Antrochoanal polyp: a transmission electron and light microscopic study

Pheno-Endotyping Antrochoanal Nasal Polyposis

PURPOSE OF REVIEW

Antrochoanal polyps (ACPs) are benign polypoid lesions arising from the inner wall of the maxillary sinus and extending into the choana. Although the diagnosis and treatment strategies of ACP have changed since this entity was first described, the underlying pathogenic mechanism of APC is poorly understood. This article reviews the current knowledge of the etiology, inflammatory parameters, and microscopic findings of ACP.

RECENT FINDINGS

The inflammatory pattern of ACP appears to center around a neutrophilic inflammation T1-dominant endotype. Apart from the inflammatory component of ACP, at the microscopic level, the presence of tissue remodeling, mostly fibrin deposition and edema, and cysts in the epithelium and lamina propria has been described. Although the origin of this T1-dominant endotype immune response of ACPs is not entirely clear, it could be related to a lymphatic obstruction mechanism. This review serves to define a phenotype of ACP with potential endotypes based on the characteristics of the inflammatory parameters, microscopic findings, and hypotheses about the pathogenesis of ACP.

Inflammatory Profile of Antrochoanal Polyps in the Caucasian Population - A Histologic Study

BACKGROUND

Antrochoanal polyp (ACP) is a rare and unique unilateral nasal polyp. In contrast to diffuse primary chronic rhinosinusitis (d-CRS) the inflammatory profile of ACP in the Caucasian population have not been determined.

OBJECTIVE

The purpose of the study is to describe and differentiate the inflammatory features of ACP compared with d-CRS and its phenotypic subgroups and hypertrophic turbinates (HT) in the Caucasian population, and compare the mast and plasma cell marker expression of each pathology.

METHODS

A retrospective case control study of 96 patients operated on between the years 2005-2017. Nasal biopsies of ACPs, d-CRS and HTs were compared. A comparison of the different phenotypic subgroups of d-CRS was made as well. Demographics, comorbidities, and histologic and immunohistochemical (IHC) staining of mast (CD117) and plasma cell (CD138) receptor antibodies, were compared and analyzed.

RESULTS

A total of 96 patients were included, consisting of 40 (41.6%) ACP, 36 (37.5%) d-CRS and 20 (20.8%) HT patients. ACPs displayed a significantly higher level of edema and intramural cysts compared to the other groups. Squamous metaplasia was demonstrated in ACP (27.5%) and d-CRS (25.6%), but not in HT. The ACP group was characterized by neutrophilic predominant infiltrates as opposed to the eosinophilic predominance in the d-CRS group, especially in eosinophilic CRS and central compartment allergic disease. ACP presented lower levels of both mast and plasma cells compared to d-CRS and HT in IHC staining.

CONCLUSIONS

ACP in the Caucasian population has unique features of cyst formation and edema which is compatible with its clinical presentation. It is characterized by neutrophilic predominant infiltrates and expresses lower levels of mast and plasma cells as demonstrated by IHC.

Detection of nasal microbiota in pediatric patients with antrochoanal polyps by TLDA

OBJECTIVE

To evaluate and compare the microbiological features in ACPs groups and control subjects in pediatric group, further to explore the potential role of microbial in the etiology of ACPs.

METHODS

A total of 32 patients with ACPs, and 10 control subjects were enrolled in this study. Demographic datas were collected. The TaqMan low-density array assays were used to detect the microbial of swab specimens and nasal tissue samples from ACPs patients.

RESULTS

A total of 15 species were identified in all groups. Of all the species, Mycoplasma pneumoniae was the most common species in ACP patients, but was negative in control group. Of all the viruses detected, Adenovirus positivity was significantly higher in control group than that in ACPs middle meatus on unaffected side, ACPs middle meatus on affected side, and ACPs polypous surface group (P < 0.05). Cytomegalovirus positivity was significantly higher in control group than that in ACP polypous group (P < 0.05). Human herpesvirus 6 (HHV-6) was absent in control goup, and positive in ACP middle meatus on affected side was significantly higher than that in ACP polypous surface and ACP polyp group (P < 0.05). The expression of other microbial differed not significantly in unaffected side, affected side of ACPs, ACPs polypous surface, and ACPs polyp.

CONCLUSIONS

Mycoplasma pneumoniae was the most common species in ACP patients. Streptococcus pneumonia and Moraxella catarrhalis were the only bacteria detected at certain frequency in nasal polyps and control subjects. Human herpesvirus 6 andMycoplasma pneumoniae may have potential role in the development of ACPs. The isolates rate of microbial differed in middle meatus on unaffected and affected side of ACPs, ACPs polypous surface, ACPs polyp, and their role in the etiology of ACPs need to be further studied.

