xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

remodeling of adjacent bone is seen in 38% of cases. 602 MRI findings include a wide variation in T1 and T2 sig nal depending on protein content. 602,604 Ultrasound in five cases has reported well-defined cysts with anechoic to hypoechoic fluid. 602 On histopathology, these cysts demonstrate a range of epithelial cell types, including columnar, cuboidal, and squamous epithelium, and roughly half of lesions demonstrate goblet cells and mucous glands. 602 The two most common surgical treatments for NLCs are transoral sublabial excision and transnasal endoscopic marsupialization, and both approaches can be performed under local or general anesthesia. 603,606–613 A 2016 sys tematic review of all reported cases found an overall recurrence rate of 2.2%, with 1.6% following transoral exci sion and 5.0% following endonasal marsupialization. 602 A prospective randomized study directly comparing these techniques in 20 patients found that, while there was no recurrence at 1 year in either treatment group, the endonasal marsupialization group had significantly shorter operative time (18.3 vs. 46.4 min, p < 0.002) and lower postoperative pain (3.5 vs. 6.1 as measured by visual analog score, p < 0.01). 614 A retrospective study of 30 patients found significantly lower operative time, blood loss, and hospitalization time for endonasal marsupializa tion compared to transoral excision, with no recurrences in either group. 609 Furthermore, endonasal marsupializa tion imposes significantly less medical costs compared to sublabial excision. 609 Recently, a series of 31 patients describe endonasal microwave ablation under local anes thesia, with minimal complications and no recurrences or oroantral fistula at 1 year. 615 C Antrochoanal polyps Antrochoanal polyps (ACP) are benign, typically unilat eral lesions that arise from the maxillary sinus and extend through the nasal cavity to, and often through, the choana, representing 4%–10% of adult polyps and 35% of pedi atric polyps. 616–618 ACPs commonly present with unilateral nasal obstruction, rhinorrhea, and postnasal drainage; when larger, they can cause snoring, obstructive sleep apnea, dysphonia, and dysphagia. 616–620 While the exact etiology is unknown, inflammation is thought to play a key role in the pathogenesis of ACP. ACPs demonstrate type 1 inflammation (neutrophilic), with higher expression of IL-8, IFN-y, and myeloperoxi dase compared to eosinophilic and noneosinophilic nasal polyps 621 and higher levels of IL-6 and IL-10 compared to control tissue. 622 Any correlation between ACP and anatomic variations such as septal deviation, concha bul

losa, or Haller cells has been studied with inconclusive results. 623,624 Diagnosis is made using nasal endoscopy and CT. Endo scopic exam typically reveals a smooth polypoid mass originating from the middle meatus and often filling the entire nasal cavity. 625 CT demonstrates a homogenous, low-density soft tissue mass emanating from the maxil lary sinus through a widened ostium or patent posterior fontanelle, and extending to the choana. Typically, no bony destruction is observed, though the posterior choana may be remodeled and widened if the polyp extends to the nasopharynx. 625 While MRI is not necessary, it can be help differentiate ACP from other unilateral sinonasal masses. ACPs are typically hypo- to isointense on T1-weighted and hyperintense on T2-weighted images, with periph eral enhancement postcontrast. 626,627 On histopathology, ACPs generally demonstrate a sparsity of mucous glands and eosinophils as compared to sinonasal polyps, and may additionally show areas of infarction as well as stromal cells with cytologic atypia. 628 ACPs are treated surgically, using standard endoscopic techniques, with consideration given to extended endo scopic and very rarely Caldwell-Luc approaches, depend ing on site of origin. Identification and removal of the site of origin are key to preventing recurrence. 629 The majority of tumors originate from the posterior wall and are thus amenable to resection through a standard maxillary antrostomy. 619,630–635 If the ACP exits an acces sory ostium of the maxillary sinus, this opening should be brought into continuity with the natural ostium to avoid recirculation. 636,637 In cases of anterior or inferior wall attachment or in cases of recurrence, an endoscopic medial maxillectomy or prelacrimal approach can achieve successful removal. 637 A Caldwell-Luc approach in com bination with an endonasal approach is also effective in removing anteriorly based or recurrent ACPs. 629,638–642 A 2018 systematic review of 285 cases of ACP identified an overall 15% recurrence rate. In this study, the differ ence in recurrence rate between endoscopic only (17.7%) and combined endoscopic + Caldwell-Luc approach (0%) was statistically significant; however, this is before the prelacrimal approach became very widely used, as it is today. The Caldwell-Luc should be used judiciously, espe cially in children, given the risk of damaging dentition and developing maxillary bone. 629,633 SINONASAL PAPILLOMAS Sinonasal papilloma, although benign, represents a locally disruptive subtype of head and neck pathology arising from the Schneiderian mucosa, an ectoderm-derived res piratory mucosa. 643 Variations in tumor morphology and XVI