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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2017  |  Volume : 35  |  Issue : 3  |  Page : 275-278
 

Antrochoanal polyp arising from benign pseudocyst of maxillary antrum


1 Consultant Oral and Maxillofacial Pathologist, i-dent Dental Clinic, Meerut, Uttar Pradesh, India
2 Fellow (Cleft and Craniofacial Surgery), Richardson Dental and Craniofacial Hospital, Nagercoil, Tamil Nadu, India
3 Senior Lecturer, Department of Oral and Maxillofacial Surgery, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India
4 Director (Dental Affairs), Al Safi Group of Hospitals, Al Sulayel, Riyadh Province, Saudi Arabia
5 Fellow (Maxillofacial Trauma), Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

Date of Web Publication31-Jul-2017

Correspondence Address:
Avi Bansal
Department of Oral and Maxillofacial Surgery, Subharti Dental College and Hospital, Meerut, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_153_16

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   Abstract 

Antrochoanal polyps (ACPs) are benign lesions that arise from the mucosa of the maxillary antrum, grow into the maxillary sinus, and reach the choana with nasal obstruction being their main symptom. Most of these lesions are small and clinically silent and found as incidental finding, but large cysts which occupy the entire antrum have also been reported in literature. Nasal endoscopy and computer tomography (CT) are the golden standard in the diagnosis of ACPs, and enucleation by Caldwell–Luc approach is the recommended treatment for larger antral cysts. This article is a report of a 9-year-old male patient diagnosed with ACP arising from a benign cyst of maxillary antrum with characteristic clinical, CT, and histopathological features along with brief review of literature.


Keywords: Antrochoanal polyp, Caldwell–Luc antrostomy, pseudocyst of maxillary antrum


How to cite this article:
Keshri N, Bansal A, Popli G, Venkatesh A, Goel S. Antrochoanal polyp arising from benign pseudocyst of maxillary antrum. J Indian Soc Pedod Prev Dent 2017;35:275-8

How to cite this URL:
Keshri N, Bansal A, Popli G, Venkatesh A, Goel S. Antrochoanal polyp arising from benign pseudocyst of maxillary antrum. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2019 Nov 14];35:275-8. Available from: http://www.jisppd.com/text.asp?2017/35/3/275/211841



   Introduction Top


Pseudocyst of maxillary antrum is inflammatory in origin caused by the accumulation of exudates that raise the mucosa from the bone of the antral floor. Although most often it occurs secondary to odontogenic infection, cysts of intrinsic origin have also been documented.[1],[2] Most of these lesions are small and clinically silent and found as incidental finding,[3] but large cysts which occupy the entire antrum along with associated antrochoanal polyps (ACPs) have also been reported in literature. As per the results of the “Health 2000 – Health Examination Survey,” the prevalence rate of mucosal antral cysts was 7% and most common in 40–49 years age group.[4] ACPs are benign lesions that arise from the mucosa of the maxillary antrum, grow into the maxillary sinus, and reach the choana with nasal obstruction being their main symptom.[5] Here, we present a case report of a 9-year-old male diagnosed with a large benign pseudocyst of the maxillary antrum with an associated ACP.


