Egyptian Journal of Ear, Nose, Throat and Allied Sciences 18 (2017) 17–21

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Egyptian Journal of Ear, Nose, Throat and Allied Sciences

journal homepage: www.ejentas.com

Original article

Antrochoanal polyp in pediatric age group

Zeyad Mohamed Mandour ⇑
Oto-Rhino-Laryngology Head & Neck Surgery Department, Faculty of Medicine, Alexandria University, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Antrochoanal polyp (ACP) is a benign solitary polypoid lesion affecting mainly adults and rarely children.
Received 13 December 2016 It originates from a hypertrophy of the mucous membrane of the maxillary sinus antrum, and grows
Accepted 28 December 2016 through the maxillary sinus ostium towards the nasal cavity and the choana. The clinical data and imag-
Available online 6 January 2017
ing studies of 39 children with ACP were reviewed. The most commonly affected age group was from 10
to 15 years. Clinical presentations included nasal obstruction, rhinorrhea; and rarely, bloody discharge.
Keywords: Ig-E-mediated allergy was established in 61.5% of the patients and only 17.9% of patients had history
Antrochoanal polyp
of asthma. 92.3% of patients had aberrant nasal anatomy, including septal deviation, pneumatized middle
Pediatric nasal polyp
Nasal anatomic variations
turbinate, and inferior turbinate hypertrophy. The development of ACP could be due to an increased pres-
sure level within the maxillary sinus caused by obstruction of the sinus natural ostium and/or anatomical
alteration at the ostiomeatal complex at middle meatus level, in a patient with a pre-existing silent antral
cyst, subsequently forced to herniate outside, through the sinus fontanelle. For treatment, we suggest
performing wide middle meatotomy in addition to correction of all the predisposing anatomical factors.
Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

1. Introduction
Antrochoanal polyp (ACP) or Kilian’s polyp is a benign solitary
polypoid lesion that mainly affects children and young adults. Kil-
ian’s polyp generally represents 4–6% of all nasal polyps,1–3 how-
ever; in the pediatric population this percentage reaches 33%.4
Only one report of ACP in members of same family was published.1
On the contrary, it is documented that simple nasal polyps can
occur in several members of the same family.5–7
ACP originates from a hypertrophy of the mucous membrane of
the maxillary antrum, and grows for unknown reasons, through
the maxillary sinus ostium towards the nasal cavity and the choana
towards the nasopharynx.1 The etiology of ACP remains obscure.
Chronic sinusitis and cystic fibrosis are implicated.4 Some cases
develop as a complication of allergy8 and 24% of patients with
ACP had the Aspirin- sensitive asthma triad.4,9
Chronic inflammatory processes, augmented by and predis-
posed to by anatomical variations affecting the ostiomeatal com-
plex could cause the development of an antral cyst together with
swelling at the ostiomeatal complex/middle meatus level; thus
compromising the maxillary ostium. The air, passing to the sinus
Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied
Sciences.
⇑ Address: 25 Fawzi Moaz, Smouha, Alexandria, Egypt.
E-mail address: ziad301@hotmail.com
through will not be released during breathing with increased pres-
sure within the Highmore antrum. Additionally, the mucociliary
drainage would force the ACP preferentially through the posterior
fontanelle and lately through the natural ostium. This mechanism
will probably be enhanced by all the anatomical features which
may lead to changes in the pressure gradient between the middle
meatus and the Highmore antrum level. Based on these observa-
tions, we questioned the causative factors responsible for antral
cyst herniation through the maxillary antrum into the nose giving
rise to an ACP.
The aim of the current study is addressed to the role of nasal
anatomic variations and their corrections at the time of ACP
removal to avoid recurrence.
2. Patients and methods
Thirty-nine(39) pediatric patients (between 5–16 years) with
antrochoanal polyps who presented to the Oto-Rhino-
Laryngology Department- Alexandria University- during the period
from January 2008 to October 2015 were subjected to full routine
history taking as well, clinical history of bronchial asthma.
Nasal endoscopic assessment was performed using rigid 4 mm
and 2.7 mm 30° rigid nasal endoscopes. Complete and differential
blood counts in addition to total Ig-E level were estimated for all
children. MDCT (Multi-detector CT) of the nose and paranasal
sinuses was obtained in all cases with the images reviewed in

