nasal polip.doc

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http://emedicine.medscape.com/article/994274-overview

Nasal Polyps

•

Author: John E McClay, MD; Chief Editor: Glenn C Isaacson, MD, FACS, FAAP

Background

Broadly defined, nasal olys are a!nor"al lesions that ori#inate fro" any ortion of the nasal

"ucosa or aranasal sinuses$ Polys are an end result of %aryin# disease rocesses in the nasal

ca%ities$ &he "ost co""only discussed olys are !eni#n se"itransarent nasal lesions 'see the

i"a#es !elo() that arise fro" the "ucosa of the nasal ca%ity or fro" one or "ore of the aranasal sinuses, often at the outflo( tract of the sinuses$

Rigid endoscopic view of the left nasal cavity, showing

the septum on the left. olyps with some !lood and hemorrhage are on top of them

in the center portion. "he rim of white from # o$cloc% to 4 o$cloc% indicates the

lateral nasal wall vesti!ule. "he polyps cover the inferior tur!inate, which is partially

visi!le at 4 and & o$cloc%. 'ndoscopic view of the left

nasal cavity, showing a polyp protruding from the uncinate process. "he middle

tur!inate is to the left. ( suction is visi!le on top of the inferior portion of the

uncinate process and inferior portion of the polyp. "he lateral nasal wall is on the far


http://refimgshow%282%29/





right. "he polyp is directly in the center and is pale, glistening, and white.

'ndoscopic view of the left middle meatus. "he septum

is on the far left. "he middle tur!inate is ne)t to the septum on the left. ( large,

glistening, translucent polyp is visi!le in the center of the screen ne)t to the middle

tur!inate. "he lateral nasal wall is on the right side of the screen. "he inferior

tur!inate nu! posteriorly is in the !ottom right hand corner.

Multile olys can occur in children (ith chronic sinusitis, aller#ic rhinitis, cystic fi!rosis 'CF),

or aller#ic fun#al sinusitis 'AFS)$ An indi%idual oly could !e an antral*choanal oly, a !eni#n

"assi%e oly, or any !eni#n or "ali#nant tu"or 'e#, encehaloceles, #lio"as, he"an#io"as, aillo"as, +u%enile nasoharyn#eal an#iofi!ro"as, rha!do"yosarco"a, ly"ho"a,

neuro!lasto"a, sarco"a, chordo"a, nasoharyn#eal carcino"a, in%ertin# aillo"a)$ E%aluate

all children (ith !eni#n "ultile nasal olyosis for CF and asth"a$

Pathophysiology

&he atho#enesis of nasal olyosis is unno(n$ Poly de%elo"ent has !een lined to chronic

infla""ation, autono"ic ner%ous syste" dysfunction, and #enetic redisosition$ Most theoriesconsider olys to !e the ulti"ate "anifestation of chronic infla""ation; therefore, conditions

leadin# to chronic infla""ation in the nasal ca%ity can lead to nasal olys$

&he follo(in# conditions are associated (ith "ultile !eni#n olys:

• *ronchial asthma - +n 2-& of patients with polyps• - olyps in 0-41 of patients with

• (llergic rhinitis

• ( - olyps in 1& of patients with (

• hronic rhinosinusitis

• rimary ciliary dys%inesia

• (spirin intolerance - +n 1-20 of patients with polyps




http://www.medscape.com/resource/cystic-fibrosis




http://www.medscape.com/resource/asthma








http://www.medscape.com/resource/asthma




• (lcohol intolerance - +n & of patients with nasal polyps

• hurg-trauss syndrome - 3asal polyps in & of patients with hurg-trausssyndrome

• oung syndrome 5ie, chronic sinusitis, nasal polyposis, a6oospermia

• 3onallergic rhinitis with eosinophilia syndrome 53(R' - 3asal polyps in 2of patients with 3(R'

Most studies su##est that olys are associated "ore stron#ly (ith nonaller#ic disease than (ithaller#ic disease$ Statistically, nasal olys are "ore co""on in atients (ith nonaller#ic asth"a