Is There any Possible Role of Neurotrophin 3 in the Pathogenesis of Antrochoanal Polyp?

Objective:

Antrochoanal polyp (ACP) is a benign soft tissue lesion arising from the inner wall of the maxillary sinus that extends into the nasal cavity and choana. Although it was first explained by Killian in 1906, the underlying pathogenesis has not been yet fully understood. Neurotrophins have been demonstrated to have a possible role in the pathogenesis of allergic rhinitis, idiopathic rhinitis and nasal polyps. To date any study has not investigated the function of neuronal inflammation and neurotrophins in the development of ACP. The objective of this study was to investigate the possible effect of neurotrophin-3 (NT-3) in ACP pathogenesis.

Method:

Twenty adult patients with ACP who underwent endoscopic sinus surgery in our department were included in the study group. The control group included 15 patients with concha bullosa of middle concha who underwent lateral excisional surgery. Nasal tissue NT-3 staining scores were evaluated using immunohistochemical methods. Blood NT-3 levels of both groups were evaluated by enzyme-linked immunosorbent assay (ELISA).

Results:

There were no statistically significant differences between these two groups regarding tissue NT-3 staining scores (p=0.843) and blood NT-3 levels (p=0.463). In addition, no statistically significant correlation has been observed between tissue NT-3 staining scores and blood NT-3 levels in both ACP (p=0.578) and control (p=0.359) group patients.

Conclusion:

NT-3-related neuronal inflammation does not seem to have any role in ACP pathogenesis.

Overexpression of Inducible Nitric Oxide Synthase in Allergic and Nonallergic Nasal Polyp

Sinonasal polyps are very common benign lesions of the nasal mucosa. Most of nasal polyps (NP) are idiopathic, and the pathophysiology of this disease is still incompletely understood. Nitric oxide (NO) is a reactive molecule generated by nitric oxide synthase (NOS). NO has been identified as an important mediator in airway function and pathogenesis of several respiratory system diseases. Histological and genetical expression of iNOS was detected to evaluate the role of NO in the pathogenesis of allergic (ANP) and nonallergic nasal polyps (NANP). Forty patients with nasal polyps (20 allergic and 20 nonallergic) were identified by history, clinical examination, and investigation. NPs were obtained from the middle turbinate (MT) during concha bullosa surgery. Twenty normal MT nasal tissues were taken as the control from patients undergoing concha bullosa surgery, without any evidence of allergy or inflammation. A nasal polyp specimen from each patient was subjected for immune-histochemical study followed by histological examination to detect the expression of iNOS. RT-PCR was used to evaluate the iNOS gene expression in isolated tissues. The expression of iNOS in both epithelial and stromal layers was greater in NP than in MT tissues. The ANP group showed more iNOS expression than those of the NANP group. The relative mRNA levels of iNOS gene were significantly higher in ANP (2.5-fold) compared to the normal (1.02-fold, P < 0.001) and NANP (1.5-fold, P < 0.01) groups. NP exhibited a significantly high expression of iNOS at both histological and genetical levels. NO might be an essential factor in the life history of NP. Further studies in a larger sample size are required to explain the probable mechanisms of NO in pathogenesis of NP.

Investigation of Oxidative Stress in Antrochoanal Polyp Etiology

Antrochoanal polyps (ACPs) are benign lesions of the paranasal sinuses. Similarities between ACPs and nasal polyps have been previously investigated. However, oxidative stress has been implicated but not investigated in terms of the etiology of ACPs. Thus, the aim of this study was to investigate oxidative stress in the etiology of ACPs. The study population comprised 93 patients divided into 3 groups. Group 1 consisted of 30 patients with ACPs. Group 2 consisted of 33 patients with nasal septal deviation. Group 3 comprised 30 healthy individuals. Venous blood was taken from all participants, and total thiol, native thiol, disulfide, and ischemic modified albumin (IMA) levels were evaluated. When the values of native thiol (P = .097), disulfide (P = .221), total thiol (P = .140), and IMA (P = .091) were compared, no significant differences were found among the 3 groups. While many studies have been conducted related to nasal pathologies and the role of oxidative stress in their etiologies, our study concluded that oxidative stress plays no role in ACP etiology.

Is there any effect of neurotrophin-3 on the pathogenesis of non-allergic nasal polyps?

BACKGROUND

Although the role of neurotrophins such as nerve growth factor and brain-derived neurotrophic factor in nasal polyps development has been studied, the contribution of neurotrophin-3 has not been evaluated yet. This study aimed to investigate the possible role of neurotrophin-3 in nasal polyps pathogenesis.