http://dx.doi.org/10.1016/j.ejenta.2016.12.010
2090-0740/Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
18 Z.M. Mandour / Egyptian Journal of Ear, Nose, Throat and Allied Sciences 18 (2017) 17–21

the coronal, and axial orientations to assess the extension of the
lesion in relation to the sinonasal anatomic features. Endoscopic
surgical resection for all cases was performed with correction of
detected anatomical variations. All patients were followed up
post-operatively for at least one year. SPSS program (version 16)
was used for statistical analysis.
3. Results
The study included 39 children, comprising 27 males and 12
females, with a male preponderance. Regarding the age distribu-
tion, the most commonly affected age group was from 10 to
15 years. Nasal obstruction and nasal discharge (32 cases of 39
for both) were encountered, and three cases only from all cases
were presented with bloody discharge. Ig-E-mediated allergy was
established in 61.5% of the patients. Regarding clinical asthma his-
tory association; only seven (17.9%) patients had positive history of
clinical asthma.
Thirty-six (92.3%) patients had aberrant nasal anatomy
(p < 0.001) while 20% had a clinical history of allergy manifesta-
tions. 20 children had ACP in the left nasal cavity (51.3%), and 19
(48.7%) in the right side. Anatomical disorders encountered
included 28 (71.8%) patients with septal deviation, 32 (82.1%)
patients with pneumatized middle turbinate, and 32 (82.1%)
patients with inferior turbinate hypertrophy (Figs. 1: A, B and 2
A, B).
Intra-operative nasal endoscopic examination revealed that all
(39) cases exhibit ACP protrusion from the posterior fontanelle of
the maxillary sinus (Fig. 3: A and B). Endoscopic excision of ACP
was performed for all cases (Fig. 4: A and B) concomitant with cor-
rection of any nasal anatomic variations if present by either limited
endoscopic septoplasty, inferior turbinate reduction techniques or
middle turbinate crushing turbinoplasty whenever indicated. None
of the operated cases exhibited any recurrence after at least one
year of follow-up period.
4. Discussion
Antrochoanal polyps are rare lesions within the pediatric aged
group involving the maxillary sinus, nasal cavity via middle mea-
tus and thereafter the choana and pharyngeal regions extending
along the floor of the nose.10 To minimize surgical recurrence, it
is mandatory to completely remove the antral portion of ACP. Rad-
ical surgery (Caldwell-Luc operation) of the maxillary sinus for ACP
has been replaced by FESS. Powered instrumentation provides a
good surgical field 5. In 1891, Zuckerkandl described the case of
a polyp arising from the maxillary sinus and coming out through
a wide accessory ostium.11 Professor Gustav Killian, from Freiburg,
in his paper ‘‘The origin of Choanal polyps” published in The Lancet
on July 14, 1906, was the first to describe antrochoanal polyp (ACP)
giving specificity among nasal polyposis: ‘‘Choanal polyps are usu-
ally unilateral and solitary. They have a peculiar pear-shaped form.
In the thick part of the polypus, there is usually a large cystic space.
This may be prolonged well into the stalk or the stalk may consist
of nothing more than the thin wall of a cyst. Microscopically, these
polyps differ very little from the common nasal polyps. Choanal
polyps must, in fact, all be in the form of a constricted sac of which
one half is in the antrum and the other in the nose and nasophar-
ynx. Thus a maxillary part is distinguished from a naso-pharyngeal
part. By means of inflation or irrigation of the antrum through the
accessory ostium, a polypus is occasionally driven out of the cavity
into the nose.12 According to an interesting statement in the liter-
ature, Palfyn, in 175313, had already observed such a case. Three
years after Gustav Killian, Brown Kelly, in 1909, observing a fre-
quent association between antral cyst and the presence of a wide
accessory ostium, demonstrated a correlation between these con-
ditions.14 ACPs represent 4–6% of all nasal polyps.6 Nasal bilateral
polyposis is a clinical condition found in 1–4% of the Caucasian
population.14
ACP could arise from an antral cyst, present in 8–10% of the
population.15 The development of the cystic part of ACP can be
caused by acinar mucous gland obstruction as a result of chronic
polyposis, whether allergic or infectious.8 Piquet et al. hypothe-
sized that these cysts arise from lymphatic duct stenosis following
inflammation of sinus mucosa.16
Intramural cysts are frequent in young patients, and may
emerge from tooth channels through which the permanent teeth
have migrated.17 The concomitant development of antral cysts
and maxillary ostium obstruction could be caused by the same
chronic inflammatory (allergic or infectious) condition.9
Microscopically, the antral part of an ACP polyp shows a central
cystic cavity surrounded by a homogeneous edematous stroma
with few cells. The surfaces of the ACP are covered by a respiratory