'-./) than (ith aller#ic asth"a '0/), and only 1$0/ of .111 atoic indi%iduals ha%e nasal

olys$

Se%eral theories ha%e !een ostulated to e2lain the atho#enesis of nasal olys, althou#h nonesee"s to account fully for all the no(n facts$ So"e researchers !elie%e that olys are an

e2%a#ination of the nor"al nasal or sinus "ucosa that fills (ith ede"atous stro"a; others !elie%e

olys are a distinct entity arisin# fro" the "ucosa$ Based on a re%ie( of the literature andse%eral intricate studies of the !ioelectric roerties of olys, Bernstein deri%ed a con%incin#

theory on the atho#enesis of nasal olys, !uildin# on other theories and infor"ation fro" &os$3-, 45

In Bernstein6s theory, infla""atory chan#es first occur in the lateral nasal (all or sinus "ucosaas the result of %iral*!acterial host interactions or secondary to tur!ulent airflo($ In "ost cases,

olys ori#inate fro" contact areas of the "iddle "eatus, esecially the narro( clefts in the

anterior eth"oid re#ion that create tur!ulent airflo(, and articularly (hen narro(ed !y "ucosalinfla""ation$ 7lceration or rolase of the su!"ucosa can occur, (ith reeitheliali8ation and

ne( #land for"ation$ Durin# this rocess, a oly can for" fro" the "ucosa !ecause the

hei#htened infla""atory rocess fro" eithelial cells, %ascular endothelial cells, and fi!ro!lasts

affects the !ioelectric inte#rity of the sodiu" channels at the lu"inal surface of the resiratoryeithelial cell in that section of the nasal "ucosa$ &his resonse increases sodiu" a!sortion,

leadin# to (ater retention and oly for"ation$

9ther theories in%ol%e %aso"otor i"!alance or eithelial ruture$ &he %aso"otor i"!alance

theory ostulates that increased %ascular er"ea!ility and i"aired %ascular re#ulation causedeto2ification of "ast*cell roducts 'e#, hista"ine)$ &he rolon#ed effects of these roducts

(ithin the oly stro"a result in "ared ede"a 'esecially in the oly edicle) that is (orsened

!y %enous draina#e o!struction$ &his theory is !ased on the cell*oor stro"a of the olys, (hichis oorly %asculari8ed and lacs %asoconstrictor inner%ation$

&he eithelial ruture theory su##ests that ruture of the eitheliu" of the nasal "ucosa is

caused !y increased tissue tur#or in illness 'e#, aller#ies, infections)$ &his ruture leads to

rolase of the la"ina roria "ucosa, for"in# olys$ &he defects are ossi!ly enlar#ed !y#ra%itational effects or %enous draina#e o!struction, causin# the olys$ &his theory, althou#h

si"ilar to Bernstein6s, ro%ides a less con%incin# e2lanation for oly enlar#e"ent than the

sodiu" flu2 theory suorted !y Bernstein6s data$ either theory co"letely defines theinfla""atory tri##er$



Patients (ith CF ha%e a defecti%e s"all chloride conductance channel, re#ulated !y cyclic

adenosine "onohoshate 'cAMP), (hich causes a!nor"al chloride transort across the aical

cell "e"!rane of eithelial cells$ &he atho#enesis of nasal olyosis in atients (ith CF could !e associated (ith this defect$

Epidemiology

Frequency

United States

&he o%erall incidence of nasal olys in children is 1$-/; the incidence in children (ith CF is *<=/$ A"on# adults, the incidence is -*</ o%erall, (ith a ran#e of 1$4*4=/$

International

>orld(ide incidence is the sa"e as the incidence in the 7nited States$

Mortality/Morbidity

o si#nificant "ortality is associated (ith nasal olyosis$ Mor!idity is usually associated (ith

altered ?uality of life, nasal o!struction, anos"ia, chronic sinusitis, headaches, snorin#, and ostnasal draina#e$ In certain situations, nasal olys can alter the craniofacial seleton !ecause

unre"o%ed olys can e2tend intracranially and into the or!ital %aults$

Race

asal olys occur in all races and social classes$

Sex

Althou#h the "ale*to*fe"ale ratio is 4*<:- in adults, the ratio in children is unreorted$ A re%ie(

of articles reortin# on children (hose nasal olyosis re?uired sur#ery sho(ed aarently e?ual re%alence in !oys and #irls, althou#h the data are inconclusi%e$3.5 &he reorted re%alence is

e?ual in atients (ith asth"a$

Age

Beni#n "ultile nasal olyosis usually "anifests in atients older than 41 years and is "ore

co""on in atients older than <1 years$ asal olys are rare in children youn#er than -1 years$