   Case Report Top


A 9-year-old North Indian male reported to our dental office with the complaint of headache and heaviness of the right side of the face along with fullness and numbness of the cheek of the same side for the past 20 days. The patient had accompanying nasal obstruction, dyspnea, fever, and fatigue. Medical and dental history of the patient was insignificant. On examination, a deviation of the nasal septum and tenderness over the right cheek region was seen. A white, translucent, jelly-like growth was appreciable in the right nostril with no visible discharge from the growth [Figure 1]. Intraorally, no carious teeth, pulpal/periapical pathology, or missing teeth were evident; although, right maxillary molars were slightly tender on percussion. No abnormalities were detected in the labial, buccal, palatal, and alveolar mucosa. The computer tomography (CT) scan revealed a mass filling the right maxillary sinus growing through the ostium into the middle meatus and the posterior choana. Coronal CT revealed a hypoattenuating mass occupying the right maxillary sinus and extending through the middle meatus into the nasal cavity [Figure 2]. Based on the clinical and CT features, a provisional diagnosis of cyst of maxillary antrum with ACP was made. The differential diagnosis included inverted papilloma, angiofibroma, olfactory neuroblastoma, and hemangioma. A Caldwell–Luc antrostomy was performed under general anesthesia. Part preparation was done and an intraoral incision was made for the Caldwell–Luc antrostomy. A vestibular incision was given and a bony window measuring 5–6 mm was created. The cystic lining was elevated using a periosteal elevator, detached from all the bony surfaces. The polyp along with the cystic lining was enucleated in toto after freeing from the maxillary sinus and delivered from the nasal side. The excised specimen was sent for histopathological examination. Macroscopically, the specimen was composed of a cystic part (filling the maxillary sinus) and a solid part coming out through the maxillary ostium measuring approximately 15 cm × 1 cm × 0.5 cm in dimensions and soft in consistency [Figure 3]. Microscopically, both the cystic lining and polyp revealed pseudostratified ciliated columnar epithelium (representing respiratory epithelium) and an underlying inflamed, loose/edematous stroma. A moderate amount of inflammatory cell infiltrate primarily composed of eosinophils was evident [Figure 4]. Based on the histopathological findings along with clinical correlation, a final diagnosis of ACP arising from benign pseudocyst of maxillary antrum was made. The patient had an unincidental hospital stay and was discharged after he was fully recovered.
Figure 1: Clinical photograph showing a white, translucent, jelly-like growth in the right nostril with no visible discharge

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Figure 2: Coronal computer tomography scan showing a hypoattenuating mass occupying the right maxillary sinus and extending through the middle meatus into the nasal cavity

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Figure 3: Macroscopic view of the antrochoanal polyp composed of a cystic part (filling the maxillary sinus) and a solid part coming out through the maxillary ostium

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Figure 4: Pseudostratified ciliated columnar epithelium with an underlying edematous stroma showing inflammatory infiltrate composed of lymphocytes and eosinophils (PAS, ×200)

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   Discussion Top


The mucosal cysts of the maxillary sinus have historically been known by a plethora of names. These include mucous retention cyst, pseudocyst, mesothelial cyst, interstitial cyst, secretory/nonsecreting cyst, lymphangiectatic cyst, false cyst, benign cyst of the antrum, mucosal cyst of the maxillary sinus, mucocele of maxillary sinus, mucous retention phenomenon, and mucosal antral cyst.[6]

The distinctive features and criteria for diagnosis of various reported cysts associated with maxillary antrum were reviewed by Meer and Altini in 2006, and based on their findings, a simple classification was proposed to classify the cysts of maxillary antrum into four entities, namely, mucocele, retention cyst, pseudocyst, and postoperative maxillary cyst.[7]

Antral pseudocysts are inflammatory in origin caused by accumulation of exudates that raise the mucosa from the bone of the antral floor.[1] Some large antral cysts extrude through the nasal ostium to form an ACP.[8]

ACPs represent 4%–6% of all nasal polyps.[9] In a study conducted by Frosini et al., on 200 ACPs, the age range of occurrence of ACP was observed as 5–81 years with a mean of 40 years. Only 4% of the cases reported were of <10 years [10] as that of the present case. In a survey conducted by Hadar et al., in sixty patients, the age range observed was 12–73 years (mean: 43 years) and only 5% (3/60) of the cases demonstrated polyps in the middle meatus.[3]

Schramm and Effron proposed that nasal polyps in pediatric population occur as inflammatory response to bacterial infection.[11] The extrusion of cyst of maxillary antrum through the nasal ostium into the nose was first observed by Killian in 1906 and he suggested the terminology “ACP.”[12] Based on their observations in 200 ACPs, Frosini et al. in 2009 proposed a hypothesis for antral cyst causing herniation through the accessory maxillary ostium into the nose. It is proposed that the ACP develops from an increase in pressure in the maxillary antrum due to a phlogistic-anatomical alteration at ostiomeatal complex/middle meatus level, in patients with a pre-existing silent antral cyst, subsequently forced to herniation outside, through the accessory ostium.[10]

Nasal endoscopy and CT represent the golden standard in the diagnosis of ACP.[10]

Surgery is the only feasible treatment.[10] Intranasal polypectomy is the primary mode of treatment of patients with unilateral nasal polyps.[11] Large cysts with associated nasal polyps as that of the present case are best removed through a Caldwell–Luc approach,[8] since it offers good exposure and ensures complete removal of the polyp and the associated antral mucosa.[11]

Functional endoscopic sinus surgery combined endoscopic middle meatal surgery and transcanine sinusoscopy,[13] powered instrumentation of the polyp by trocar inserted through the canine fossa,[14] and combined endoscopic and transcanine approach [15] are the other proposed methods of treatment for ACPs.