Fig. 1. (A and B): A. Coronal CT section showing opacification of the left maxillary sinus (S), hypertrophied left inferior turbinate (I), deviated septum to the left, and
pneumatized right middle turbinate (⁄). B. Coronal CT section showing opacification of the left maxillary (S), polyp protrusion (P).
 Z.M. Mandour / Egyptian Journal of Ear, Nose, Throat and Allied Sciences 18 (2017) 17–21 19

Fig. 2. (A and B): Axial CT sections showing ACP (P) filling the left maxillary sinus (S) and growing through the accessory/ natural ostium into the middle meatus and the
posterior choana.

Fig. 3. (A and B): Intra-operative nasal endoscopy view of the right nasal cavity showing: A. ACP (P)appeared as a bright, white mass in the middle meatus. B. The stalk (⁄) of
ACP rising from the posterior fontanelle of the right maxillary sinus.

Fig. 4. ACP is composed of a cystic part (filling the maxillary sinus) and a solid part coming out through the posterior fontanelle of maxillary sinus (filling the nasal cavity).

epithelium.18 The cysts are often collapsed with an endothelial lin-
ing.15–19 No histological differences exist between maxillary intra-
mural cysts and the cystic part of ACP.15 Occasionally, ACP display
pseudo-sarcomatous changes.18 ACP shows clear histological dif-
ferences when compared to bilateral ethmoidal polyps encoun-
tered in cystic fibrosis, consisting of a lower inflammatory
infiltrate and a lower eosinophilic infiltrate.19
Based on these observations, we questioned the factors respon-
sible for causing antral cyst herniation through the maxillary
antrum into the nose giving rise to an ACP. The aim was to address
20 Z.M. Mandour / Egyptian Journal of Ear, Nose, Throat and Allied Sciences 18 (2017) 17–21

Antrochoanal polyp- Hypothesis

Fig. 5. (A, B,C, D and E): Antrochoanal polyp- Hypothesis, A: First of all, it is possible that the same chronic inflammatory (allergic or infectious) factors could cause not only
the development of an antral cyst and mucosal oedema but also swelling at the ostiomeatal complex/middle meatus level. Therefore, the partial closure of the maxillary
ostium could be possible. The air, penetrating the sinus through the narrowed natural ostium would be unable to be released during breathing out on account of the mucosal
oedema or swelling at ostiomeatal complex/middle meatus level. B, C: According to Bernoulli theory, the rate of flow is higher at the stricture, creating a pressure drop
perpendicular to the wall of the stricture, thus complete obstruction of the natural ostium during breathing out is more likely to occur with subsequently increase pressure
level within the Highmore antrum which acts as a unidirectional valve. D, E: Additionally, we hypothesize that the mucociliary drainage of the maxillary antrum against
gravity would force the ACP preferentially towards middle meatus through the posterior fontanel and lately through the natural ostium, the latter aided by markedly
increased pressure and partial resorption of the uncinate process. ("P = increased pressure, ⁄ = posterior fontanelle, = intra-sinus portion of ACP and = intra-nasal
portion of ACP).