History

&he "anifestation of nasal olys deends on the si8e of the oly$ S"all olys "ay not roduce sy"to"s and "ay !e identified only durin# routine e2a"ination (hen they are anterior

to the anterior ed#e of the "iddle tur!inate$ Polys located osterior to the site are not tyically

seen durin# routine anterior rhinoscoy e2a"ination erfor"ed (ith an otoscoe and are "issedunless the child is sy"to"atic$ S"all olys in areas (here olys nor"ally arise 'ie, the

"iddle "eatus) "ay roduce sy"to"s and !loc the outflo( tract of the sinuses, causin#

chronic or recurrent acute sinusitis sy"to"s$

Sy"to"*roducin# olys can cause nasal air(ay o!struction, ostnasal draina#e, dullheadaches, snorin#, and rhinorrhea$ Associated hyos"ia or anos"ia "ay !e a clue that olys,

rather than chronic sinusitis alone, are resent$ Eista2is that does not arise fro" irritation of the

anterior nasal setu" 'ie, @iessel!ach area) usually does not occur (ith !eni#n "ultile olysand "ay su##est other, "ore serious, nasal ca%ity lesions$

Massi%e olyosis or a sin#le lar#e oly 'e#, antral*choanal oly 3see the i"a#es !elo(5 thato!structs the nasal ca%ities, nasoharyn2, or !oth) can cause o!structi%e slee sy"to"s and

chronic "outh !reathin#$


the septum on the left, inferior tur!inate on the right, middle tur!inate superiorly,

and antral-choanal polyp among the 8oor of the nose.

Rigid endoscopic view of the left anterior nasal cavity, showing the septum on the

left, a suction pushing the inferior tur!inate on the right, and the clear antral-







choanal polyp at the center of the endoscopic view.

lose-up of the middle meatus, showing the stal% of the antral-choanal polyp

emanating from the ma)illary sinus !ehind the uncinate process on the !ottom

right-hand side of the picture. "he left side of the picture shows the septum and the

middle tur!inate !eing pushed over via suction. ()ial "

scan section through the ma)illary sinuses showing opacication of the left

ma)illary sinus with antral-choanal polyp in the posterior nasal cavity and choana

e)iting from !eneath the middle tur!inate in the area of the ostiomeatal comple)

unit. cale is in centimeters. oronal " scan through the

anterior sinuses showing opacication of the left ma)illary sinus with opacication

of the inferior half of the nasal cavity on the left, lled !y the antral-choanal polyp.






"he rest of the sinuses are clear. oronal " scan section

through the posterior nasopharyn) showing the sphenoid sinus superiorly and the

antral-choanal polyp lling the nasopharyn) in the center of the scan.

ral cavity and oropharyngeal view of antral-choanal

polyp lling the posterior oral pharyn) and pushing the soft palate anterior and

inferiorly. "he polyp is visi!le !ehind the uvula and the soft palate.

cale is in inches. "he left side of the lesion was the

portion of the polyp in the nasal cavity. "he right was a stal% attached to the medial






ma)illary wall. 'ndoscopic view of the left middle

meatus, showing the septum on the left, the middle tur!inate in the center

superiorly, and a large ma)illary antrostomy with a curved suction on the right. "his

is following antral-choanal polyp removal.

arely, atients (ith cystic fi!rosis 'CF) and atients (ith aller#ic fun#al sinusitis 'AFS) ha%e

"assi%e olyoses$ &hese can alter the craniofacial structure and cause rotosis, hyerteloris",

and diloia$ See the i"a#es !elo($


the septum on the left. olyps with some !lood and hemorrhage are on top of them

in the center portion. "he rim of white from # o$cloc% to 4 o$cloc% indicates the

lateral nasal wall vesti!ule. "he polyps cover the inferior tur!inate, which is partially

visi!le at 4 and & o$cloc%. 'ndoscopic view of the left

nasal cavity, showing a polyp protruding from the uncinate process. "he middle

tur!inate is to the left. ( suction is visi!le on top of the inferior portion of the






uncinate process and inferior portion of the polyp. "he lateral nasal wall is on the far

right. "he polyp is directly in the center and is pale, glistening, and white.