METHODS

The study group comprised 70 non-allergic nasal polyps patients and the control group consisted of 53 patients with middle turbinate concha bullosa. Specimens were taken, during surgery, from the ethmoid sinus nasal polyps in the nasal polyps group and from the lateral part of the middle turbinate concha bullosa in the control group. Tissue and serum levels of neurotrophin-3 were assessed by immunohistochemistry and enzyme-linked immunosorbent assay, respectively.

RESULTS

Nasal polyps patients had higher tissue neurotrophin-3 scores (p < 0.001). There was no statistically significant difference between groups regarding serum neurotrophin-3 levels (p = 0.417). Tissue neurotrophin-3 staining scores in the nasal polyps group had no statistically significant correlation with Lund-Mackay scores (p = 0.792).

CONCLUSION

Neurotrophin-3 may have a local effect in nasal polyps pathogenesis, without joining systemic circulation.

Antrochoanal polyp concomitant with turbinoethmoidal osteoma: A case report

INTRODUCTION

Antrochoanal polyps (ACPs) have several unique features that distinguish them from other nasal polyps. Despite many investigations, the pathogenesis of ACP has not yet been elucidated. Sinonasal osteoma is the most common type of tumor of the sinonasal tract and can be caused by trauma, infection and developmental anomaly.

PRESENTATION OF CASE

We report the case of a 35-year-old man with left nasal obstruction for more than 20 years. Examination revealed ACP concomitant with an osteoma that arose from the middle turbinate and ethmoid sinus. The osteoma had an air cell in its anterosuperior area and was in a position of being pulled downward. The intranasal part of the ACP covered the posterior area of the osteoma.

DISCUSSION

Considering the radiological and surgical findings, the intranasal part of the ACP seems to have affected the turbinoethmoidal osteoma during its growth.

CONCLUSION

The authors describe a very rare condition in which an ACP was connected with a turbinoethmoidal osteoma.

WDPCP regulates the ciliogenesis of human sinonasal epithelial cells in chronic rhinosinusitis

Damage to the mucociliary clearance system is a typical change in the pathogenesis in chronic rhinosinusitis. However, the mechanisms underlying cilia loss remain unclear. WDPCP is a key protein essential for ciliogenesis, and is also an effector of the planar cell polarity signaling system. In this study, we sought to determine the role of WDPCP in cilia loss in patients with chronic rhinosinusitis. We demonstrated the expression of WDPCP in human sinonasal epithelium from patients with chronic rhinosinusitis and control subjects. We also used air-liquid interface to culture primary human sinonasal epithelial cells in-vitro model and to investigate WDPCP function. We then explored links between rhinosinusitis, WDPCP and inflammation. Accompanied with cilia loss, expression of WDPCP in human sinonasal epithelium from patients with chronic rhinosinusitis was decreased significantly compared with control subjects. In vitro study, we found that WDPCP level increased at first, and then decreased. Inhibiting WDPCP expression could lead to the poor quantity and length of cilia with reduced expression of Septin7. Also, Th1 type inflammatory mediators could decrease the expression of WDPCP. In conclusion, inflammatory cytokines cause reduced WDPCP expression, which contributes to impaired ciliogenesis in human rhinosinusitis.

Transnasal Prelacrimal Recess Approach for Recurrent Antrachoanal Polyp

PURPOSE

To assess the effectiveness and usefulness of transnasal prelacrimal recess approach (TPRA) in patients with recurrent antrochoanal polyps.

METHODS

Twelve patients with antrochoanal polyp recurrence underwent surgery with a transnasal endoscopic prelacrimal recess approach. Success for visualization of the origin of the polyps, surgical complications, and recurrence was evaluated.

RESULTS

Transnasal prelacrimal recess approach was successful in 83% of the patients (10/12); polyps that originated from a posterior location (2 patients) were excised using the middle meatal approach. Nasolacrimal duct injury occurred in 2 patients but neither had epiphora postoperatively. Three patients (3/12; 25%) had synechia formation between the lateral nasal wall and septum just superior to the inferior turbinate. One of the 3 patients (1/12; 8.3%) with synechia was symptomatic and required surgical treatment under local anesthesia. During a mean follow-up period of 14.2 months (range, 8-21 months) no recurrence had developed.

CONCLUSION

In experienced hands, TPRA is a novel, reliable, and useful method for the treatment of recurrent antrochoanal polyps. It ensures good exploration of the maxillary antrum and easy access to the polyp origin on the maxillary wall without the need of additional approaches.

