International Journal of Pediatric Otorhinolaryngology 84 (2016) 143–146

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International Journal of Pediatric Otorhinolaryngology

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

Difference of antrochoanal polyp between children and adults

Dong Hoon Lee, Tae Mi Yoon, Joon Kyoo Lee, Sang Chul Lim *
Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School & Chonnam National University Hwasun Hospital,
160 Ilsimri, Hwasun, Jeonnam 519-809, South Korea

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

Article history: Objective: The purpose of this study was to review the clinical characteristics of the antrochoanal polyp
Received 28 December 2015 (ACP) and to compare the differences between children and adults.
Received in revised form 3 March 2016 Patients and methods: This study was performed in 56 patients who underwent endoscopic surgery for
Accepted 4 March 2016
ACP between 2004 and 2014. The study population was subdivided into children (8 years old) and
Available online 12 March 2016
adults (>18 years old). Clinical findings of ACP, including symptoms, CT stages, and surgical outcomes
were retrospectively analyzed.
Keywords:
Results: CT Stage II and III lesions were more common than CT stage I lesions in children (p < 0.001).
Antrochoanal polyp
Accompanying maxillary sinus diseases were more common in adults (p < 0.005). Purely endoscopic
Child
Adult surgery for ACPs was performed in all children and 25 (86.2%) adults. The combined approach,
Endoscopic surgery endoscopic and canine fossa approach, was applied in 4 (13.8%) adults. The success rate was 88.9% in
Computed tomography children and 93.1% in adults. According to the approach method, the success rate was 90.4% for the
purely endoscopic approach and 100% for the combined approach.
Conclusion: High incidence of CT stage II and III lesions in the child group with ACP in our study suggests
that children with ACP present at a more advanced state because of late diagnosis. Accompanying
maxillary sinus diseases can be present in patients with ACP, especially adults, which should be
considered preoperatively and treated appropriately.
ß 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction 2. Patients and methods

Antrochoanal polyps (ACPs) are benign polypoid lesions arising
from the mucosa of the maxillary sinus, through the maxillary
sinus ostium with extension into the choana [1–3]. ACPs represent
approximately 4–6% of all nasal polyps in the general population;
however, the incidence is increased to 35% in children [1,4]. ACPs
are almost always unilateral, although there are few cases of
bilateral ACPs in the literature, mainly in children [1–3].
The pathogenesis and etiology of ACPs are still unknown
[2]. Nasal endoscopy and computed tomography (CT) are the gold
standard for determining the diagnosis and the treatment plan
[1,5]. Surgical removal of ACPs is the treatment of choice [1–4].
The purpose of this study was to review the clinical
characteristics of the ACPs, and to compare the differences
between the child and adult groups.
* Corresponding author. Tel.: +82 61 379 8190; fax: +82 61 379 7761.
E-mail address: limsc@chonnam.ac.kr (S.C. Lim).
After obtaining approval from the Institutional Review Board of
Chonnam National University Hwasun Hospital (CNUHH-2015-
145), this study was performed in 56 patients who underwent
endoscopic surgery for ACP between 2004 and 2014. This study
population was subdivided into children (18 years old) and
adults (>18 years old).
Demographic characteristics, sinonasal complaints, localization
of ACPs, imaging findings, accompanying maxillary sinus diseases,
histopathologic results, treatment outcomes, and postoperative
complications were reviewed. We classified ACPs into 3 patterns
according to the CT findings [6]: Stage I (antronasal polyp), Stage II
(ACP extended to the nasopharynx and the ostium of the maxillary
sinus was occluded fully by the neck of the ACP), and Stage III (ACP
extended to the nasopharynx and the ostium of the maxillary sinus
was occluded partially by the neck of the ACP).
The type of surgical approach was determined by endoscopic
accessibility for the antral portion of ACPs. The antral portion of
ACPs was removed via endoscopic approach through the natural
maxillary ostium after it was adequately widened. However, in
some cases, it was difficult to access the antral portion of ACPs
endoscopically, and additional access was obtained through the

http://dx.doi.org/10.1016/j.ijporl.2016.03.004
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144 D.H. Lee et al. / International Journal of Pediatric Otorhinolaryngology 84 (2016) 143–146

canine fossa. A 5 mm diameter window was created 1 cm above

the canine fossa by trocar puncture. A powered instrumentation
was inserted into the maxillary sinus through the canine fossa
puncture, and removed the antral portion of ACPs. Fisher’s exact
test was used for the statistical analysis with SPSS version
14.0. Statistical significance was defined as a p-value <0.05.

