Sphenochoanal polyp: Current diagnosis and management Abstract Choanal polyps arise from inflamed, edematous mucosa in the

paranasal sinuses. They extend into the choana and cause nasal obstruction and mouth breathing. In most cases, these polyps arise in the maxillary sinus, but rare cases of origin in the sphenoid sinus and other nasal structures have been reported. The presence of a choanal polyp in an atypical location can lead to diagnostic confusion and exploration of the wrong sinus at surgery. The author reports the case of a 15-year-old girl who was diagnosed with a sphenochoanal polyp. The patient was successfully treated via an endoscopic surgical approach. Introduction Sphenochoanal polyps are rare, benign, solitary masses that arise from the sphenoid sinus, exit through the sphenoid ostium, pass across the sphenoethmoid recess, and extend into the choana. They were once commonly mistaken for their more common counterparts, antrochoanal polyps, which produce similar symptoms. Fortunately, advancements in imaging and endoscopic rhinology have allowed for more precise diagnoses. In this article, the author reports the case of a patient with a sphenochoanal polyp, and he discusses the clinical presentation, pathogenesis, endoscopic and radiologic evaluation, and surgical management of this clinical entity. Case report A 15-year-old girl with persistent nasal obstruction was referred for evaluation. Her obstruction had been present for 2 years, and it primarily affected the left side. She also complained of persistent snoring and anterior nasal discharge. She had no other significant medical history. Endoscopic examination revealed the presence of a glistening, smooth polyp on the floor of the left nasal cavity. The lesion appeared to have originated in the sphenoethmoid recess. The polyp extended posteriorly to fill the nasopharynx, and it obstructed both choanae (figure 1). There was no pathologic finding in the left middle meatus. Findings on the rest of the otorhinolaryngologic examination were normal. Figure 1. Endoscopic view (0, 4 mm) shows the sphenochoanal polyp causing total obstruction of the posterior choana

Axial and coronal computed tomography (CT) of the nose and paranasal sinuses demonstrated a softtissue opacity filling the left sphenoid sinus and extending into the choana (figure 2). A skin-prick test revealed reactions to the fungus Penicillium (7 mm) and to house dust mite (5 mm). The results of other laboratory tests were within normal limits. Figure 2. CT shows the sphenochoanal polyp filling the left sphenoid sinus and extending into the nasopharynx

Removal of the polyp was performed with general anesthesia. The choanal part of the mass was reduced with a microdebrider under endoscopic guidance. The pedicle of the polyp was traced to the left sphenoid ostium in the sphenoethmoid recess. The sphenoid ostium was enlarged, and the sphenoidal component of the polyp was then removed. Pathologic examination of the specimen showed a polyp lined with benign respiratory epithelial cells with intraepithelial neutrophil infiltrate. The stroma was loose with prominent infiltration by eosinophils and lymphocytes (figure 3). The patient completed a normal recovery after surgery, with no evidence of recurrence in the 14 months following the procedure.

Figure 3. Histopathology shows pseudostratified columnar epithelium and stromal mononuclear cells (H&E, original magnification x150)

Discussion Choanal polyps are benign, relatively uncommon mucous growths that by definition protrude through the choana. They represent 3 to 6% of all nasal polyps.1 They differ from common nasal polyps in that they are solitary and dumbbell-shaped, and they contain fewer mucous glands and eosinophils. Choanal polyps are classified according to the origin of their pedicle as eitherantrochoanal (originating in the maxillary sinus) or sphenochoanal. Althoughethmochoanal polyps have also been described, there is controversy as to whether they are different from the common nasal polyps that originate in the ethmoid air cells. The presence of clefts in the ethmoid labyrinth instead of discrete ostia, as is seen in the maxillary and sphenoid sinuses, and the ill-defined junction between ethmoid and nasal mucosa make it difficult to precisely identify the site of origin of an ethmoid polyp.2 Cases of origination in the turbinates, nasal septum, and other nasal structures have been reported, but they are extremely rare.3,4The most common presenting symptoms are nasal obstruction, snoring, and unilateral purulent discharge. Sphenochoanal polyps have no predilection for either sex. They are seen mostly in adolescents and young adults. The youngest case of sphenochoanal polyp, which occurred in a 4-year-old girl, was reported by Lim and Sdralis.5 That patient experienced a spontaneous regression. The authors hypothesized that most such polyps are small, asymptomatic, and regress. In only a few cases do polyps enlarge (secondary to persistent infection) and become clinically symptomatic.5 A careful preoperative endoscopic examination can usually identify the origin of a choanal polyp. Antrochoanal polyps exit through the maxillary ostium and pass between the middle turbinate and the lateral nasal wall to reach the choana. Sphenochoanal polyps, on the other hand, exit through the

sphenoid ostium and pass through the sphenoethmoid recess into the choana, leaving the middle meatus clear. CT and/or magnetic resonance imaging can identify the origin of a choanal polyp and the involved sinus, thereby eliminating the risk that the wrong sinus will be opened. Imaging can also lessen the possibility of a downward extension of intracranial pathology. The differential diagnosis of choanal polyp includes hypertrophied adenoid, angiofibroma, Thornwaldt cyst, pituitary tumor, lymphoma, and carcinoma. Various theories have been proposed to explain the pathogenesis of choanal polyps, but the cause remains unknown. The most widely accepted theory is that the polyp arises from a submucosal cyst secondary to thrombosis of lymphatic vessels caused by a post-infection sinus inflammation.6 The fact that maxillary sinusitis is more common than sphenoid sinusitis may explain why antrochoanal polyps are more common than sphenochoanal polyps. The association between choanal polyps and allergic disease is controversial. Some authors have reported that allergy was present in 50 to 69% of their choanal polyp patients.7-9 On the other hand, Ozcan et al studied the histopathology of choanal polyps by transmission electron microscopy and light microscopy and postulated that inflammatory etiology rather than allergy may be the cause.10 Their theory was based on findings of (1) a relatively low number of eosinophils and a high number of other inflammatory cells and (2) a normal-appearing basement membrane with intact and normal surface epithelium. On occasion, a sphenochoanal polyp has degenerated into an angiomatous polyp as a result of the occlusion and compression of vessels at vulnerable sites (e.g., the ostium opening and dependent positions in the nasal cavity, choana, and nasopharynx). In such cases, the polyp undergoes a sequential process that involves dilation and stasis of blood flow, edema, infarction, neovascularization, repeat occlusion, and reinfarction. The process continues until there is either total necrosis or, more commonly, angiomatous degeneration.11 The advantage of endoscopic removal is evident, especially in pediatric cases where a destructive external approach to gain access to a benign sphenoid sinus lesion is not advisable. Endoscopic surgery with powered instrumentation allows for precise excision with minimal complications. Acknowledgment The author gratefully acknowledges the physicians in the Department of Pathology at the Jordan University of Science and Technology for their contributions to the preparation of the pathology slide. From the Division of Otorhinolaryngology-Head and Neck Surgery, Department of Special Surgery, Jordan University of Science and Technology, Irbid, Jordan. Dr. Mohannad A. Al-Qudah, Assistant Professor of Otolaryngology, Department of Special Surgery, Jordan University of Science and Technology, P.O. Box 3030, Irbid (22110), Jordan. E-mail: malqudah@gmail.com References

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