Antrochoanal Polyps

RICHARD TOWBIN, J. S. DUNBAR,2 AND KEVIN BOVE3

The antrochoanal polyp, a benign solitary polypoid lesion, posterior choana protruded into the nasopharynx. There was no
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usually arises In a maxillary sinus, opacifying and enlarging bone destruction. A Caldwell-Luc procedure was performed
the sinus cavity without bone destruction. It passes through and a 5 x 2.2 x 1 .4 cm granular gray mass, arising from the
the ostium of the sinus into the choana, and from there into maxillary antrum and extending into the nasopharynx, was
the posterior nasopharynx. The soft tissue mass does not removed (fig. 1D).
erode or destroy contiguous soft tissue or bony structures. In
this sequence of events, its radiologic findings are character- Case 3
istic. Five case reports are presented, and the differential
S. W., a 12-year-old white girl, was admitted with a 5 week
diagnosis is discussed.
history of increasing left nasal obstruction. No pain or discharge
was present. There were no known allergies. Physical examina-
The antrochoanal polyp, usually a solitary benign tion was unremarkable except for a large, glistening, soft and
growth, arises from the maxillary antrum of a nonatopic fleshy, nonpulsatile mass in the left nostril. It was not seen in
patient. It grows by extension from the antrum through the nasopharynx. Sinus radiography showed opacification of
its ostium into the middle meatus, then into the posterior the left maxillary antrum with minimal expansion but no bone
choana and may extend into the nasopharynx. destruction The lateral view demonstrated
. a water-density mass
in the posterior choana (fig. 2). A left Caldwell-Luc procedure
Antrochoanal polyps are known to otolaryngologists
with partial ethmoidectomy was performed. The mass arose in
and have been frequently reported in the otolaryngologic
the left maxillary sinus and extended into the nasopharynx. The
literature after Killians excellent description in 1906 [1].
pathologic findings were consistent with an antrochoanal polyp.
In the radiologic literature, the antrochoanal polyp has
been largely ignored. Since it has distinctive features Case 4
which allow radiologic diagnosis, we present five cases
J. M., an 11-year-old white boy, developed an upper respira-
and discuss the diagnosis and differential diagnosis.
tory infection associated with right epistaxis 2 weeks before
admission. One day before admission, his mother noted tissue
Case Reports
protruding from the right naris with swallowing. On physical
Case 1 examination there was complete obstruction of the right naris
H. B. (female) was followed by an otolaryngologist since 19 by a fleshy mass. The mass extended into the oropharynx,
months of age because of recurrent otitis media and its compli- appeared multilobular, and was cystic to palpation. No adenop-
cations. During this interval physical examinations revealed no athy was present. Radiography showed complete opacification
nasal polyp. No history of allergy was elicited. At 6 years of age, of the right maxillary antrum, with enlargement but no bony
she was admitted to Childrens Hospital Medical Center for destruction. A water-density mass in the right naris extended
observation after incurring a linear skull fracture. Radiography into the nasopharynx (fig 3). A mucus retention cyst was
showed a linear frontal fracture and opacification of the left incidentally noted on the floor of the left maxillary antrum. At
maxillary antrum. The antrum was slightly expanded without surgery, a biopsy was followed by a right Caldwell-Luc proce-
bone destruction. A water-density mass extended from the dure. An antrochoanal polyp which originated in the right
posterior choana into the nasopharynx, but was not appreciated maxillary antrum and extended into the posterior choana was
at that time. At age 7 a large polyp filled the left naris and removed. The left maxillary antrum was not investigated.
extended into the nasopharynx. An antrochoanal polyp (8.0 x
1 .5 x 1 .2 cm) was removed by snare avulsion.The antrochoanal Case 5
polyp recurred 11 months after removal. The polyp was then J, B., a 105/12-year-old white boy, was seen in the emergency
removed at its base in the antrum by a CaIdwelI-Luc procedure. room with epistaxis and an autoamputated polypoid mass from
his left naris. For the previous 2 months he had had recurrent
Case 2 epistaxis and a sensation of a left nasal blockage. He had no
P. 5., a 12-year-old white boy, was admitted for evaluation of allergic history. Examination of the nasopharynx revealed mu-
left nasal obstruction which had gradually progressed over the copurulent discharge and a polypoid mass exiting from the
previous year. There was no history of allergic disease. Because middle meatus and extending into the nasopharynx. Radiogra-
of changes in his voice and a feeling of something in the back phy of the sinuses demonstrated mucoperiosteal thickening of
of his throat, otolaryngologic consultation was requested. Ex- the right maxillary antrum, and opacification and slight expan-
amination of the pharynx revealed a nasopharyngeal mass at sion of the left antrum. A soft-tissue mass extended into the
the level of the velum. On radiologic examination, the left nasopharynx. Pathologic examination of the autoamputated 3.0
maxillary antrum was shown to be slightly enlarged and com- x 0.9 x 0.3 cm polyp was consistent with the diagnosis of
pletely opacified (figs. lA-iC). A water-density mass in the antrochoanal polyp.