TNF-α and IL-1 β Cytokine Gene Polymorphism in Patients with Nasal Polyposis

Objective

Nasal Polyp (NP) is a benign mass of the paranasal sinuses that protrudes into the nasal cavity. The exact underlying pathogenesis is not known. In this study we aimed to determine the genetic susceptibility of NP formation in relation to TNF-α-308 and IL-1β-511 promoter region gene polymorphisms.

Methods

A total of 71 patients with NP with asthma (n=21) or without asthma (n=50) were taken as the study group, and 91 healthy volunteers were taken as the control group. Blood was gathered into EDTA-containing tubes, and patient DNA was extracted. The polymorphisms of the IL-β and TNF-α cytokine genes were analyzed using real time polymerase chain reaction.

Results

The GG genotype in the TNF-α-308 region and the CC genotype in the IL-1β-511 region were found to be risk factors for NP formation (OR: 9.2, p=0.007 and OR: 33.3, p=0.001, respectively). Regarding allelic frequencies, the G allele at the TNF-α-308 promoter region was a risk factor for NP formation (OR: 6.06, p<0.001).

Conclusion

TNF-α GG genotype in the -308 promoter region and the IL-1β CC genotype in the -511 region are genetic risk factors for NP formation.

Role of Apoptosis in the Pathogenesis of Nasal Polyps Based Upon Galectin-3 Expression

OBJECTIVE

The authors aimed to investigate the antiapoptotic mechanisms in nasal polyps that occur after glandular hyperplasia.

STUDY DESIGN

Retrospective histopathological analyses of patients with nasal polyps.

METHODS

The study comprised 54 patients (19 females; 35 males). Group-1 patients with a diagnosis of nasal polyposis; group-2 patients with a diagnosis of antrochoanal polyps; group-3 with a diagnosis of deviation of the nasal septum as a control group. Tissues were taken during their surgery and fixed in paraffin blocks, stained to detect galectin-3, and evaluated under a light microscope. Polymorphonuclear leukocytes on the surface epithelium, glandular epithelium, and connective tissue were divided into groups according to the intensity of galectin-3 staining: "mild," "moderate," and "strong." The percentage of stained tissue was also graded: <10%, 10% to 50%, 51% to 80%, and >80%. Hence, the extent of expression of galectin-3 and percentage of stained tissue was calculated.

RESULTS

Significant differences in the staining intensity of polymorphonuclear leukocytes for galectin-3 were observed between the 3 groups (P <0.01). Staining intensity in control group was significantly lower than that in group I and group II (P = 0.001; P <0.01). However, there was no significant difference between group I and group II (P >0.05).

CONCLUSION

These findings suggest that galectin-3 has a role in the formation of nasal polyps.

Influence of metals on rhinosinusal polyposis in Sardinian population (Italy)

Metals have strong toxic effects in humans and can act as immunoregulatory factors. The purpose of our study was to determine whether the concentrations of metals are associated with the clinical course of nasal polyposis (NP). We measured the concentrations of 10 metals and non-metal (Zn, Mn, Se, Fe, Cr, Ni, Pb, Al, Cd, and Cu) in 58 patients with NP, and 29 controls with a healthy nasal mucosa. We used electron microscopy to compare the ultrastructural features of the nasal mucosa between NP patients and healthy controls. Concentrations of metals in nasal polyps and healthy mucosa were determined by mass spectrometry. Transmission electron microscopic (TEM) and scanning electron microscopic (SEM) images of the nasal mucosa were obtained. The mean tissue concentrations of all 10 metals and non-metal were significantly lower in NP patients than in healthy controls (P < 0.05).TEM and SEM revealed changes in the mucosal ultrastructure in NP with progressive fibrosis, devascularisation, and inflammation. Tissue concentrations of metals were lower in NP patients than in healthy controls, and this was particularly evident in massive polyposis.

Update on Select Benign Mesenchymal and Meningothelial Sinonasal Tract Lesions

Several benign and malignant mesenchymal and meningothelial lesions may preferentially affect or extend into the sinonasal tract. Glomangiopericytoma (GPC, formerly sinonasal-type hemangiopericytoma) is a specific tumor with a predilection to the sinonasal tract. Sinonasal tract polyps with stromal atypia (antrochoanal polyp) demonstrate unique histologic findings in the sinonasal tract. Juvenile nasopharyngeal angiofibroma (JNA) arises from specialized tissue in this location. Meningioma may develop as direct extension from its intracranial counterpart or as an ectopic tumor. Selected benign mesenchymal tumors may arise in the sinonasal tract and pose a unique differential diagnostic consideration, such as solitary fibrous tumor and GPC or lobular capillary hemangioma and JNA. Although benign and malignant vascular, fibrous, fatty, skeletal muscle, and nerve sheath tumors may occur in this location, this paper focuses on a highly select group of rare benign sinonasal tract tumors with their clinicopathological and molecular findings, and differential diagnosis.

