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PATIENT STORY

A 35-year-old man complains of unilateral nasal obstruction for the past several months of gradual onset. On examination of the nose, a nasal polyp is found (Figure 32-1).

FIGURE 32-1

Nasal polyp in left middle meatus with normal surrounding mucosa. (Reproduced with permission from William Clark, MD.)

INTRODUCTION

Nasal polyps are benign lesions arising from the mucosa of the nasal passages, including the paranasal sinuses. They are most commonly semitransparent.

EPIDEMIOLOGY

  • Prevalence of 1% to 4% of adults; 0.1% of children of all races and classes1.

  • The male-to-female ratio in adults is approximately 2-4:1.

  • Peak age of onset is 20 to 40 years; rare in children younger than 10 years.

  • Associated with the following conditions:

    • Nonallergic and allergic rhinitis and rhinosinusitis

    • Asthma—In 20% to 50% of patients with polyps

    • Cystic fibrosis

    • Aspirin intolerance—In 8% to 26% of patients with polyps

    • Alcohol intolerance—In 50% of patients with polyps

ETIOLOGY AND PATHOPHYSIOLOGY

  • The precise cause of nasal polyp formation is unknown.

  • Infectious agents causing desquamation of the mucous membrane may play a triggering role.

  • Activated epithelial cells appear to be the major source of mediators that induce an influx of inflammatory cells, including eosinophils prominently; these in turn lead to proliferation and activation of fibroblasts.2 Cytokines and growth factors play a role in maintaining the mucosal inflammation associated with polyps.

  • Food allergies are strongly associated with nasal polyps.

DIAGNOSIS

CLINICAL FEATURES

  • The appearance is usually smooth and rounded (Figure 32-1).

  • Moist and translucent (Figure 32-2).

  • Variable size.

  • Color ranging from nearly none to deep erythema.

FIGURE 32-2

Nasal polyp in right nasal cavity in a patient with inflamed mucosa from allergic rhinitis. (Reproduced with permission from William Clark, MD.)

TYPICAL DISTRIBUTION

  • The middle meatus (origin from the ethmoid sinus) is the most common location. Nasal polyps are frequently bilateral.

LABORATORY AND IMAGING

  • Consider allergy testing.

  • In children with multiple polyps, order sweat test to rule out cystic fibrosis.

  • CT of the nose and paranasal sinuses may be indicated to evaluate extent of lesion(s) (Figure 32-3).

FIGURE 32-3

CT scan showing polyps (asterisk) and bilateral opacified maxillary sinuses (MS). Note that the nasal polyp appears to be coming from the left maxillary sinus and is above the inferior turbinate. (Reproduced with permission from Richard P. Usatine, MD.)

BIOPSY

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