Recurrence of ACP is rare. A recurrence rate of 2% is reported in patients <7 years treated only with polypectomy.[10] In another clinical trial, recurrence was noticed in 1 of 22 patients who underwent Caldwell–Luc procedure, whereas 11 of 17 patients treated with polypectomy alone required further surgery due to recurrence of the pathology.[11]


   Conclusion Top


Pseudocysts of the maxillary antrum are not destructive and usually remain static. Although smaller cysts appear to regress spontaneously, treatment by surgical intervention is indicated only if specific/pertinent clinical features are seen as in the present case. Although limited treatment to lesions which occupy 50% of the sinus through endoscopic approach is a well-accepted treatment protocol,[3] larger lesions with ACPs are best treated through a Caldwell–Luc procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Shear M, Speight P. Cysts of the Oral and Maxillofacial Regions. 4th ed. Oxford: Blackwell Munksgaard; 2007. p. 164.  Back to cited text no. 1
    
2.
Pierse JE, Stern A. Benign cysts and tumors of the paranasal sinuses. Oral Maxillofac Surg Clin North Am 2012;24:249-64, ix.  Back to cited text no. 2
[PUBMED]    
3.
Hadar T, Shvero J, Nageris BI, Yaniv E. Mucus retention cyst of the maxillary sinus: The endoscopic approach. Br J Oral Maxillofac Surg 2000;38:227-9.  Back to cited text no. 3
[PUBMED]    
4.
Vallo J, Suominen-Taipale L, Huumonen S, Soikkonen K, Norblad A. Prevalence of mucosal abnormalities of the maxillary sinus and their relationship to dental disease in panoramic radiography: Results from the Health 2000 Health Examination Survey. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e80-7.  Back to cited text no. 4
[PUBMED]    
5.
Maldonado M, Martínez A, Alobid I, Mullol J. The antrochoanal polyp. Rhinology 2004;42:178-82.  Back to cited text no. 5
    
6.
MacDonald A, Newton CW. Pseudocyst of the maxillary sinus. J Endod 1993;19:618-21.  Back to cited text no. 6
[PUBMED]    
7.
Meer S, Altini M. Cysts and pseudocysts of the maxillary antrum revisited. SADJ 2006;61:10-3.  Back to cited text no. 7
[PUBMED]    
8.
Seward G, Kay L, Killey H, Harris M, McGowan D. An Outline of Oral Surgery. 2nd Revision. London: Oxford-Wright; 1992. p. 142-3.  Back to cited text no. 8
    
9.
Sirola R. Choanal polyps. Acta Otolaryngol 1966;61:42-8.  Back to cited text no. 9
[PUBMED]    
10.
Frosini P, Picarella G, De Campora E. Antrochoanal polyp: Analysis of 200 cases. Acta Otorhinolaryngol Ital 2009;29:21-6.  Back to cited text no. 10
[PUBMED]    
11.
Schramm VL Jr., Effron MZ. Nasal polyps in children. Laryngoscope 1980;90:1488-95.  Back to cited text no. 11
    
12.
Killian G. The origin of choanal polypi. Lancet 1906; 2: 81-2.  Back to cited text no. 12
    
13.
el-Guindy A, Mansour MH. The role of transcanine surgery in antrochoanal polyps. J Laryngol Otol 1994;108:1055-7.  Back to cited text no. 13
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14.
Hong SK, Min YG, Kim CN, Byun SW. Endoscopic removal of the antral portion of antrochoanal polyp by powered instrumentation. Laryngoscope 2001;111:1774-8.  Back to cited text no. 14
[PUBMED]    
15.
Lee TJ, Huang SF. Endoscopic sinus surgery for antrochoanal polyps in children. Otolaryngol Head Neck Surg 2006;135:688-92.  Back to cited text no. 15
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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