Human Papillomavirus (HPV) Prevalence in Nasal and Antrochoanal Polyps and Association with Clinical Data

Objectives

The pathogenesis of sinonasal polyposis remains unclear, in spite of several investigative approaches. Antrochoanal polyps, a subgroup of sinonasal polyposis along with allergic- and chronic-inflammatory nasal polyps, mostly originate from the maxillary sinus and develop as a unilateral, pedunculated mass towards the nasopharynx. The human papillomavirus (HPV) is discussed as a possible causative and influencing factor in development and progression of sinonasal polyposis. This study aims to elucidate HPV frequency in nasal polyps and antrochoanal polyps.

Materials and Methods

Genomic DNA from 257 tissue specimens (166 nasal polyps, 39 antrochoanal polyps and 52 nasal turbinates) was subjected to three different established HPV- polymerase chain reaction assays, testing for 37 low- and high-risk HPV. In addition, immunohistochemical analyses for HPV16 were carried out, as well as immunohistochemistry and western blots of p16, a biomarker for HPV induced cancer.

Results

HPV-DNA was detected in 53.8% of antrochoanal polyps, 15.1% of nasal polyps, and 5.8% of nasal turbinates. HPV16 was the predominant type with a detection rate of 76% in nasal polyps and 62% in antrochoanal polyps. Immunohistochemically, HPV positive tissues stained positive for HPV16 antigens and p16 in epithelial cell layers. No significant p16 overexpression was traceable in antrochoanal polyps, nasal polyps and nasal turbinates by western blot. There was no correlation of HPV-status with sex, age, smoking, alcohol consumption or allergic background.

Conclusion

The present study shows a significant frequency of high-risk type HPV16 in antrochoanal polyps. Absence of oncogenic transformation or correlation of the HPV-status with clinical data suggests a latent superinfection, possibly because of anatomical proximity to the oropharynx.

Antrochoanal polyp: clinical presentation and retrospective comparison of endoscopic sinus surgery and endoscopic sinus surgery plus mini-Caldwell surgical procedures

Antrochoanal polyp is a benign polypoid lesion orginating from the maxillary sinus antrum and extending to the choana. Our aim was to assess the clinical presentation and associated rhinological findings of antrochoanal polyp patients and to evaluate results of 2 surgical treatments termed endoscopic sinus surgery (ESS) and ESS plus mini-Caldwell operation. The study included 46 patients. Factors such as patient age, sex, history of chronic sinusitis, allergic rhinitis, septal deviations, chonca bullosa, turbinate hypertrophy, and the origin of the polyp were assessed. We also evaluated ESS and ESS plus mini-Caldwell surgical procedures for recurrences, synechia, bleeding, and ostium stenosis. Overall, there were 27 men and 19 women. The ESS approach was used in 26 cases, and 20 cases had combined ESS and mini-Caldwell procedures. The statistical significant difference between the 2 groups was only recurrence (P < 0.05). In the ESS group, bleeding, synechia, and ostium stenosis were seen more than in the ESS + mini-Caldwell group, but there was no significant difference between the 2 groups in bleeding, synechia, and ostium stenosis (P > 0.05). We thought that lower rate of recurrence found in ESS + Caldwell group in this study was associated with better visualization of the maxillary sinus walls and, therefore, easier resection of the remnant polyp. We concluded that higher incidences of bleeding and synechia were related to the mucosal damage occurring in the septum and the inferior concha due to excessive manipulation of endoscope and surgical instruments.

Lymphatic obstruction: a novel etiologic factor in the formation of antrochoanal polyps

OBJECTIVES

Antrochoanal polyps (ACPs) originate from the inner wall of the maxillary sinus and either pass through the natural sinus ostia or cause pressure-induced destruction of the medial sinus wall. Eventually, they extend into the choanae and nasopharynx. Most authors who have studied the microstructure of ACPs, including the component stromal cells and surface epithelium, have not examined the transitional area between the sinus mucosa and the pedicle of the polyp. No explanation has been given for the absence of a cystic intrasinus portion of the polyp, in many cases refuting the therapy (most accepted) that polyps are caused by a mucous gland with a blocked acinus. We noted during endoscopic removal of the ACPs that the antral part of the polyp was cystic in only 5% of patients, and polypoid in 95%. The cystic intrasinus portion of the polyp is a cornerstone of the pathophysiology of ACPs, whether caused by inflammation, cicatrization, or allergy. This finding prompted us to examine the transitional area between the sinus mucosa and the pedicle of the polyp to verify the possibility that lymphatic obstruction--whether primary (areas of higher tissue pressure) or secondary (cicatrization or inflammation)-could be an etiologic factor in the formation of ACPs.

