Clinical Case Discussion: Antrochoanal Polyp

👃🏻 Clinical Case Discussion : Antrochoanal Polyp (AC Polyp)

Today, we'll be doing a clinical case discussion on Antrochoanal Polyp (AC Polyp), a common case often encountered in examinations.

This case discussion format will be helpful for both undergraduates and postgraduates.

We'll go through the patient's history, discuss how history guides us to a provisional diagnosis, cover the clinical examination findings and their significance, summarize the case, arrive at a provisional diagnosis, and outline the management plan.

Let's begin!

📋 Patient History

Here's the history of our patient:

• Patient Name: Aparna
• Age: 35 years
• Sex: Female
• Location: Hyderabad
• Religion: Hindu
• Occupation: Homemaker

History of Present Illness (HPI):

Patient was apparently asymptomatic 6 months back when she started complaining of:

1. Nasal Obstruction on the Right Side:

   • Onset: Insidious
   • Duration: 6 months
   • Progress: Gradually progressive to present state.
   • Increases during expiration and while lying down.
   • No diurnal variation.
   • Aggravated by cold weather.
   • NOT relieved on using nasal drops.

2. Nasal Discharge from the Right Side:

   • Onset: Insidious
   • Duration: 4 months
   • Character: Mucoid type.
   • Smell: Non-foul smelling.
   • Blood: Non-blood stained.
   • Associated with snoring for the last 2 months.

Negative History (Rule-outs):

(Though not a formal heading, these points are crucial to ask and document within the History of present illness)

• No history of recurrent episodes of runny or itchy nose, watering of eyes, sneezing
• No history of bleeding from the nose
• No history of double vision
• No history of chronic irritation in throat, throat clearing
• No history of headache
• No reduced or altered sense of smell
• No history of trauma
• No history of loosening of teeth
• No history of significant weight loss, change in voice
• No history of ear complaints

Past History:

• No history of similar complaints in the past.
• No history of Diabetes Mellitus, Hypertension, Bronchial Asthma, or TB.
• No history of surgeries in the past.
• No history of known drug allergies.

Family History:

• No significant family history.

Treatment History:

• History of usage of nasal decongestant drops (with no relief).

Personal History:

• Sleep - Reduced
• Appetite - Normal
• Diet - Non-vegetarian
• Bladder/Bowel - Normal
• No addiction history

🗣️ Discussion of History Points

Let's analyze the significance of the historical findings.

1. Nasal Obstruction (Unilateral, Right-sided):

• Unilateral Nasal Obstruction: Possible causes include AC Polyp (especially in adults/older children), Foreign Body (children)

What are all the causes of Unilateral Nasal Obstruction?

• Gradually Progressive: Suggests a benign process (polyp, benign tumor) rather than a rapidly progressive malignant mass.

• Increases During Expiration and While Lying Down: This is a very characteristic feature of a mobile nasal mass (like a polyp).

Why does nasal obstruction caused by a mobile nasal mass increase during expiration?

Why does nasal obstruction caused by a mobile nasal mass increase while lying down?

• No Diurnal Variation: Indicates a non-fixed, dynamic cause (polyp) rather than a structural lesion (DNS).

Name some diseases where you see no diurnal variation in nasal obstruction.

• NOT Relieved on Using Nasal Drops: Decongestant drops cause vasoconstriction and shrink vascular/mucosal tissues (like hypertrophied turbinates or allergic mucosa).

Lack of relief strongly suggests a mass that does NOT shrink on vasoconstriction (like a polyp or tumor), ruling out primary allergic rhinitis or simple turbinate hypertrophy as the sole cause of obstruction.

• Aggravated by Cold Weather: Could be related to mucosal swelling in cold, dry air, but less specific than other features.

2. Nasal Discharge (Right-sided, Mucoid):

Why is taking the history of nasal discharge important here?

• Mucoid Discharge: Suggests inflammation and mucus production.

What are the causes of Mucoid discharge from the nose?

What are the different types of nasal discharge? Name a few causes of each.

• Non-foul Smelling: Points away from infection with specific bacteria, extensive osteomyelitis, neglected foreign body, atrophic rhinitis, fungal sinusitis, myiasis.

• Non-blood Stained: Points away from highly vascular lesions or those with significant ulceration/friability (JNA, neglected FB, Rhinolith, Rhinosporidiosis, Malignancy, Trauma, Granulomatous diseases).

