A Case of Antrochoanal Polyp

An 18-year-old boy comes to the ENT outpatient with complaints of left sided nasal obstruction for the past 6 months. Insidious in onset, the obstruction is worsening progressively. It is associated with occasional whitish, mucoid nasal discharge that is not foul smelling or blood stained.

There is no history of headache or symptoms of nasal allergy like excessive sneezing and watery rhinorrhoea.

Examination

The external appearance of the nose is normal as are the vestibules. On anterior rhinoscopy, a solitary, greyish mass is seen in the left nasal cavity. The mass is smooth and glistening and occupies the lower part of the nasal cavity. The middle turbinate appears to be normal. The mass is further examined with a cotton tipped probe – it is insensitive to touch, does not bleed and can be probed all around.

Cold spatula test shows decreased fogging on the left side. There is no tenderness over the paranasal sinuses. The right nasal cavity, ears, throat and neck are normal.

Questions

Answer the following questions before you go on to read the case discussion below.

• What is your diagnosis?
• What further tests does this condition require?
• How will you manage this case?

Discussion

Unilateral nasal obstruction may be caused by a deviated nasal septum, hypertrophied inferior turbinate, rhinolith, unilateral nasal polyps or a nasal tumour. Here, the cause of nasal obstruction is the mass in the nasal cavity. The appearance of the mass (smoothy, shiny, greyish) suggests a polyp. Polyps are insensitive to touch and do not bleed unlike hypertrophied turbinates and nasal tumours. Also, polyps can be probed all around (except at their point of origin from the middle meatus) whereas a hypertrophied inferior turbinate cannot be probed laterally where it is attached to the lateral nasal wall.

Since the polyp is unilateral and single, it is likely to be an antrochoanal polyp. AC polyps usually grow backwards and may be seen occupying the choana and even the nasopharynx sometimes. This can be seen by posterior rhinoscopy or nasal endoscopy. They cause bilateral nasal obstruction when they reach the nasopharynx.

Diagnosis

Antrochoanal polyp, right side

Management

Diagnostic nasal endoscopy is done to evaluate the nasal mass. The origin of the polyp from the middle meatus may be seen. AC polyps can sometimes be seen coming out of an accessory ostium of the maxillary sinus. CT scan of the nose and paranasal sinuses will help study the extent of the mass and also reveal any anatomical variations in the lateral wall of the nose (the knowledge of which is important during surgery).

The treatment is surgical removal. Part of the polyp is inside the maxillary antrum, this has to be removed completely as well to prevent a recurrence of the condition. Endoscopic sinus surgery is done to remove the polyp. Uncinectomy and middle meatal antrostomy are done as part of the procedure to widen the opening of the maxillary antrum and the polyp is completely removed.

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