METHODS

The study material consisted of 25 ACPs and 25 chronic maxillary sinusitis mucosal biopsy specimens (control group). The detection of lymphatic vessels was based on the identification of lymph vessel endothelial hyaluronic acid receptor I (LYVE-I) in the endothelial cells of the lymphatic capillaries. This was the first lymph-specific hyaluronic acid receptor to be characterized, and is a uniquely powerful marker for lymph vessels, differentiating them from (blood) capillaries.

RESULTS

The density of the lymphatic vessels was marked in 22 of the 25 ACP specimens, ie, 88% of the ACP cases, compared with 16% of the control group.

CONCLUSIONS

This study resulted in two main findings. The first was the absence of intramaxillary cysts in the ACPs in 23 cases (92%). The second was the markedly high density of lymphatic vessels in the transitional area between the sinus mucosa and the pedicle of the ACPs, in comparison with the density in the control group. These two findings refute the "blocked acinus theory" and indicate that lymphatic obstruction, whether primary or secondary to chronic sinus infection, might play a leading role in the formation and further growth of ACPs.

Endoscopic management of antrochoanal polyps: a single UK centre's experience

Antrochoanal polyps (ACPs) are benign lesions that originate from the mucosa of the maxillary sinus, and extend into the nasal cavity to reach the choana and nasopharynx. The treatment of ACPs is surgical, with a number of different surgical techniques having been described. We describe the first case series of ACPs from the UK and the endoscopic surgical technique that we have employed. A retrospective case note review of patients with ACPs managed under the care of the senior author was conducted. Demographic and clinical data for all patients were reviewed. The main outcome parameter measured was any sign of recurrence. A total of 29 consecutive patients were included for analysis from a 5-year study period, with 19 males and 10 females, and a mean age of 37.4 ± 13.6 years. Four patients within our group were referred to us with recurrent ACPs for revision surgery. All patients underwent surgery via the same endoscopic technique. The mean follow-up period was 14.7 ± 16.9 months, with an average follow-up of 22.5 months for the four revision cases. There were no recurrences in any of our patients. We describe the first reported series of endoscopic sinus surgery for antrochoanal polyps in the UK, and the largest worldwide series described for endoscopic management of ACPs in adults. We have had no recurrent cases, with a mean follow-up period of 14.7 months.

Antrochoanal polyposis: analysis of 34 cases

An antrochoanal polyp (ACP) is a benign polypoid lesion originating from the maxillary sinus and extending to the choana. The objective of our study is to assess etiological and associated features of ACPs, and outcome following surgical treatment. Thirty-four patients who had received surgical treatment for ACPs were followed for 35 ± 17.7 months. Factors including patient age, gender, history of allergic rhinitis, chronic sinusitis, nasal septal deviation, turbinate hypertrophy, concha bullosa, accessory ostia, as well as the origin of the polyp, the surgical technique used and any recurrence, were evaluated. Overall, there were 12 females and 22 males. Mean age was 24.94 ± 8.08. Septal deviation was present in 50 %, turbinate hypertrophy in 32.3 %, concha bullosa in 17.6 %, mucous retention cyst in 32.3 %, allergic rhinitis in 44.11 %, and chronic sinusitis in 20.5 %. An accessory ostia was observed in 97.05 %. The functional endoscopic sinus surgery (FESS) approach was used in 31 cases, and three cases had combined FESS and Caldwell Luc procedures. The mean follow-up time was 35.8 ± 17.7 months. Two cases, who had been treated with FESS alone, experienced a recurrence. In conclusion, the commonest predisposing factors for ACPs are chronic inflammatory pathologies such as chronic sinusitis and allergic rhinitis. ACP left the maxillary sinus via an accessory ostium in 97.5 % of the cases. The FESS procedure is a safe and reliable method, and can be combined with the Caldwell Luc procedure when the origin of the maxillary component cannot be properly cleaned. In order to prevent recurrence, total extirpation of the maxillary component is essential.

Endoscopic surgery in pediatric recurrent antrochoanal polyp, rule of wide ostium

OBJECTIVE

To evaluate the use of wide middle meatal antrostomy in recurrent antrochoanal polyp (ACP) in children as regard technical difficulty, efficacy, and safety in children.

STUDY DESIGN

Retrospective study.

PATIENTS AND METHODS

In a retrospective study, 12 children with unilateral recurrent ACP (5 left-sided, 7 right-sided). All the ACPs were documented by preoperative endoscopy and computer tomographic (CT) scans. All cases were treated using endoscopic wide middle meatal antrostomy. The average age at the onset of symptoms was 9.3 years (median age: 10 years; range: 6-15 years).

