0.367). The total mean preoperative LMK score of
recurrence (+) patients was significantly higher than that of recurrence (–) patients (p = 0.049)
Conclusion: In our study, it was observed that recurrencies increased in patients with ACP where sinus opacity was
more intense, but contralateral sinus opacity had no effect on recurrence.
Keywords: Antrochoanal polyp, sinus obliteration, Lund–MacKay scoring system
INTRODUCTION
Antrochoanal polyps (ACP) are benign slow-growing masses derived from the maxillary sinus mucosa, progressing
toward the choana by protruding into the nasal cavity. ACP usually form a cystic part at the antrum and a solid part in
the nasal cavity, which are connected to each other by a peduncle (1-4). They do not cause erosion or destruction of
surrounding tissues. Although almost always unilateral, some bilateral cases have been reported (5). ACP can also be
derived, albeit rarely, from sinuses other than the maxillary sinus, nasal septum, and nasal concha (6-8). The incidence
of ACP in all nasal polyps for the general population is between 3-6 %, this rate in the pediatric population is 35% (9,
10).
ACP cause mostly nasal obstruction and nasal discharge, and more rarely can lead to symptoms such as snoring,
headache, postnasal discharge, anosmia/hyposmia, dysphonia, dysphagia, dyspnea, and epistaxis (11). Diagnosis is
confirmed by rhinoscopic examination, nasal endoscopy, and computed tomography (CT). ACP is treated surgically,
and many techniques have been reported. It has been demonstrated that prevention of ACP recurrence requires full
excision of the affected portion of the antrum (12, 13).
Although many hypotheses have been proposed, the etiopathogenesis of ACP remains unclear. ACPs are a frequently
encountered problem in otolaryngology practice especially in some region; however, the mechanisms underlying
that condition are poorly understood. The main targets of management of ACPs are to eradicate polyps, eliminate
symptoms and prevent recurrence also improve life quality. There is also a dilemma concerning the etiopathogenesis
of ACP. The most emphasized causes are chronic sinusitis, allergy, and lower respiratory tract infections (14). In the
present study, we investigated the association of ACP with contralateral sinus obliteration and their effect on recur-
rence.
 14 Yazıcı et al. Antrochonal Polyps and Sinus Obliteration
MATERIAL AND METHODS
The present study was a retrospective medical chart review of all subjects
who were diagnosed and surgically treated for ACP at İstanbul Bakırköy
Sadi Konuk Training and Research Hospital between January 2010 and
January 2018. The study was performed with the permission of the clinical
research ethics committee of the same hospital. Information on informed
consent were taken from all patients.
Hundred and ten patients (n=110) who underwent surgery with a diag-
nosis of ACP were evaluated in this study. Patients in whom nasal ma-
lignancy was determined by histopathological examination, those for
whom CT data were unavailable, and those that were lost to postoper-
ative follow-up were excluded from the study. Cases of revision surgery
were also excluded. Two patients diagnosed with inverted papilloma and
angiofibroma on postoperative histopathological examination and two
patients lost to follow-up were excluded from the study. The study was
performed in 106 patients.
Figure 1. The Lund MacKay scores of the the sides with and without
ACPs
Figure 2. The relation of recurrence with the overall Lund MacKay
scores
Eur J Rhinol Allergy 2020; 3(1): 13-6
The ACP diagnosis of patients was confirmed by preoperative anterior
rhinoscopic examination, nasal endoscopic examination, paranasal sinus
CT, and postoperative histopathology. Functional endoscopic sinus sur-
gery (FESS) was performed for all patients under general anesthesia. The
patients with anatomical pathology underwent septoplasty and concha
resection. The average follow-up period after surgery was 25 months, and
ranged from 12 to 47 months. The diagnosis of recurrence was deter-
mined by endoscopic examination and CT.
Determination of the presence of sinus opacity in patients and sinus scor-
ing were performed by analyzing the results of preoperative paranasal
sinus tomography. The CT results were evaluated by the same otorhino-
laryngologist by examining the reports and graphs, and the Lund-MacKay
(LMK) scoring system was used for scoring (15). This scoring system was
used to provide information about same side with ACP and other side. In
addition, we investigated whether extensive contralateral sinus opacity
has an effect on treatment outcome. Scoring was performed separately
for each part. The frontal, maxillary, sphenoid, ethmoid, anterior and pos-
terior ethmoid sinuses, and ostiomeatal complex were evaluated. Each
sinus was evaluated as follows: absence of sinus opacity, 0 points; mild
mucosal thickening, 1 point; complete opacification, 2 points; open os-
teomeatal unit, 0 points; closed osteomeatal unit, 2 points.
In this study, we examined the operations performed for ACP patients by
the same surgeon (ZMY), the presence of accessory ostium, the origin of
ACP, association of contralateral sinus, and the rates of recurrence. With
scoring, we also examined the effects of sinusitis on both the side with
and without polyps in patients with recurrence, to determine whether the
contralateral sinus obliteration affects recurrence.
