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Coincidence of Conchachoanal Polyp
and Complete Mulberry Hypertrophy
of Inferior Concha
Davut Akduman, MD; Murat Karaman, MD; Eda Aydin, MD; Deniz Korkmaz, MD;
Ahmet Karaaslan, MD; Suat Turgut, MD
We report two unique cases with coincidence of
conchachoanal polyp and mulberry hypertrophy of the
inferior concha, which was removed by endoscopic endonasal surgery.
We report two unique cases of 50- and 28-yearold Turkish men with coincidence of conchachoanal
polyp and mulberry hypertrophy of the inferior concha. We operated on both cases with endoscopic stripping of the polypoid tissue while preserving the periosteum and healthy mucosa of the inferior nasal
concha. The polypoid tile of the left inferior nasal concha was resected in the case with mulberry hypertrophy at only the tail of the concha. Both cases reported
significant relief of symptoms after the operations.
Key Words: Conchachoanal polyp, mulberry
hypertrophy, inferior concha.
Laryngoscope, 119:762–764, 2009
CASE 1
INTRODUCTION
Nasal polyps are abnormal lesions that arise from
any region of the nasal mucosa or paranasal sinuses.
They are typically smooth, round, semitranslucent, and
commonly located along the middle meatus and ethmoid
sinus, although more rarely originating from the maxillary or sphenoid sinuses. Nasal polyps are present in 1%
to 4% of the population.1 A choanal polyp originating
from the inferior nasal concha is an extremely rare
entity.2
Polypoid formation at the tail of the inferior concha
is common and usually bilateral. The overall effect of
mulberry hypertrophy is obstruction of the posterior
nasal cavity near the posterior choana.3 A comprehensive literature review did not display any conchachoanal
polyp with complete mulberry hypertrophy of the inferior
concha.
The most preferred treatment for choanal polyps is
endoscopic surgery with removal of the polypoid tissue.
From the Otorhinolaryngology Department, Umraniye Education
and Training Hospital, Istanbul, Turkey.
Editor’s Note: This Manuscript was accepted for publication
November 11, 2008.
Send correspondence to Davut Akduman, MD, Umraniye Education and Training Hospital, Otorhinolaryngology Department, 34766/
Umraniye, Istanbul, Turkey. E-mail: [email protected]
DOI: 10.1002/lary.20117
Laryngoscope 119: April 2009
762
A 50-year-old man presented with a history of nasal
obstruction and snore during the past five years. He had
medical treatment for this several times in his medical
history. He had been treated several times with various
medications but failed to obtain significant relief of
symptoms. On otolaryngologic endoscopic examination,
rhinoscopy revealed an isolated right conchachoanal
polyp with complete mulberry hypertrophy of the inferior
nasal concha, with only 2 mm to 3 mm normal mucosa
on the lateral side and a septal deviation to the left side.
A paranasal sinus computed tomography was performed.
There was an isolated right inferior concha hypertrophy
with obstructed right choana and septum deviation to
the left side. Moreover, he had a right middle concha
bullosa and his left inferior concha was retracted to the
lateral nasal wall. Hence, histopathologic results of two
different incisional biopsies were inflammatory polyp.
An endoscopic stripping of polypoid tissue with preserving periosteum and healthy lateral mucosa of the
inferior nasal concha with outfracture and septoplasty
operations were performed. The hemorrhage was managed by using bipolar cautery (Fig. 1). The patient was
followed up for five months. He healed well and reported
significant relief of symptoms postoperatively.
CASE 2
A 28-year-old man presented with a history of nasal
obstruction, gaping during sleep, nasal discharge, and
headache for the past five years. He had been treated
several times with various medications but failed to
obtain significant relief of symptoms. On otolaryngologic
endoscopic examination, anterior rhinoscopy revealed a
right conchachoanal polyp with complete mulberry
hypertophy of the inferior nasal concha and similar hypertrophy at the tail of the left inferior nasal concha. A
Akduman et al.: Conchachoanal Polyp and Mulberry Hypertrophy
Fig. 1. In case 1, an isolated right
conchachoanal polyp with complete
mulberry hypertrophy of the inferior
nasal concha. (A, B) Preoperative
appearance. (C, D) An endoscopic
stripping of polypoid tissue with preserving periosteum and healthy
lateral mucosa of the inferior nasal
concha was performed. (E) Endoscopic appearance, three months
after operation.
paranasal sinus computed tomography was performed.
There was an isolated right inferior concha hypertrophy
with obstructed right choana and septum deviation to
the left side. Moreover, there was a right osteomeatal
complex disease and right maxillar sinusitis. Histopathologic result of incisional biopsy was inflammatory polyp.