RESULTS

Postoperative improvement in all cases was achieved using both subjective measures (symptoms improvement) and objective measures (radiological and endoscopical). No postoperative complications or recurrence during the follow up period.

CONCLUSIONS

Endoscopic wide middle meatal antrostomy is a useful and easily applicable technique to manage recurrent antrochoanal 3 polyp in children. Managing associated pathology as turbinate hypertrophy, associated adenoids, anterior ethmoidectomy, uncinectomy and endoscopic limited septoplasty should be put in mind in order to improve ventilations. Powered instrumentations, angled endoscopes (45 and 70°) and angled instrumentations can assure complete clearance of the polyp by identifying the origin of polyp in maxillary antrum.

Angiogenesis in chronic rhinosinusitis with nasal polyps and in antrochoanal polyps

OBJECTIVES AND STUDY DESIGN

Angiogenesis may be related to the pathogenesis and prognosis of chronic rhinosinusitis with nasal polyposis. This cross-sectional study, in a tertiary university hospital, evaluates angiogenesis parameters in nasal polyps, antrochoanal polyps and middle turbinates.

SUBJECTS

Nasal polyps obtained from 24 consecutive patients, were compared to 10 normal middle turbinates and to 11 antrochoanal polyps.

METHODS

Analyzing for the expression of the angiogenic marker CD34 by immunohistochemistry. Blood vessels count, vascular surface density and microvessel density were measured by manual and computerized methods.

RESULTS

Angiogenesis was significantly higher in nasal polyps compared to control turbinates and to antrochoanal polyps (p = 0.0001 and p = 0.007, respectively). Antrochoanal polyps showed significantly more angiogenesis than normal middle turbinates (p = 0.001). Angiogenesis was not elevated in sub-groups of nasal polyposis patients considered to have worse prognosis.

CONCLUSIONS

Angiogenesis probably plays a role in the pathogenesis of both nasal polyposis and antrochoanal polyps. However, the significantly higher angiogenesis found in nasal polyps compared to antrochoanal polyps may support a different mechanism of growth. The lack of difference between angiogenesis and nasal polyposis patients sub-groups, may imply that angiogenesis is not associated with the prognosis of chronic rhinosinusitis with nasal polyposis.

Evaluation and management of antrochoanal polyps

Antrochoanal polyps (ACPs) are benign polypoid lesions arising from the maxillary antrum and they extend into the choana. They occur more commonly in children and young adults, and they are almost always unilateral. The etiopathogenesis of ACPs is not clear. Nasal obstruction and nasal drainage are the most common presenting symptoms. The differential diagnosis should include the causes of unilateral nasal obstruction. Nasal endoscopy and computed tomography scans are the main diagnostic techniques, and the treatment of ACPs is always surgical. Functional endoscopic sinus surgery (FESS) and powered instrumentation during FESS for complete removal of ACPs are extremely safe and effective procedures. Physicians should focus on detecting the exact origin and extent of the polyp to prevent recurrence.

Endothelial L-selectin ligand expression in nasal polyps

BACKGROUND

L-selectins on leukocytes and their counter-receptors on endothelial cells have been shown to be involved in leukocyte recruitment in chronic rhinosinusitis without nasal polyps (NP).

OBJECTIVES

The purpose of this study was to evaluate the expression level of functionally active endothelial L-selectin ligands in NP obtained from patients with NP of different etiology [simple NP, antro-choanal polyps (ACP) and cystic fibrosis (CF) NP] and inferior turbinate specimens of healthy controls and to compare these levels to the presence of various leukocyte subsets.

METHODS

Nasal polyp specimens and healthy nasal mucosa specimens were obtained from patients undergoing surgery and were immunohistochemically stained with monoclonal antibodies detecting CD34, sialyl Lewis x (sLe(x)) of sulfated extended core 1 lactosamines and various leukocyte subsets.

RESULTS

All NP are characterized by a decrease in the number of CD34+ vessels. The number of eosinophils and the percentage of vessels expressing endothelial sulfated sLe(x) epitopes is upregulated in all groups of simple NP. Tissue eosinophilia is increased in those patients with increased disease severity (acetyl salicylic acid intolerance), but the percentage of endothelial sulfated sLe(x) epitopes is not. Results on CF NP are similar to those observed for simple NP. Antro-choanal polyps, on the contrary, are characterized by low numbers of tissue eosinophils and relatively few vessels expressing endothelial sulfated sLe(x) epitopes.

CONCLUSIONS

Our results suggest that functionally active L-selectin ligands might play a role in guiding leukocyte traffic into NP in patients with simple NP and CF NP but not ACP.

