Management of Antrochoanal (AC) Polyp
Endoscopic sinus surgery via the middle meatal approach with complete removal of both the antral (maxillary sinus) and nasal components is the definitive treatment for antrochoanal polyps, as this approach minimizes recurrence while preserving maxillary sinus function and avoiding complications associated with more invasive procedures.
Surgical Approach
The functional endoscopic sinus surgery (FESS) technique is the preferred method for AC polyp removal, as it allows complete extirpation of the maxillary component through the middle meatus while preserving healthy antral mucosa and sinus function 1, 2. This approach can be performed as an outpatient procedure with minimal morbidity 3.
Key Technical Considerations
Complete removal of the antral (maxillary) component is essential to prevent recurrence, as simple avulsion of only the nasal portion results in high recurrence rates 4, 1.
The polyp typically exits the maxillary sinus through an accessory ostium in 97% of cases, which must be identified and addressed during surgery 1.
Endoscopic removal through the middle meatus should be the first-line approach in the vast majority of cases, with excellent outcomes and no recurrence reported in series with 6-30 months follow-up 3.
When to Consider Combined Approach
The Caldwell-Luc procedure should be reserved only for cases where the maxillary component origin cannot be adequately visualized or removed endoscopically 1, 2.
Avoid routine Caldwell-Luc as primary treatment, as this approach is associated with damage to maxillary and dental growth centers, particularly problematic given that AC polyps commonly affect younger patients 4.
Preoperative Evaluation
Nasal endoscopy and computed tomography are the essential diagnostic modalities for surgical planning 4.
Important Clinical Features to Identify
Assess for predisposing inflammatory conditions: chronic sinusitis (present in 20.5% of cases) and allergic rhinitis (44% of cases) are the most common associated factors 1.
Evaluate for anatomic variants: septal deviation (50%), turbinate hypertrophy (32%), concha bullosa (18%), and mucous retention cysts (32%) frequently coexist and may require concurrent management 1.
Confirm unilateral presentation, as AC polyps are characteristically unilateral, distinguishing them from bilateral nasal polyposis 4.
Expected Outcomes and Complications
FESS for AC polyps has a favorable safety profile with minimal complications 2:
- Minor hemorrhage occurs in approximately 15% of cases 2
- Mild cheek swelling with pain in approximately 10% 2
- Infraorbital hypoesthesia is rare, occurring in less than 5% 2
Recurrence rates are low (approximately 6%) when complete removal of the maxillary component is achieved 1.
Common Pitfalls to Avoid
Do not perform simple polypectomy or avulsion of only the nasal portion, as this results in high recurrence rates due to retained antral component 4, 3.
Do not routinely use Caldwell-Luc as first-line treatment, particularly in younger patients where growth center damage is a concern 4.
Ensure complete removal of the antral component at the site of origin within the maxillary sinus, as incomplete removal is the primary cause of recurrence 1.
Do not confuse AC polyps with bilateral nasal polyposis, as they have different pathophysiology, demographics (younger patients), and treatment approaches 4.