Orbital invasion by an antrochoanal polyp in a factor V-deficient patient: A case report of diagnostic and surgical challenges

Abstract

Introduction

Antrochoanal polyps (ACPs) typically extend posteriorly into the choana and nasopharynx; orbital invasion is exceptionally rare. This report details an atypical ACP with orbital extension in a coagulopathic patient, highlighting diagnostic and surgical complexities.

Case presentation

A 46-year-old woman with severe Factor V deficiency (0.8 %) presented with 2 years of progressive left nasal obstruction, rhinorrhea, headaches, and snoring. Examination revealed a left nasal polyp extending to the vestibule and bilateral turbinate hypertrophy. Coagulation profiles showed marked prolongation (PTT 126.8 s, INR 3.45). CT imaging identified a hypodense polyp originating from the left maxillary sinus, expanding through the infundibulum into the choana. Crucially, MRI confirmed orbital fossa invasion through bony dehiscence, with T2 hyperintensity and no gadolinium enhancement excluding malignancy. Histopathology post-functional endoscopic sinus surgery (FESS) demonstrated an inflammatory, angiomatous polyp featuring telangiectatic vasculature and stromal hemorrhage.

Discussion

Orbital extension likely resulted from chronic erosion of the lamina papyracea, exacerbated by mass effect. Angiomatous histology—uncommon in adults—and profound coagulopathy amplified bleeding risks. Multidisciplinary management (hematology/ENT) guided preoperative factor replacement and hypotensive anesthesia. Angled endoscopes facilitated precise dissection at the orbital interface, avoiding combined approaches (e.g., Caldwell-Luc) due to coagulopathy. This case underscores MRI's indispensability in delineating atypical extensions and the need for tailored techniques to ensure complete resection amid coagulopathies.

Conclusion

This first reported orbital invasion by an ACP in a Factor V-deficient patient illustrates that benign polyps may erode critical boundaries under chronic pressure. Vigilance for aberrant extensions via advanced imaging, coupled with individualized surgical planning for coagulopathic patients, is essential to mitigate recurrence and complications.