Received June 22, 1978; accepted after revision October 2, 1978.

I Division of Roentgenology, Pediatrics, Childrens Hospital Medical Center, Cincinnati, Ohio 45229.
2 Division of Roentgenology, Pediatrics, University of Cincinnati College of Medicine, Childrens Hospital Medical Center, Cincinnati, Ohio 45229.
Address reprint requests to J. S. Dunbar at Childrens Hospital.
3 Departments of Pediatrics and Pathology. Childrens Hospital Medical Center, Cincinnati, Ohio 45229.

AJR 132:27-31, January 1979 27 0361-803x/79/1321-oo27 $0.00

1979 American Roentgen Ray Society
 28 TOWBIN ET AL. AJR:132, January 1979
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Fig. 1 . -Case 2. A, Waters view: complete opacification with slight expansion of left maxillary antrum. No bony destruction.
B, Lateral view: a large. rounded water-density mass extends into nasopharynx (arrows). C. Tomogram: left maxillary antrum is
opacified and enlarged. without bony destruction. 0. 5.0 x 2.2 x 1.4cm polyp on stalk. Typical appearance of choanal polyp.

L I
Fig. 2.-Case 3. A, Waters view: left maxillary antrum is opacified and expanded. No bony destruction. B, Lateral view:
choanal polyp (arrows) extends into upper nasopharynx. Pterygoid plates and posteriorwall of maxillary sinus are unaffected.
 AJR:132, January 1979 ANTROCHOANAL POLYPS 29
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Fig. 3.-Case 4. A, Waters view: opacification and expansion of right maxillary antrum. No bony destruction. Round
water density mass in inferomedial aspect of left maxillary antrum, representing mucus retention cyst. B. Lateral view: a
polypoid mass extends into nasopharynx (arrows).

Discussion Radiographic Features

The first description of antrochoanal polyps was by In the series of Heck et al. [5], radiography of the
Palfyn in 1753 [2]. He reported a female in whom a sinuses was performed in 61 of 64 patients with antro-
nasopharyngeal polyp extended to the level of the uvula. choanal polyp. In only one instance was the examination
The tumor was round, smooth, whitish, insensitive, and negative. In 57.4% there was evidence of a unilateral
soft. She had difficulty speaking and could only breath lesion on the involved side, and 42% showed bilateral
through her mouth. Throughout the nineteenth century involvement of the maxillary or other sinuses. A naso-
there were scattered reports of removal of antrochoanal pharyngeal soft tissue mass was demonstrated in 7
polyps. However, in 1906 Killian [1] first accurately de- (1 1 .4%) of the 61 patients.
scribed the natural history of the antrochoanal polyp, In Hardys series [7], interpretation of radiographs was
including its true site of origin in the maxillary sinus. made in only 13 of 31 cases. In comparison with Heck et
Prior to this time, it had been thought that the antro- al. [5], a large number (69.2%) showed involvement of
choanal polyp arose in a posterior choana. However, one or more sinuses on the side of the polyp, and a
Killian did not confirm the maxillary antrum origin of the smaller number (23%) showed bilateral involvement. In
lesion by opening or dissecting the antrum. This docu- only one instance was a choanal mass demonstrated. No
mentation is credited to Ino Kubo in 1909. Since then, examination failed to indicate an abnormality.
there have been many reported cases, most arising from In all of our patients there was evidence of slight but
a maxillary antrum, but occasionally from the ethmoid or definite expansion of the involved maxillary antrum.
sphenoid sinuses. Hiranandani and Melgiri [8] and Chhangani [9] described
The benign inflammatory or allergic polyp is the most this phenomenon; the latter also documented erosion of
frequent new growth in the nasal fossa and the paranasal the lateral nasal wall in one of his patients. This compli-
sinuses. The antrochoanal polyp is infrequent. Syme [3] cation was believed to result from failure of the polyp to
found 26 (3%) of 878 patients with antral disease to have pass posteriorly after it had traversed the maxillary os-
antrochoanal polyp. Myers [4], in over 25,000 ear-nose- tium into the choana; it had therefore expanded and
throat examinations during 3 years in the military, found eroded contiguous structures.
only three cases of antrochoanal polyp. In the series of
Heck et al. [5], 56 of 1720 patients (3.7%) with nasal
Differential Diagnosis
polyps had antrochoanal polyp. In the large experience
of 118,374 patients examined over 13 years at Helsinki The diagnosis of antrochoanal polyp is strongly sug-
University Central Hospital, 1 295 cases of nasal polyps gested when an opacified maxillary antrum is expanded
were discovered [6]. Of the latter there were 80 cases of and there is a nasopharyngeal mass. Other possible
antrochoanal polyp. Thus, the incidence of antrochoanal diagnoses include the following.
polyp was 0.07% of otolaryngologic cases and 6.2% of Normal or hypertrophied inferior turbinates. The infe-
nasal polyps in the Helsinki series. Data from three well nor turbinate projects into the nasopharyngeal fossa.
documented series [5-7] indicate that about 71% of This normal finding is sometimes misinterpreted as a
patients with antrochoanal polyps are 10-39 years of nasopharyngeal mass, but should easily be recognized
age. Also noted was a 1 .3 to 1 male-to-female ratio. for what it is [10, ii].
 30 TOWBIN ET AL. AJR:132, January 1979
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Fig. 4.-Typical nasopharyngeal angiofibroma. Large mass originates in nasopharynx, and invades and displaces contiguous
structures, but does not distend antra.