'ndoscopic view of the left middle meatus. "he septum

is on the far left. "he middle tur!inate is ne)t to the septum on the left. ( large,

glistening, translucent polyp is visi!le in the center of the screen ne)t to the middle

tur!inate. "he lateral nasal wall is on the right side of the screen. "he inferior

tur!inate nu! posteriorly is in the !ottom right hand corner.

;iew <ust inside the nasal vesti!ule of a fteen-year-old

adolescent !oy with allergic fungal sinusitis showing di=used polyposis e)tending

into the anterior nasal cavity and vesti!ule> the septum is on the right, and the right

lateral vesti!ular wall 5nasal ala is on the left. "he polyps are all in the center. "he

polyps almost hang out of the nasal vesti!ule. oronal

section through the ethmoid ma)illary sinuses and or!its. "his is a 2-year-old child






with cystic !rosis, showing complete opacication of the ma)illary and ethmoid

sinuses. *ulging in the medial ma)illary walls is o!served.

oronal section showing soft tissue windows rather than

!ony windows. +t indicates the infection !y the thic% mucus in the ma)illary and

ethmoid cavities !y the heterogeneity of the opacication in the sinuses. 3ote that

the nasal cavity is completely o!literated !y polyp disease.

oronal " scan showing e)tensive allergic fungal

sinusitis involving the right side with mucocele a!ove the right or!it and e)pansion

of the sinuses on the right. oronal " scan showing

typical unilateral appearance of allergic sinusitis with hyperintense areas and

inhomogeneity of the sinus opacication> the hyperintense areas appear whitish in






the center of the allergic mucin. oronal ?R+ scan showing

e)pansion of the sinuses with allergic mucin and polypoid disease> the hypointense

!lac% areas in the nasal cavities are the actual fungal elements and de!ris. "he

density a!ove the right eye is the mucocele. "he fungal elements and allergic mucin

in allergic fungal sinusitis always loo% hypointense on ?R+ scanning and can !e

mista%en for a!sence of disease. ifteen year-old

adolescent !oy with allergic fungal sinusitis causing right proptosis, telecanthus,and malar 8attening> position of his eyes is asymmetrical, and his nasal ala on the

right is pushed inferiorly compared with the left. 3ine-

year-old girl with allergic fungal sinusitis displaying telecanthus and asymmetrical

positioning of her eyes and glo!es.

In an article su!"itted for u!lication, the author has reorted <1/ of children (ith AFS

resented (ith craniofacial a!nor"alities, co"ared (ith -1/ of adults (ith AFS$ Massi%e






olyosis rarely causes enou#h e2trinsic co"ression on the otic ner%e to decrease %isual

acuity$ Further"ore, !ecause they #ro( slo(ly, "assi%e olyoses usually cause no neurolo#ical

sy"to"s, e%en those that e2tend into the intracranial ca%ity$

Physical

Be#in hysical e2a"ination for nasal olys (ith an anterior rhinoscoy rocedure 'see the

i"a#e !elo()$ For s"all children, a handheld otoscoe and otolo#ic seculu" are tyically used$An otoscoe laced in the nasal ca%ity ro%ides %ie(s of the inferior tur!inate, anterior setu",

and areas in the nasal ca%ity e2tendin# to the anterior ed#e of the "iddle tur!inate and

"idortion of the setu"$ &he "iddle "eatus 'ie, the area under the "iddle tur!inate laterally)can often !e seen usin# anterior rhinoscoy if the child is cooerati%e and if no si#nificant

"ucosal ede"a or secretions are resent in the anterior nasal ca%ity$

(n anterior endoscopic view of the nasal cavity in a &-

month-old infant. "he vesti!ule is seen in the periphery of the picture. +n the centerof the picture, the septum is visi!le to the left, and the inferior tur!inate is to the

right. "hese structures are reddish in hue. ome congestion in the nasal cavity is

usually present. "hese are often structures that can !e seen only !y anterior

rhinoscopy. +f the area is decongested, the area of the middle meatus can

occasionally !e seen.

