Is Antral Choanal Polyp Best Managed by an Endoscopic or Caldwell-Luc Approach?
The authors have no funding, financial relationships, or conflicts of interest to disclose.
BACKGROUND
The antrochoanal polyp (ACP), or Killian’s polyp, first described in 1906 by Dr. Gustav Killian, is an almost exclusively unilateral polyp originating from the mucosa of the maxillary sinus. Although benign, its natural progression is to expand through the maxillary ostium, true or accessory, into the nasal cavity and nasopharynx. This expansion causes the characteristic symptoms of ipsilateral nasal obstruction and rhinorrhea and accounts for the smooth polypoid lesion emerging from the middle meatus noted upon rhinoscopy. ACPs occur more commonly in the pediatric age group, representing approximately one-third of all pediatric nasal polyps, but can present at any age, accounting for 10% of adult nasal polyposis.
Although there is consensus that ACP requires surgical management, debate remains as to the safest and most definitive operative approach. The most common primary surgical techniques cited are the Caldwell-Luc (CWL) approach, the endoscopic sinus surgery (ESS) approach, or a combination of the two. The CWL approach offers wide exposure, facilitating complete removal of the ACP and underlying maxillary sinus mucosa, inclusive of the polyp’s base. Downsides include potential postoperative sequelae such as infraorbital paresthesia and detrimental impacts on developing dentition. Alternatively, the endoscopic approach offers decreased postoperative morbidity as well as the added benefit of potentially restoring sinus ventilation via treatment of the ostiomeatal complex. This approach, however, limits access to the anterior inferior maxillary antrum, thereby potentially compromising complete removal of the polyp’s origin, exposing the patient to increased risk of recurrence. A combination approach, incorporating either a mini-CWL or transcanine sinoscopy with an endoscopic procedure, has also been advocated as a means of maximizing the benefits of both techniques.
LITERATURE REVIEW
The current literature regarding the surgical management of ACPs is limited predominantly to single-center case studies and institution-specific experiences. The endoscopic approach to ACP involves the creation of a wide middle meatal antrostomy through which the resection of the maxillary component of the lesion is achieved with the help of angled telescopes, articulated instruments, and power instrumentation. In a series by Choudhury et al. in which 29 adult patients (mean age of 37.4 years, range 18–78 years) were treated by a primary endoscopic approach, no intraoperative or postoperative complications were reported, and no recurrences occurred over a mean follow-up period of 14.7 months (range 1–66 months).1 With respect to the pediatric population, El-Sharkawy et al. reported on 36 patients (mean age 13.2 years, range 9–17 years) who underwent primary endoscopic surgery for ACPs.2 Ten patients (27.8%) experienced postoperative complications, the most frequent being nasal adhesions between the inferior turbinate and nasal septum. Four patients (11.2%) experienced ACP recurrence within a 6 to 18 month follow-up period. These recurrences were managed with a combined endoscopic and transcanine approach in three patients, and with a second ESS procedure in the fourth patient. Pagella et al. also described 54 pediatric patients with ACP treated with ESS, in addition to four adolescents who underwent primary combined endoscopic and canine fossa surgery.3 Three of these four combined procedures were performed before 2004; the authors attribute a change in surgical approach thereafter. Mean age at surgery was 11.7 years. Postoperative complications included three cases of nasal synechiae (5.2%). ACP recurrence occurred in 12 patients (20.7%) within the ESS group, including one case of second recurrence. There were no recurrences in the combined approach group.
These results are corroborated by a 2017 systematic review inclusive of 13 articles addressing postsurgical ACP recurrence, totaling 285 subjects with a mean age of 11 years.4 ESS was the most commonly performed primary surgery (75.4%), with subsequent recurrence in 17.7% of cases. A primary CWL approach was performed in 8% of cases, with a recurrence rate of 9.1%. A combined endoscopic and mini-CWL approach was performed in 14% of patients, with no recurrences reported for this group. In the event of recurrence, the CWL procedure was the selected revision procedure for half of these patients; the combined ESS and CWL was performed in 27% of cases; and ESS alone was elected in 16% of patients.
Most recently, Mantilla et al. compared the use of ESS versus the combined ESS and CWL approach with respect to ACP recurrence.5 The authors included 27 pediatric patients with a mean age of 10.4 years at diagnosis. The rate of second recurrence after ESS alone was quite high (72.9%) compared to 12.5% after the combined approach. The authors report a tendency toward transition from EES alone to the combined approach when multiple recurrences occurred. As many as seven procedures were performed in one patient before disease control was achieved.
BEST PRACTICE SUMMARY
Data pertaining to the safest and most effective surgical management of ACPs is based predominantly on institutional practice reports. Review of these experiences supports the endoscopic sinus surgery approach as the more appropriate primary treatment of both pediatric and adult ACPs. The widespread familiarity of surgeons with the ESS technique, as well as the low complication rate and morbidity associated with the procedure, argue in favor of this approach for the initial resection of ACPs. Although the endoscopic approach is clearly associated with a higher rate of recurrence compared to the CWL approach,2, 4 especially in the pediatric population, this recommendation is justified by its lower complication profile. The use of the endoscopic approach is particularly relevant in children under 12 years of age in whom performing a CWL procedure is technically challenging, with potential long-term risks of dentition disruption and postoperative craniofacial deformity. A combined CWL and ESS approach may alternatively be considered for initial ACP treatment in age-appropriate patients in whom anatomical factors suggest limited access to the anterior inferior maxillary sinus antrum by ESS alone given the greater likelihood of incomplete disease removal and recurrence risk. This combined technique should also be strongly considered in cases of ACP recurrence because the greater exposure enhances the capability of obtaining a complete resection of the mucosal pedicle. Finally, the appropriate management of additional ACP recurrence after revision surgery remains to be determined. The risks associated with repeated surgeries in such cases need to be weighed relative to the severity of recurrence symptoms and the benign nature of the underlying pathology.
LEVEL OF EVIDENCE
All studies included in this review are level 4 evidence.