the distinguishing clinical and radiological features of antro-
choanal polyps in the pediatric patients emphasizing the anatom-
ical basis of local extension of the lesion; thus, a pathogenesis can
be hypothesized. First, the same chronic inflammatory process,
allergic or infectious, augmented by and predisposed to by
anatomical variations affecting the ostiomeatal complex could
cause not only the development of an antral cyst and mucosal
edema but also swelling at the ostiomeatal complex/middle mea-
tus level; thus partial compromise of the maxillary ostium could
be possible. The air, passing to the sinus through the narrowed nat-
ural ostium would be unable to be released during breathing out
on account of the mucosal edema or swelling at ostiomeatal com-
plex/middle meatus level. According to Bernoulli theory, the rate of
flow is higher at the stricture, creating a pressure drop perpendic-
ular to the wall of the stricture, thus complete obstruction of the
natural ostium during breathing out is more likely to occur with
subsequently increased pressure level within the Highmore
antrum which acts as a unidirectional valve. Additionally, we
hypothesize that the mucociliary drainage of the maxillary antrum
against gravity would force the ACP preferentially towards middle
meatus through the posterior fontanelle and lately through the
natural ostium, the latter aided by markedly increased pressure
and partial resorption of the uncinate process. This mechanism will
probably be enhanced by all the anatomical features which may
lead to changes in the pressure gradient between the middle
meatus and the Highmore antrum level; including septal deviation
or spur, alteration of uncinate process, hypertrophy of inferior
turbinate and bulla ethmoidalis, or concha bullosa (Fig. 5 A, B, C,
D and E).
In our series, 36 (92.3%) of patients had nasal anatomical disor-
ders, of these; 28 (71.8%) patients had septal deviation, 32 (82.1%)
had middle turbinate pneumatization and 32 (82.1%) had inferior
turbinate hypertrophy. The presence of nasal disorders of an
anatomical nature (92.3% of cases) represents the only statistically
significant factor correlated to the presence of ACP in our review
(p < 0.001) while only 20%of patients had clinical history of allergy.
It is important to emphasize that the presence of an anatomic
alteration was the only significant correlating factor (p < 0.001)
when evaluating the present series (Chi-square test).
Surgery is the only feasible treatment for ACP. Several surgical
techniques were described. In the past, Caldwell-Luc technique
was used.20,21 FESS is currently the gold standard technique. The
antral portion of an ACP should be removed, together with the base
of its origin, to minimize post-operative recurrence.15 The use of a
micro-debrider may be indicated, as complementary to endoscopic
surgery.15 Combining endoscopic surgery and trans-canine sinu-
soscopy is an alternative technique.17 The success rate was 76.9%
in the trans-nasal endoscopic approach.16 On the other hand, there
was no recurrence on our series after long-term follow up period.
This could be attributed to the correction of the associated nasal
anatomic variations at the time of surgery for ACP removal.
5. Conclusion
Years after the first detailed description by Killian, development
of ACP could be due to an increased pressure level within the max-
illary sinus caused by obstruction of the natural ostium of the sinus
by an inflammatory process and/or anatomical alteration at the
ostiomeatal complex/middle meatus level, in a patient with a
pre-existing silent antral cyst, subsequently forced to herniate out-
side, through the sinus fontanelle. Nasal endoscopy and computed
tomography currently represent the golden standard tool in ACP
diagnosis and concomitant nasal anatomic variations.
The primary aim of surgery is to complete removal of both nasal
and cystic parts of the polyp, as well, to correct all predisposing
anatomical factors as a mandatory step to avoid its recurrence.
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