Statistical Analysis
NCSS (Number Cruncher Statistical System) 2007 Statistical Software
(Utah, USA) program was used for statistical analysis. While evaluating the
study data, Shapiro Wilk test and box plot charts were used for descriptive
statistical methods (Mean, Standard deviation, median, frequency, ratio)
as well as the normal distribution of variables. Mann Whitney U test in
comparison of LMK variables that do not show normal distribution be-
tween groups; In the group comparisons, Wilcoxon sign test was used.
Pearson Chi-Square test was used to compare qualitative data. Signifi-
cance was evaluated at the level of p<0.05.
RESULTS
The patient population was 39.6% (n=42) male and 60.4% (n=64) female.
The patients range in age from 9 to 64, with a mean age of 29.44±14,49.
The ACPs were derived from the maxillary sinus in 106 cases. A total of
53.8% of the ACPs (n=57) were derived from the left nasal cavity, and
46.2% (n=49) were derived from the right nasal cavity.
All surgeries were performed endoscopically with the patients under gen-
eral anesthesia by the same surgeon (ZMY). The ACPs were removed from
the nasal cavity in most cases, and from the oral cavity in some patients
after surgical uncinectomy and large middle meatal antrostomy. Accesso-
ry ostium was observed in 39 patients, and accessory ostium and natural
ostium were combined in these cases. Major complications due to sur-
gery were not observed in any of the patients, and minimal postoperative
bleeding occurred in three patients.
Anatomical pathologies were not observed in 22 of the ACP patients
(21%), while one or more anatomical disorders, including septal deviation,
concha hypertrophy, and concha bullosa disorders, were observed in the
Eur J Rhinol Allergy 2020; 3(1): 13-6
other ACP patients. After evaluation of preoperative CT findings, the over-
all average preoperative LMK score for 106 patients was determined to be
7,49±3,76. The sides with and without ACPs were examined. The average
LMK score of the sides with ACP (5,49±2,56) was significantly higher than
the sides without ACP (2,00±2,31) (p=0.0001) (Figure 1).
Recurrence occurred in 11 of 106 patients undergoing ESS (10.4%). Among
the sides with ACP; the mean LMK score of the recurrence patients were
significantly higher in patients without recurrence (p=0.039). There was
no significant difference between mean LMK scores of the sides without
ACP, in recurrence (–) and recurrence (+) patients (p=0.367). The overall
mean preoperative LMK score of recurrence (+) patients was significantly
higher than that of recurrence (–) patients (p=0.049) (Figure 2).
DISCUSSION
ACP are solitary, polypoid lesions usually derived from edematous max-
illary sinus mucosa. Patients usually present with complaints of unilater-
al nasal obstruction. In our study, 64 patients (60.4%) were female, and
the mean age was 29.44±14,49. In addition, ACP was observed more fre-
quently on the left side, in agreement with the previous reports (16, 17).
Juvenile angiofibroma, nasopharynx and nasal cavity malignancies, ade-
noid hypertrophy, concha hypertrophy, nasal polyposis, mucocele, nasal
glioma, encephalocele, and allergic fungal sinusitis must be included in
the differential diagnosis of ACP (10). Two of our patients were exclud-
ed—one due to determination of inverted papilloma and the other to
juvenile angiofibroma. In order to obtain correct diagnosis, pathological
examination of the whole operative material is necessary to allow differ-
entiation from other of ACP.
Chronic sinusitis has been indicated as a reason for ACP (5). Al-Mazrou et
al. (16) and Basak et al. (1) reported the association of sinusitis in 50% of
cases. Lee et al. (2) reported sinusitis in 65% of patients even with applica-
tion of antibiotics and local treatment. Some investigators have suggest-
ed that chronic sinusitis accompanying ACP is a result of ACP rather than
a cause (2, 16). Ertugrul (18) stated that, 22.7% of the ACP patients were
identified to have signs of chronic sinusitis. The association between aller-
gy and ACP is unclear. Some authours have suggested that ACP induces
inflammation in the sinuses by widening of accessory ostium (19). We de-
tected accessory ostium in 39 of our cases.
Surgery is the only treatment available for ACP. Three surgical approaches
are utilized. Functional endoscopic sinus surgery is considered the first
choice for primary surgery. If complete control of the disease cannot be
achieved endoscopically, the combined approach (endoscopically and
maxillofacial surgeries) should be suggested in order to minimize recur-
rences. The external open approach such as Caldwell-Luc is reserved in
case of revision surgery (20). Simple polyp excision is not commonly per-
formed today due to high recurrence rates (21). The Caldwell–Luc meth-
od provides very good exposure and makes complete excision of the
antral portion possible, and therefore the rates of recurrence are low (19).
