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September 2020Background
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.
Best Practice
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 (Acta Otorhinolaryngol Ital. 2013;33:107–111; Int J Pediatr Otorhinolaryngol. 2018;106:26–30), 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.