For !eni#n nasal olys, the "iddle "eatus is the "ost co""on location$ If ade?uately %isi!le,

%ie(s of the "iddle "eatus can re%eal (hether sufficient atholo#y is resent to (arrant

orderin# a C& scan of the sinuses, rather than refor"in# a ri#id or fle2i!le endoscoic

rocedure that "ay distress a youn# atient and the arents$ o(e%er, ri#id or fle2i!le

endoscoy is the !est "ethod to e2a"ine the nasal ca%ity and nasoharyn2 to fully assess thenasal anato"y 'see the i"a#es !elo() and to deter"ine the e2tent and location of nasal olys$




( rigid rhinoscopy photograph of the left anterior nasal

cavity of a 0-wee%-old infant. "he middle tur!inate is superiorly in the midline, and

the inferior tur!inate is to the right. "he septum is to the left.

( rigid rhinoscopy photograph ta%en in the midportion of

the left nasal cavity of a 0-wee%-old infant showing the septum on the left, the

inferior tur!inate on the right, and the middle tur!inate superiorly. "he choanae is

seen in the dar% area in the center. ( rigid rhinoscopy

photograph ta%en two thirds of the way !ac% along the 8oor of the nose of the left

nasal cavity of a 0-wee%-old infant. "his photograph shows the septum on the left,

the choanae straight ahead, and the posterior portion inferior tur!inate to the right.






( rigid rhinoscopy photograph of the the nasal cavity of a

0-wee%-old infant ta%en all the way !ac% into the choanae of the left nasal cavity.

"he photograph shows the septum on the left, the small adenoids on the posterior

superior wall of the nasopharyn) in the center, and the eustachian tu!e orice on

the right.

For s"all children, a fle2i!le fi!erotic nasoharyn#oscoe is often used !ecause it is less

trau"atic for children (ho "ay "o%e their heads fro" an2iety or disco"fort$ In older

cooerati%e children and adolescents, a ri#id endoscoy can !e used to assess the "iddle "eatusand the shenoeth"oid recess$ Perfor" ade?uate decon#estion and anesthesia of the nasal

ca%ities !efore an endoscoic rocedure for any child older than "onths$ ideo docu"entation

of the rocedure decreases the a"ount of ti"e necessary for the rocedure and later enhances

atient and arent education$

For children, e%aluatin# the osterior (all of the oral ca%ity also can indicate the

sy"to"atolo#y of olyosis 'e#, ostnasal draina#e conco"itant (ith chronic sinusitis)$ ar#e

olys or lesions of the nasal ca%ity "ay also rotrude into the osterior oroharyn2 fro" thenasoharyn2; these "ay occur as a lesion !ehind the alate and u%ula or "ay deress the alate

inferiorly and anteriorly 'see the i"a#e !elo()$ Perfor" otoscoic e2a"inations !ecause

e2tensi%e olyosis that causes eustachian tu!e dysfunction can cause fluid and infection in the"iddle ear sace$ Careful e2a"ination of the inner%ated syste"s of the cranial ner%es and of thecraniofacial structure hels define a nasal lesion6s otential e2ansion into surroundin# %ital

structures$

ral cavity and oropharyngeal view of antral-choanal

polyp lling the posterior oral pharyn) and pushing the soft palate anterior and

inferiorly. "he polyp is visi!le !ehind the uvula and the soft palate.





auses

As descri!ed in Pathohysiolo#y, chronic infla""ation 'fro" (hate%er source) aarently hasan initial role in the atho#enesis of nasal olys$ Multile olys occur in children (ith chronic

sinusitis, aller#ic rhinitis, CF, and AFS$ An isolated oly could !e an antral*choanal oly, a

!eni#n "assi%e oly, a nasolacri"al duct cyst 'as sho(n !elo(), or any con#enital lesion or !eni#n or "ali#nant tu"or listed !elo($

• 3asolacrimal duct cysts rontal view of a 2-day-oldinfant with swelling in the inferior medial canthal area on !oth sides. "heright side appears more prominent on this picture. " scan showed infected

nasal lacrimal duct cysts. Rigid endoscopic view of the left nasal cavity. "he septum is on the left, and the lateral nasal wall is onthe right. "he inferior tur!inate is in the center of the picture, and the middletur!inates are visi!le in the superior midsection of the picture. "he nasallacrimal duct cyst is the yellow dilated lesion underneath the inferior

tur!inate. ()ial " scan section through the or!it,showing the dilated nasal lacrimal ducts in the medial anterior areacompared to the or!its. cale on the !ottom right is in centimeters.