Chronic hypertrophic polypoid rhinosinusitis. This defined, smooth, mucus-filled epithelial cyst arising from
condition affects the upper respiratory epithelium. It is the floor or one of the walls of the cavity. It does not
characterized by vasomotor instability, polypoid mucosal extend into the choana, nor enlarge the sinus cavity.
hypertrophy, and superimposed infection. Numerous Mucocele. This represents an interstitial mucin pool
etiologies are associated with vasomotor instability of resulting from rupture of glands or ducts [15, 16]. The
the upper respiratory tract and include drugs. infection, mucocele usually occurs in the frontoethmoid region,
endocrine imbalance, and psychogenic factors. Allergy and only rarely in the maxillary sinuses. It causes en-
is often a factor, especially when the changes are bilat- largement (sometimes severe) of the cavity in which it
eral [12]. occurs, erosion or sclerosis of the walls of the cavity,
The hypertrophic polyps may be unilateral or bilateral, and sometimes sclerosis of the surrounding bone. How-
most frequently occurring in the nose and ethmoid ever, it does not extend into or through the choana when
sinuses, although no sinus is spared. Expansion of the the maxillary sinus is involved.
sinus lumen or nasal cavity may occur and occasionally Malignant tumors of the nasopharynx. These tumors
is so marked as to produce hypertelorism and widening account for about 1% of all malignancies [17-20]. These
of the nasal bridge [13]. When nasal polyps are seen in neoplasms may cause difficulty in differential diagnosis.
children, cystic fibrosis of the pancreas should be con- However, they tend to cause destruction of contiguous
sidered. However, in our experience, no nasopharyngeal bony structures, airway obstruction, enlargement of the
component occurs. adenoidal tissue outside of its normal confines, or inva-
Juvenile nasopharyngeal angiofibroma. This is a highly sion into the paranasal sinuses. Tomography may be
vascular, benign neoplasm with potential for local de- necessary to evaluate the extent of the neoplastic in-
struction; most occur in the nasopharynx or posterior volvement. The most common malignant tumors of the
nasal cavity of pubescent males. The symptoms can be nasopharynx in childhood are lymphoma, rhabdomy-
epistaxis, nasal obstruction, or a mass in the nasophar- osarcoma, lymphoepithelioma, olfactory neuroblastoma,
ynx. and chordoma. These usually cannot be differentiated
The radiologic features (fig. 4) of this tumor are (1) a by radiographic means.
large soft-tissue mass in the nasopharynx extending into
Pathology and Treatment
the areas of the parapharyngeal structures; (2) anterior
bowing of the posterior wall of the maxillary antrum of Grossly the antrochoanal polyp is a large, solitary,
the involved side, best seen on lateral projection; (3) gray-white, smooth polyp with a stalk of variable length.
bony erosion of contiguous structures-erosion of the Both the antrochoanal polyp and nasal polyps are
sphenoid bone above the sphenooccipital synchron- myxoid and both are lined by ciliated pseudostratified
drosis, the hard palate, one or both pterygoid processes, columnar epithelium, the characteristic mucosa of nasal
and the medial wall of the maxillary sinus may occur; passages and paranasal chambers.
and (4) displacement of the nasal septum. When neces- Reports indicate that the histology of antrochoanal
sary, carotid angiography and computed tomography polyp does not differ substantially from that of the nasal
can be performed to demonstrate the tumor. polyp. Heck et al. [5] stated that antrochoanal polyp was
Mucus retention cyst. This lesion is common within less likely to contain eosinophils and mucus glands. The
sinus cavities, particularly in the antra. It is a well latter may be a function of local differences in density of
 AJR:132, January 1979 ANTROCHOANAL POLYPS 31

