1. Dr Saeid Atighechi Department of Otolaryngology, Yazd medical sciences

2. Introduction: Antrochoanal polyp (ACP) is a polyp originating in the maxillary sinus. It protrudes through the sinus ostium or its accessory ostia into the nasal cavity and then extends to the choana. Treatment: To diminish the re-growth rate of choanal polyp, a complete removal of the antral portion and its attachment is necessary.

3. Introduction:(cont.) Different Surgical Techniques for ACP: Caldwell-Luc Endoscopic endonasal Endoscopic endonasal plus transcanine sinuscopy Micro-debrider Trans-nasal Trans-canine Endoscopic endonasal plus mini-Caldwell

4. Materials and methods This retrospective study was conducted by analyzing the database for 59 patients who were operated on for ACP in ENT ward of Shahid Sadughi hospital in Yazd, Iran during 2002-2007. 19 underwent an endoscopic endonasal surgery for removal of polyps. 21 experienced endoscopic surgery with mini- Caldwell operation.

5. Materials and methods(cont.) The first technique is a classical endoscopic sinus surgery (ESS) technique with removal of ACP after uncinectomy and antrostomy with an endoscope and forceps. The second technique was a combined one. It was a combination of endoscopic endonasal surgery with uncinectomy and antrostomy and mini-Caldwell (with a window of 0.5- 0.7 0.5 cm) through which an endoscope and forceps were introduced into the sinus to remove the entire stalk of polyp

7. Materials and methods(cont.) follow-up : The patients were then called to come to have a diagnostic endoscopy for detection of recurrence; the follow-up time was a minimum of 12 months with a mean of 29.2 months. Any residual maxillary portion or choanal portion during the follow-up endoscopy was to be considered as recurrence.

8. Results: ESS Mini-Caldwell & ESS Pre-opPost-opPre-opPost-op P v post-op ESS vs. mini- Caldwell Nasal obstruction 18(94.7%)2(10.5%)21(100%)2(9.5%)>.05 PND 10(52.6%)5(26.3%)12(57%)5(23.8%)>.05 Rhinorrhea 6(31.5%)3(15.7%)12(57%)3(14.2%)>.05 Synechia ---------7(36.8%)---------5(23.8%) >.05 Bleeding ---------5(26.3%)---------4(19%) >.05 Ostia stenosis ---------3(15.7%)---------3(14.2%) >.05 Recurrence---------4(21.1%)---------0.042<.05

9. Discussion: One of the recent treatment alternatives is endoscopic sinus surgery (ESS), but it can not completely resect the polyp stalk sometimes. Removal of the polyp stalk through ostium with forceps is time-consuming; once it is not removed completely, it may re-grow. This can be specifically said about polyps with anterior or inferior or wide base in which the visibility is little and preserving normal mucosa for repair is so hard. Although in some studies no or a little recurrence was reported after endoscopic trans nasal resection of ACP, in some others recurrence rates between 8 to 15% were reported.

10. Discussion:(cont.) combination of ESS with mini-Caldwell leaves physiology of the sinus intact as sinus ostium opens via uncinectomy and antrostomy. It also makes it possible to easily pass an endoscope through the anterior wall for a better visualization of the medial and the floor of the sinus. This window allows using forceps and curette with which the polyp remnant can be completely resected without mucosal damage. There was a significant difference between the two groups in re-growth rate (P =.042 0.05).

11. Conclusion: Although endoscopic endonasal surgery is a useful technique in ACP surgery (recurrence 21.1%), mini-Caldwell with endoscopic endonasal surgery is without the complication of Caldwell. Besides, it has minimal recurrence. It is a useful option for a complete removal of the stalk. Therefore, employing mini-Caldwell technique is a viable option. An exception to this is a polyp originating in the posterior wall of the sinus, which can be completely removed transnasal.