()ial " scan through the inferior nasal cavities,showing the dilated nasal lacrimal duct cysts at the inferior location. cale onthe !ottom right is in centimeters. "he dilated cysts are in the center of the

image. ( frontal view of the decompressed nasallacrimal ducts following surgical marsupiali6ation. welling in the inferiormedial canthal areas prior to surgery is no longer seen.

• 'ncephaloceles 5see the image !elow ( @-month-old infant with hypertelorism and !ulging of the nasal dorsum, secondary toencephalocele.

• Aliomas 5see the images !elow +nterior view of thenose and nasal cavities. "o the right of the patient$s left nostril, the right nasalcavity has no o!struction. n the left of the picture, a reddish polyp is visi!le.







"he reddish mass is a nasal glioma. ( close-upview of the right nasal cavity and polyp B& in a &-month-old infant. "heo!structing reddish polyp is visi!le. "his is an intranasal glioma that wasarising from the attachment of the inferior tur!inate anteriorly> it wastransnasally removed.

• Cermoid tumors 5see the images !elow Dateralview of a preteenaged child showing infected nasal dermoid. 3ote the

protrusion of the dorsum of the nose. reteenaged

!oy with infected nasal dermoid. ( pith is visi!le over the superior portion ofthe swelling !etween the eyes. 3asal pith is commonly seen with the nasal






dermoid. rontal view of a &-month-old infant,showing hypertelorism and protrusion in the gla!ellar region secondary to a

small nasal dermoid. ()ial " scan 5!ony windowsshowing a &-month-old infant with nasal dermoid anterior to the nasal andma)illary !ones. 3o !ony dehiscence or !ony a!normalities are visi!le.

( coronal ?R+ scan through the nasal dermoid of a&-month-old infant. "he scale on the left is 2 mm per small !ar and # cm pertall !ar. "he arrow points to the lesion. "he lesion appears to !e

appro)imately 0-7 mm in this dimension. (ninteroperative view of dermoid removal from a &-month-old infant.

• Eemangiomas







• apillomas 5see the image !elow (nterior nasalpapilloma arising from the septum. "he s%in of the nasal vesti!ule is seensurrounding the papilloma in the center of the image.

• Fuvenile nasopharyngeal angio!romas

• Rha!domyosarcoma 5see the images !elow ()ial ?R+scan of the or!its, posterior fossa, and nasal cavity. "he solid tumor is seenlling the posterior ethmoid comple), !rain stem, cavernous sinuses, and left

anterior cranial fossa. ()ial " scan through the or!itsand ethmoid sinuses, showing the rha!domyosarcoma in the same areas,including the posterior ethmoid comple), left middle fossa, and s%ull !ase of






cavernous sinuses. Rigid endoscopic view of leftnasal cavity, showing a polyp in the center of the picture, with e)tension ofthe rha!domyosarcoma. "he septum is on the left and the middle tur!inate ison the right.

• Dymphomas

• 3euro!lastomas

•

arcomas

• hordomas

• 3asopharyngeal carcinomas

• +nverting papillomas

E%aluate all children (ith !eni#n nasal olyosis for CF and asth"a

!i"erentials• (sthma• ystic i!rosis

• 3euro!lastoma

• 3euro!romatosis

• Rha!domyosarcoma

• inusitis

#aboratory Studies• Cirect la!oratory studies at the pathological process !elieved responsi!le for

the nasal polyps.• hildren with polyposis that is associated with allergic rhinitis should have an

evaluation for their allergies> this may include a serologicalradioallergosor!ent test 5R(" or some form of allergic s%in testing. ?a!ry etal showed a decrease in the recurrence rate of polyps in children treated with
















immunotherapy directed at all antigens for which they are allergic, especiallymolds>G4H therefore, allergy testing and treatment may !e important in treatingallergic fungal sinusitis 5(.

• erform a sweat chloride test or genetic testing for cystic !rosis 5 in anychild with multiple !enign nasal polyps.

• ( nasal smear for eosinophils may di=erentiate allergic from nonallergic sinusdiseases and indicate whether the child may !e responsive to glucocorticoids.

"he presence of neutrophils may indicate chronic sinusitis.

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