mucus glands, but the disparity in content of eosinophils choanal polypus.J Laryngol Otol 80:175-177, 1966
suggests differing pathogenesis. Hyperplasia of surface 9. Chhangani DL, Agarwal KK, Popli SP: Expansion of antrum
epithelium is, in our series, more prominent in antro- and erosion of lateral nasal wall: antrochoanal polypus. J

choanal polyp. We concur that nasal polyps exhibit Laryngol Otol 81 : 1 049-1 051 1967
,

10. Capitano MA, Kirkpatrick JA: Upper respiratory tract ob-

greater density of submucosal glands, more mucus re-
struction in infants and children. Radio! Clin North Am
tention, and more eosinophils. However, the validity of
6:265-277, 1968
such distinction has not been established.
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1 1 . Dunbar JS: Upper respiratory tract obstruction in infants

It would seem that the best results occur when the and children. AJR 109 : 227-245, 1970
CaIdwell-Luc operation is used. If simple polypectomy 12. Wilson M: Chronic hypertrophic polypoid rhinosinusitis.
by snare and avulsion is performed, there is a recurrence Radiology 120:609-613, 1976
rate of about 20% [5, 7]. 13. Rulon JT, Brown HA,
Logan CB: Nasal polyps and cystic
fibrosis of the pancreas.
Arch Otolaryngol 78 : 94-i 01 , 1963
ACKNOWLEDGMENTS 14. Holman CB, Miller WE: Juvenile nasopharyngeal fibroma.
We thank Dr. Corning Benton for his thoughtful suggestions AJR 94:292-298, 1965
15. Samuel E: The radiology of the paranasal sinuses, in Text-
and N. Woolum for her fine secretarial work. book of X-Ray Diagnosis, Head and Neck (vol 1), 4th ed.,
edited Shanks SC, Kerley P. Philadelphia, Saunders, 1969,
REFERENCES
pp 61 3-614
1. Killian G: The origin of choanal polyps. Lancet 2:81-82, 16. Dubois PJ, Schultz JC, Perrin AL, Dastur KJ: Tomography
1906 in expansile lesions of the nasal and paranasal sinuses.
2. Palfyn J:Anatomie Chirurgicale. Paris, 1753 Radiology 125:149-158, 1977
3. Syme WS: Choanal polyps. J Laryngol Otol 31:515-518, 17. Dehner LP: Tumors of the mandible and maxilla in children.
1916 I. Clinicopathologic study of the 46 histologically benign
4. Myers D: Obstruction of the nasopharynx secondary to lesions. Cancer 31 :364-383, 1973
choanal polyp of antral origin. Arch Otolaryngo! 44:328- 18. Floyd JH: Tumours of the head and neck, in Tumours of
333, 1946 Infancy and Childhood, edited by Jones PG. Campbell PE,
5. Heck WE, Hallberg OE, Williams HL: Antrochoanal polyps. Philadelphia, Lippincott, 1976, pp 343-364
Arch Otolaryngol 52:538-548, 1950 19. Jaffe BF, Jaffe N: Head and neck tumors in children.
6. Sirola A: Choanal polyps. Acta Otolaryngol (Stockh) 61:42- Pediatrics 51:731-740, 1973
48, 1965 20. Donaldson SS, Castro JR. Wilbur JR. Jesse RH: Rhabdo-
7. Hardy G: Choanal polyps. Annals Otol 66:306-326, 1957 myosarcoma of the head and neck in children. Cancer
8. Hiranandani LH, Melgiri AD: Expansion of antrum by antro- 31:26-35, 1973