3. Results

Fifty-six patients with ACPs were identified. There were 27

(48.2%) patients in children and 29 (51.8%) patients in adults.
Clinical findings in children and adults are summarized in
Table 1. In children, there were 16 males and 11 females; the
mean age was 15.5  1.5 years, with a range of 4 to 17 years. In
adults, there were 19 males and 10 females; the mean age was
49.0  3.0 years, with a range of 19 to 65 years.
The sinonasal complaints in both groups were nasal obstruc-
tion, followed by nasal discharge. Nasal obstruction prevalence is
similar in adults (79.3%) and children (66.7%). Of the 56 lesions,
Fig. 1. In a 9-year-old male patient, coronal CT scans show a soft tissue mass in
30 ACPs (53.6%) were located in the left maxillary sinus and bilateral maxillary sinus, extending to the nasopharynx.
25 ACPs (44.6%) were located in the right maxillary sinus. Bilateral
ACP was detected in 1 case (1.8%, Fig. 1). There was a slight
follow-up period after surgery was 55.4  29.8 months, with a range
predominance of the left maxillary sinus in both the child (15/26,
of 11 to 122 months.
57.7%) and adult (15/29, 51.7%) groups.
Purely endoscopic surgery for ACPs was performed in all (100%)
On CT classification of the ACPs, there was a significant difference
children and 25 (86.2%) adults. The combined approach, endo-
between children and adults. In children, the majority of patients
scopic and canine fossa approach, was applied in 4 (13.8%) adults in
were stage II (22/27, 81.5%), followed by stage III (4/27, 14.8%) and
whom it was difficult to access the antral portion of ACPs
stage I (1/27, 3.7%). However, in adults, the majority of patients were
endoscopically. The success rate was 88.9% in children and 93.1% in
stage I (13/29, 44.8%), followed by stage II (12/29, 41.4%) and stage III
adults. According to the approach method, the success rate was
(4/29, 13.8%). In this study, stage II and III lesions were more
90.4% (47/52 patients) for the purely endoscopic approach and
common than stage I lesions in children (p < 0.001).
100% (4/4 patients) for the combined approach.
We reviewed accompanying maxillary sinus diseases of ACPs,
Recurrence of ACPs was identified in 3 (11.1%) children and 2
excluding chronic sinusitis. There were no accompanying maxil-
(6.9%) adults. The recurrence of ACPs did not differ significantly
lary sinus diseases in children. However, in adults, accompanying
between the two groups. All five cases with recurrence were
maxillary sinus diseases included fungus ball in 4 patients,
previously treated by the purely endoscopic approach. Among the
inverted papilloma in 2 patients, and odontogenic sinusitis in
three children, two patients were disease-free after re-operation
2 patients. All fungus balls were present in the ipsilateral maxillary
through endoscopic approach. One patient was regularly followed
sinus. Two inverted papillomas were detected in the ipsilateral
up without surgery because she had intermittent and mild
maxillary sinus and ipsilateral ethmoid sinus. In this study,
symptoms. In the two adults, one patient had been disease-free
accompanying maxillary sinus diseases were more common in
after re-operation through endoscopic approach, and the other
adults than in children (p < 0.005). No one needed additional
patient had been on regular follow-up without surgery.
endoscopic sinus surgery for other sinuses, except ACPs.
There were no major complications resulting from surgical
In all patients, histopathological findings of the resected
intervention. Middle turbinate synechiae occurred in 1 child
specimens were consistent with ACPs. In particular, two patients
patient and septal perforation was noted in 1 adult patient.
in children were diagnosed as having angiomatous polyps, the rare
variant of sinonasal polyp. These patients included 1 male (14 years
old) and 1 female (17 years old, Fig. 2). Both patients presented 4. Discussion
with nasal obstruction. After endoscopic surgery, the patients were
followed up with endoscopic examination and recurrence was not It is known that ACPs most commonly occur in children and
observed in any patient. The mean follow-up period after surgery young adults [1,4]. However, only 48.2% of all cases occurred
was 60.7  35.7 months (mean follow-up  standard deviation), among children in this study. In addition, approximately 40% of the
with a range of 8 to 120 months in children. In adults the mean patients were between 30 and 65 years. Therefore, the findings in