3. Associated Symptoms:

• Snoring: Indicates significant airway obstruction, consistent with a large nasal mass blocking the airway, especially posteriorly (choana/nasopharynx).

• Negative History: These rule out important differential diagnoses or complications:

  • No allergic history (runny/itchy nose, sneezing, watering eyes): Rules out typical Allergic Rhinitis as primary cause.

  • No bleeding: Rules out vascular tumors (JNA, Hemangioma), friable tumors (Inverted Papilloma, Malignancy, Rhinosporidiosis), Rhinoliths, trauma.

  • No trauma: rules out underlying nasal fracture

  • No double vision/loosening of teeth: Rules out orbital or maxillary sinus invasion (malignancy).

  • No weight loss/change in voice: Rules out malignancy (often associated with systemic symptoms or laryngeal involvement).

  • No headache/throat clearing: Less typical for significant bacterial sinusitis (though can occur).

  • No ear complaints: Suggests the mass is not significantly obstructing the Eustachian tube orifice in the nasopharynx yet, or the obstruction is intermittent enough not to cause OME.

What do the following terms mean - Anosmia, Parosmia, Cacosmia, Hyposmia Hyperosmia?

What is Rhinolalia Clausa? Name some causes.

What is Rhinolalia Aperta? Name some causes.

Past History Significance:

• No History of Similar Complaints: While AC polyps can recur, a lack of previous episodes can simply mean this is the first presentation.

• Diabetes Mellitus & Hypertension:

  • Important for preoperative evaluation.
  • Epistaxis in Hypertensive patient.
  • Fungal infections of nose are common in Diabetic patients.

• Bronchial Asthma:

  • Associated nasal allergy

• TB:

  • Evening rise of temperature, loss of weight and appetite seen in cases of TB Nose

Treatment History Significance:

• Usage of nasal decongestants with no relief reinforces that the obstruction is due to a non-shrinking mass, not just mucosal swelling.

Personal History Significance:

• Sleep Reduced: Nasal obstruction due to the nasal mass is causing an obstruction in breathing and snoring leading to disturbed sleep at night.

• No addiction: Lessens suspicion for malignancies strongly linked to tobacco/alcohol.

Note: Malignancies can occur without these risk factors.

✨ Clinical Examination Findings

General & External Nose:

• Facial symmetry, skin, osteocartilaginous framework, ala, columella, vestibule: All normal.

What are the different External nasal deformities? Name conditions for each.

What is Saddle Nose deformity? List the causes.

What are the conditions in which you see Frog Nose deformity?

Anterior Rhinoscopy (Right Side):

• Septum midline. Floor normal. Inferior turbinate not visualized (hidden by the mass).

• Solitary, pale, glistening, polypoidal mass filling the nasal cavity - This appearance is classic for a nasal polyp. "Solitary" points towards AC polyp over Ethmoidal (usually multiple).

• Characteristics on Probe Test:

  • Smooth surface.

  • Mobile (Differentiates from fixed lesions like tumors or hypertrophied turbinates).

  • Insensitive to touch (Suggests lack of nerve endings, typical of polyps; differentiates from sensitive malignant tumors or hypertrophied turbinates).

  • Does NOT bleed on touch (Suggests relatively avascular, typical of simple polyps; differentiates from vascular/friable lesions like JNA, Hemangioma, Inverted Papilloma, Rhinosporidiosis, Malignancy).

  • Soft in consistency (Typical of polyps; differentiates from firmer tumors or bony lesions like Rhinolith).

  • Can be probed all around (Indicates the mass is not fixed anteriorly; helps determine origin if probe stops elsewhere).

• Nasal mucosa congested (suggests inflammation/infection).

• Left side: Normal (rules out bilateral disease process).

What instrument is used to do probe test?

What are the features you test while performing the probe test?

Posterior Rhinoscopy:

• Pale, glistening, polypoidal mass seen in the right choana.
• Eustachian tube opening visualized on the right side (not obstructed).
• Left side: Normal.

What is Posterior Rhinoscopy? How is it performed?

What is the size of Posterior Rhinoscopy mirror?

What are the methods of preventing fogging of Posterior Rhinoscopy mirror on introducing it into oral cavity?

What structures are seen on Posterior Rhinoscopy?

What is the difference between Posterior Rhinoscopy and Indirect Laryngoscopy technique?

What are the differences between Posterior Rhinoscopy and Indirect Laryngoscopy mirrors?