The glutathione-S-transferase gene polymorphisms (Gstt1, Gstm1, and Gstp1) in patients with non-allergic nasal polyposis

There is an ongoing dilemma about the pathogenesis of nasal polyp (NP). The etiology of NP is multifactorial. Reactive oxygen species and oxidative stress are also suggested to be among the possible factors in NP development. Glutathione-S-transferase (GST) is one of the important detoxifying enzymes. It is not known whether GST plays any role in NP development. We aimed to investigate the relationship between GST subgroup (GSTT1, GSTM1, and GSTP1) polymorphisms, and NP development. Seventy-five patients with NP with or without asthma (NP with asthma: 22, NP without asthma: 53) were used as a study group. As much as 167 healthy individuals were involved as the control group. NP diagnosis was made by nasal endoscopy and paranasal sinus computed tomography (CT). NP was defined as the presence of endoscopically visible bilateral polyps originated from the middle meatus to the nasal cavity and affecting more than one paranasal sinus confirmed by CT. Blood was collected in EDTA-containing tubes and DNA was extracted from the leukocytes. The genotyping of polymorphisms of GSTT1, GSTM1, and GSTP1 were done using real time polymerase chain reaction. Chi-square (chi(2)) and Fisher's (F) exact tests were used for statistical evaluation. A 2-fold increased risk of NP could be found in individuals with the GSTT1 null genotype (OR = 2.03, 95% CI = 1.03-4.011). The distribution of GSTM1 null genotypes was not significantly different between the NP patients and controls and there was also no significance between the GSTP1 genotypes and NP. In conclusion, GST gene polymorphisms may be important in pathogenesis of NP. Additional studies which include larger study groups in different geographic localizations may be more useful to evaluate association with GST polymorphism and NP.

Does Helicobacter pylori play a role in etiology of nasal polyposis?

OBJECTIVE

Investigation of the possible relation between nasal polyposis (NP) and Helicobacter pylori (HP).

PATIENTS AND METHODS

Biopsy specimens of 25 patients with NP were evaluated. There were 16 men and 9 women enrolled in the study (NP) group. There were 10 men and 4 women in the control group. Campylobacter-like organism (CLO) test, immunohistochemical examination on nasal polyp tissue biopsy specimens and serological analysis were used for detecting HP.

RESULTS

There was only one (4%) positive NP case for CLO test. There were six cases in the study group with positive anti HP IgG test. Two control nasal mucosa were CLO positive. There were three cases in control group with positive anti HP IgG. There were no positive cases with positive anti IgM HP regarding both the study and the control groups. The immunohistochemical examination of the specimens taken from the patients with NP and control patients revealed that all patients were negative for HP. Positive CLO test and serologic test ratios were not statistically significant between NP and control groups.

CONCLUSION

The results of this study did not confirm other investigators. The suggested role of HP in the previous reports regarding NP may demonstrate transient occurrence of HP. It may not be treated as a possible etiological factor in NP.

Choanal polyps: an evaluation of 53 cases

BACKGROUND

The aim of this study was to evaluate our experience on the diagnosis and treatment of choanal polyps (CP).

METHODS

This study consists of 53 patients with CP diagnosed by means of rhinoscopy, nasal endoscopy, computerized tomography, surgical, and histologic findings between 1996 and 2005.

RESULTS

The origins of the CPs were the unilateral maxillary sinus in 47 patients, simultaneously bilateral maxillary sinus in 2 patients, septum in 2 patients, sphenoid sinus in I patient, anterior ethmoid sinus in 1 patient. The most common presenting symptoms were unilateral nasal obstruction, snoring, and rhinorrhea. In the cases of the antrochoanal polyps, the most common preoperative radiological finding was the total opacification of the maxillary sinus.

CONCLUSION

Endoscopic approach for complete removal of the CPs is an extremely safe and effective procedure. It should be focused on the detection of the exact origin and the extent of the polyp to prevent recurrence.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.

Pathogenesis of nasal polyps: an update

The cause of nasal polyp formation is still unknown. Genetic predisposition has been suggested, but there are scanty data to support such theories. Activated epithelial cells may be the major source of mediators inducing influx of inflammatory cells (mostly eosinophils) and proliferation and activation of fibroblasts leading to nasal polyp formation. Infectious agents (including viruses, bacteria, or fungi) may be potential primary factors activating nasal epithelial cells. Proinflammatory cytokines and growth factors play important roles in the persistence of mucosal inflammation associated with nasal polyps. Arachidonic acid metabolites seem to be particularly important in the pathogenesis of nasal polyps in patients with aspirin hypersensitivity rhinosinusitis/asthma syndrome.