An endoscopic stripping of polypoid tissue with preserv-
ing periosteum and healthy mucosa of right inferior
nasal concha with outfracture operation was performed.
Then the polypoid tile of the left inferior nasal concha
was resected (Fig. 2). The hemorrhage was managed by
using bipolar cautery. The patient was followed up for
three months. He healed well and reported significant
relief of nasal symptoms postoperatively.
Fig. 2. In case 2, a right conchachoanal polyp with complete mulberry hypertrophy of the inferior
nasal concha. (A, B) Preoperative
appearance. (C, D) An endoscopic
stripping of polypoid tissue with preserving periosteum and healthy
lateral mucosa of the inferior nasal
concha was performed. (C1) Mulberry hypertrophy at the tail of the
left inferior nasal concha was
resected. (E) Endoscopic appearance one month after operation.
Laryngoscope 119: April 2009
Akduman et al.: Conchachoanal Polyp and Mulberry Hypertrophy
763
DISCUSSION
Nasal polyps are present in 1% to 4% of the population and are encountered more commonly in adults than
in children and in more males than in females.1 Special
attention must be carried out when a patient presents
unilateral symptoms of nasal polyposis.4
Although there are not any cases with coincidence
of conchachoanal polyps with complete mulberry hypertophy of the inferior nasal concha, Christmas et al.5
presented a case with mulberry hypertrophy at the tail
of the inferior concha who healed well after complete
resection of polypoid mucosa.
There are only a few cases with choanal polyps
originating from the inferior nasal concha in the literature.2,6,7 Aydil et al.2 reported a 21-year-old man with a
single polypoid mass, beginning at the level of the middle third of the inferior nasal concha and extending to
the choana on the left inferior nasal concha. They performed endoscopic endonasal surgery. The site where the
polyp originated from the concha was partially excised
and cauterized by using bipolar cautery. The symptoms
immediately resolved after the operation. Yariktas et al.6
reported a 14-year-old girl who had a polypoid mass that
originated from the right inferior nasal concha, completely obliterated the right nasal cavity, and totally
occluded the left choana. They performed endoscopic surgery, and the patient healed well after the operation.
And the other case with conchacoanal polyp, reported by
Gordts and Clement,7 was a 10-year-old girl with choanal polyp originating from the inferior nasal concha who
had significant relief of symptoms after endoscopic
surgery.
Our first case was the oldest conchachoanal polyp
in the literature, while the age of the second case was
similar to the Aydil et al.2 case. The other two published
Laryngoscope 119: April 2009
764
cases were children when diagnosed for conchachoanal
polyps.
We operated on both cases with endoscopic stripping of polypoid tissue with preserving periosteum and
healthy mucosa of the inferior nasal concha. The polypoid tile of the left inferior nasal concha was resected in
the case with mulberry hypertrophy at only the tail of
the concha. Both cases reported significant relief of
symptoms after operations.
CONCLUSIONS
Conchachoanal polyps rarely arise from inferior
nasal concha. Coincidence of conchachoanal polyp with
complete mulberry hypertrophy of the inferior nasal concha is an extremly rare entity.
BIBLIOGRAPHY
1. Slavin RG. Nasal polyps and sinusitis. Review. JAMA 1997;
278:1849–1854.
2. Aydil U, Karadeniz H, Sahin C. Choanal polyp originated
from the inferior nasal concha. Eur Arch Otorhinolaryngol 2008;265:477–479.
3. Yanagisawa E. Nasal endoscopic anatomy. In: Yanagisawa
E. Color Atlas of Diagnostic Endoscopy in Otorhinolaryngology. New York: Igaku Slioin; 1997.
4. Tritt S, McMains KC, Kountakis SE. Unilateral nasal polyposis: clinical presentation and pathology. Am J Otolaryngol 2008;29:230–232.
5. Christmas DA, Mirante JP, Yanagisawa E. Endoscopic view
of ‘mulberry hypertrophy’ of the inferior turbinates. Ear
Nose Throat J 2005;84:622–623.
6. Yariktas M, Dogru H, Doner F, Tüz M, Yasan H. Choanal
polyp originating from the inferior turbinate presenting
as nasal polyposis. Turk J Ear Nose Throat 2006;16:
37–40.
7. Gordts F, Clement PA. Unusual choanal polyps. Acta Otorhinolaryngol Belg 1997;51:177–180.
Akduman et al.: Conchachoanal Polyp and Mulberry Hypertrophy