Functional Tests:

Right side:

• Cottle's test (assesses nasal valve) - no improvement

• Cold Spatula test (airflow visualization by condensation) - decreased misting

• Cotton Wool test (airflow visualization by movement) - reduced movement

• Smell absent (anosmia)

All confirm significant right unilateral nasal obstruction and reduced airflow to the olfactory area.

Other Examinations:

• Paranasal Sinuses: Non-tender (Rules out typical tenderness associated with acute sinusitis)

What are the sites for checking sinus tenderness for all paranasal sinuses?

What are the boundaries of Canine fossa?

What is the clinical significance of Canine fossa?

What is Maxillary sinus also known as?

• Eye, Oral Cavity, Oropharynx, Indirect Laryngoscopy, Ear, Neck: All normal. (Rules out local extension of mass to these areas, neck nodes suggestive of malignancy, ear complications from ET obstruction).

  • Importance of Oropharyngeal exam: To see if the polyp hangs down below the soft palate.

  • Importance of Ear exam: To check for Serous Otitis Media/CHL due to ET obstruction by a mass in the nasopharynx.

  • Importance of Neck exam: To check for cervical lymphadenopathy (key in suspected malignancy).

📝 Case Summary

A 35-year-old female presents with 6 months of unilateral right nasal obstruction - insidious in onset, gradually progressive, increases on expiration/lying down, no diurnal variation, not relieved by drops, aggravated by cold. She is also complaining of 4 months of nasal discharge from right side which is mucoid, non-foul smelling, non-blood stained, associated with snoring. On Examination, we see a solitary pale, glistening polypoidal mass seen filling the right nasal cavity which has a smooth surface, mobile, insensitive to touch, doesn't bleed on touch, soft in consistency, can be probed all around. Nasal mucosa on the right side is congested. Posterior Rhinoscopy reveals a pale glistening polypoidal mass seen in the right choana, Eustachian tube opening visualised on right side. Cotton wool test shows reduced movement on right side. Cold spatula test show reduced misting. Smell is absent on right side.

🩺 Provisional Diagnosis

Right-sided Sinonasal Mass, likely Antrochoanal Polyp.

What are the points in favour of your diagnosis?

What is the definition of a Nasal Polyp?

What are the different parts of Antrochoanal Polyp?

Why does an Antrochoanal Polyp grow backwards (towards the choana) rather than forwards?

When can Antrochoanal Polyp bleed?

🤔 Differential Diagnosis

• Ethmoidal Polyp
• Inverted Papilloma
• Rhinosporidiosis
• Malignancy (Sinonasal Carcinoma)
• Allergic Fungal Sinusitis (AFS)
• Meningoencephalocele
• Hypertrophied Inferior Turbinate
• Rhinolith
• Foreign Body

What are the clinical features seen in the above mentioned conditions? How would you rule out each in this case?

What is Allergic mucin? Where do you see it?

What are the differences between Meningoencephalocele and Antrochoanal Polyp?

🏥 Management Plan

Management ALWAYS involves two key aspects: Investigations and Treatment.

🔬 Investigations

To confirm the diagnosis and plan treatment:

1. Routine Blood Investigations: For preoperative evaluation (e.g., CBC, blood sugar, renal/liver function).

2. Diagnostic Nasal Endoscopy:

   • To see origin and extent of polyp
   • Any additional pathology
   • Discharge can be sent for C/S, Fungal hyphae can be sent for KOH mount

3. CT Scan of Nose & Paranasal Sinuses (Coronal, Sagittal, Axial views):

   • To see origin and extent of polyp
   • Assess invasion of surrounding structures
   • Any anatomical deformities

What X-Ray is usually done for Antrochoanal Polyp?

How does Antrochoanal Polyp look like on X-Ray?

🏥 Treatment Plan

For Antrochoanal Polyps, the primary treatment is surgical removal.

• Surgical Treatment: Functional Endoscopic Sinus Surgery (FESS).

Why can't you suggest medical treatment in Antrochoanal Polyp?

Define FESS.

What are the Indications of FESS?

What are the Steps of FESS for Antrochoanal Polyp?

What are the complications of FESS?

What is the most dreaded injury in FESS?

What is the most common extraocular muscle injured in FESS?

What are the instruments used for Uncinectomy?

What was the treatment modality for Antrochoanal polyp before FESS?

What are the Indications of the Caldwell Luc operation?

This concludes our clinical case discussion on Antrochoanal Polyp. We've walked through the history, examination, provisional diagnosis, and management principles.