Table 1
Clinical findings of antrochoanal polyps in child and adult groups.

Children (N = 27) Adults (N = 29)

Age (years) 4–17 (15.5  1.5) 19–65 (49.0  3.0)

Sex (M:F) 16:11 19:10
Main sinonasal complain Nasal obstruction (66.7%) Nasal obstruction (79.3%)
Location (R:L:B) 11:15:1 14:15:0
CT classification (I:II:III) 1:22:4 13:12:4
Surgery Purely endoscopic (100%) Purely endoscopic (86.2%)
Combined approach (13.8%)
Accompanying maxillary sinus diseases None FB (n = 4), IP (n = 2), Odontogenic sinusitis (n = 2)
Recurrence 3 (11.1%) 2 (6.9%)

M, male; F, female; R, right; L, left; B, both; FB, fungus ball; IP, inverted papilloma.

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 D.H. Lee et al. / International Journal of Pediatric Otorhinolaryngology 84 (2016) 143–146 145

Fig. 2. Atypical presentation of an antrochoanal polyp as a reddish and hypervascularized mass (A), with focal necrosis behind the soft palate (B). MRI scan shows
heterogeneous nodular and patch enhancement on T1-weighted imaging (C), and histopathological sections shows angiomatous polyp containing thin-walled vessels,
hemorrhage, and necrosis (hematoxylin–eosin staining, 40).

our study are consistent with the claim that ACPs may manifest at
any age, as shown in few previous reports [5,7]. This study showed
that ACPs were more common in males than in females
(male–female ratio, 1.7:1). There was a slight predominance of
the left maxillary sinus in both children and adults, as shown in
previous reports [9,10]. The presenting symptoms are similar to
those of many paranasal sinus diseases, including nasal obstruc-
tion, rhinorrhea, headache, and snoring [1]. The most common
sinonasal complaints is nasal obstruction [1,8,9].
Nasal endoscopy and CT are excellent tools for diagnosing ACPs
[1,5,9]. On nasal endoscopy, ACP typically appears as a smooth
polypoid mass originating in the middle meatus, and it extends into
the choana and nasopharynx, eventually to the oral cavity [1,4,5]. CT
reveals a soft tissue masses occupying the maxillary sinus through
the maxillary sinus ostium and extending into the choana without
bony erosion or expansion [1,4,5,9]. On magnetic resonance imaging
(MRI), ACP shows hypointensity on T1-weighted image and
hyperintensity on T2-weighted image [1,5]. The differential
diagnosis is between ACPs and ipsilateral nasal tumors such as
angiofibroma, nasal glioma, encephalocele, mucocele, retention
cyst, inverted papilloma, or hemangioma [1,5,9].
According to the CT classification [6], the most common CT
finding of ACPs in this study was stage II lesions (81.5%) in children.
Only one patient in children had stage I lesion. However, in adults,
the majority of patients were stage I and II (86.2%). In this study,
stage II and III lesions were more common than stage I lesions in
children (p < 0.001). Chung et al. [6] reported that stage I may
correspond to an early proliferative stage, stage II to active
proliferative stage, and stage III to a late regressive stage.
Therefore, it can be speculated that the difference in CT staging
between the two groups may be due to late diagnosis of ACPs in
children. Children usually do not complain of early nasal
symptoms, which leads to delayed diagnosis and they often
present at an advanced stage.
In this study, we found that two patients in children presented
with a necrotic mass and it was postoperatively diagnosed as
angiomatous polyp, which is rare, representing only 4–5% of all
sinonasal polyps [10]. Angiomatous polyps are characterized by
extensive vascular proliferation and ectasia [11]. Because angio-
matous polyp develops as a result of infarction, ACP is more likely
to develop as angiomatous polyp because of strangulation of the
long pedicle of ACP. CT of angiomatous polyp reveals a heteroge-
neous mass with minimal peripheral enhancement [10]. MRI of
angiomatous polyp shows hypointensity on T1-weighted image
(WI), heterogeneous hyperintensity with peripheral hyperinten-
sity on T2-WI, and marked heterogeneous nodular and patchy
enhancement on enhanced T1-WI [12]. Angiomatous polyps are
benign; however, the clinical and radiological features of these
lesions have considerable potential for confusion with neoplastic
processes [10,11].
In patients with ACP, accompanying maxillary sinus diseases
should be thoroughly evaluated preoperatively. Accompanying
maxillary sinus diseases in ACP can aggravate ACP or cause
recurrence of ACP postoperatively or there can be residual
accompanying disease if not treated properly. In our study, there
were no accompanying maxillary sinus diseases in children.
However, adults had several accompanying maxillary diseases,
such as fungus ball in 4 patients, inverted papilloma in 2 patients,
and odontogenic sinusitis in 2 patients. In this study, accompa-
nying maxillary sinus diseases were more common in adults than
in children (p < 0.005). All accompanying maxillary sinus diseases
and ACPs were simultaneously removed via endoscopic approach.
However, two patients, one patient with odontogenic sinusitis and
another patient with inverted papilloma, had recurrence. When