However, discussion about this method going on. Some surgeons argue
for this method may have a negative effect on dental development and
the maxillary bone growth centers for pediatric patients. In addition, the
procedure includes some risks, such as cheek swelling, infraorbital nerve
damage, facial hypoesthesia, and long recovery time (1, 3, 13, 16). In re-
cent years, the FESS method has become the gold standard treatment for
ACP, with a short recovery time and fewer side effects than other treat-
ment methods (3, 4, 22). With this method, to avoid recurrence, the antral
cystic polyp should be removed completely by creating a wide middle
Yazıcı et al. Antrochonal Polyps and Sinus Obliteration 15
meatal antrostomy. The reported recurrence rates of patients undergoing
FESS ranged from 8% to 15% (22-24).
Some authors have attempted to reduce the rates of recurrence by com-
bining the Caldwell-Luc, mini-Caldwell, and transcanine-fossa methods
with the endoscopic method (25-27). Ozer et al. (28) identified three cases
of recurrence in patients undergoing FESS, but there was no recurrence in
any of the patients treated by the combined method. Lee et al. (2) report-
ed that while the success rate of patients treated by endoscopic surgery
alone was 76.9%, the success rate of those treated by the combination of
endoscopic and transcanine methods was 100% in pediatric patients. All
of the 106 patients in our study had been treated with FESS. The mean fol-
low-up period was 25 months, during which recurrence occurred in elev-
en patients (10.4%). Pagella et al. (27) suggested canine fossa approach
may offer a valid alternative for children bigger than 12 years. Bozzo et
al. (23) reported that ACPs were mostly originated from the lateral wall of
maxilla. On the other hand Lee et al. (2) found the posterior wall of maxilla
was the most of the ACPs origin. Aydin et al. (11) suggested that it is not
always possible to determine from which wall of the maxillary antrum the
polyps are originated, and they may sometimes be originated from more
than one wall. Histopathologically ACPs differed from chronic allegic na-
sal polyps by a few minor features. ACPs are lined with pseudostratified
ciliated epithelium and their highly vasculer-edematous stroma contains
infiltration of inflammatory cells (29). In the ACP stroma there was more
severe plasma cell infiltration, and less severe eosinophilic infiltration
when compared with nasal polyps, and also there were fewer submucosal
glands in the ACPs (30). Aktas et al. (21) observed that the surface epitelial
cells of ACP patients have few or no cilia.
The CT findings of our patient were evaluated using the LMK scoring sys-
tem to evaluate the sinusitis of the patients. The mean LMK score in our
study population was 7.49±3.76. Although the mean LMK score of the
side with ACPs was significantly higher than that of the contralateral side
(p= 0.0001). Aktas et al. (21) observed bilateral pansinusitis in 6 of 16 ACP
patients, and unilateral sinusitis in three patients. The additional CT find-
ings in different study showed reduction in thickness of ACP in the me-
dial part and floor of maxillary sinus region (19). The mean total LMK rate
was significantly higher in patients with than without recurrence in the
present study (p=0.039). This explained our recurrence rates, as the dis-
tinction between normal and pathological mucosa was more difficult in
patients with advanced sinusitis because mucosa is more edematous and
inflamed in such cases. Similarly, Lee and Huang reported more difficulty
in surgery for cases in which ACP is accompanied by rhinosinusitis (2) .
We tried to determine whether the contralateral sinus obliteration affects
recurrence. No relationship was found between contralateral sinus oblit-
eration and recurrence. However, recurrence of polyps is more common
in patients with higher LMK scores on the polyp side. Patients who have
additional nasal problems could affect LMK scores as well. The present
study was a retrospective medical chart review of all subjects so we didn’t
get detailed information about additional disease of patients. Also we
didn’t find information about the size of the ACPs at operation note which
can be expected that the higher in size have higher LMK scores.
CONCLUSION
Extensive bilateral sinus obliteration increased the recurrence rates by
ACP treatment. In our study, it was observed that recurrencies increased in
patients with ACP where sinus opacity was more intense, but contralateral
sinus opacity had no effect on recurrence.
 16 Yazıcı et al. Antrochonal Polyps and Sinus Obliteration
Ethics Committee Approval: Ethics committee approval was received for this
study from the Ethics Committee of the İstanbul Bakırköy Sadi Konuk Training and
Research Hospital (2018-16-13, 17.09.2018).
Informed Consent: Written informed consent was obtained from the patients
who participated in this study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept - Z.M.Y.; Design - İ.S.; Supervision - İ.S.; Resources
- E.A.; Materials - E.A.; Data Collection and/or Processing - E.A.; Analysis and/or Inter-
pretation - F.G.; Literature Search - E.A.; Writing Manuscript - S.G.; Critical Review - İ.S.;
Other - Z.M.Y.
Conflict of Interest: The authors have no conflicts of interest to declare.
Financial Disclosure: The authors declared that this study has received no finan-
cial support.
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