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146 D.H. Lee et al. / International Journal of Pediatric Otorhinolaryngology 84 (2016) 143–146
patients have ACPs with accompanying maxillary sinus diseases,
clinicians should consider the possibility of disease recurrence.
Surgical removal is the generally accepted treatment of choice
for ACPs [1,3–5,8,9,13]. Endoscopic surgery is now the main
treatment modality for ACPs because of its shorter recovery time
and fewer side effects [1,4,5,8,13]. This technique consists of
complete removal of the nasal and antral portions of the ACPs with
resection of its site of origin. Identification and removal of antral
portion of ACPs are cornerstones to successful treatment [5]. In
some cases, an additional combined approach using a canine fossa
approach may be required to ensure optimum visualization within
the confines of the maxillary sinus [4,5,13]. We performed the
combined approach only in adults because dentition interference,
infraorbital paresthesia, or facial growth disturbance after canine
fossa puncture can occur in children [4,9]. The success rate was
88.9% in children and 93.1% in adults. According to the approach
method, the success rate was 90.4% (47/52 patients) for purely
endoscopic approach and 100% (4/4 patients) for combined
approach. These success rates were similar to those in previous
reports [1,3,5,8,9].
The recurrence rate in endoscopic surgical treatment of ACPs is
usually low [8]. Recurrence of ACPs is most probably due to
regrowth of any missed residual polypoid lesions within the
maxillary antrum [3]. In this study, recurrence of ACPs was
identified in 3 (11.1%) children and 2 (6.9%) adults. All adults with
recurrence had accompanying maxillary sinus diseases. Among
them, three patients had been disease-free after re-operation
through endoscopic approach. There were no major surgical
complications such as orbital injury. Septal perforation was noted
in 1 adult patient, which was due to excessive septal trauma
caused by manipulation of curved forceps to reach the anterior
and/or lateral wall of the maxillary sinus. However, septal
perforation was small and asymptomatic and the patient had
been followed up without repair of perforation.
5. Conclusion
In our study, high incidence of CT stage II and III lesions in
children with ACP in our study suggests that children with ACP
present at a more advanced state because of late diagnosis.
Accompanying maxillary sinus diseases may occur with ACPs,
especially in adults. Therefore, clinicians should consider the
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possibility of coexistence of ACPs and another maxillary sinus
disease. Endoscopic surgery for complete removal of ACPs is a safe
and effective procedure for both children and adults.
Competing interest
The authors have no sponsorships or competing interests to
disclose for this article.
Acknowledgments
The authors have no acknowledgements to disclose for this
article.
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