8-15: Tumors & Granulomatous Disease

1. BENIGN NASAL TUMORS

A. Nasal Polyps

Nasal polyps are pale, edematous, mucosally covered masses commonly seen in patients with allergic rhinitis. They may result in chronic nasal obstruction and a diminished sense of smell. In patients with nasal polyps and a history of asthma, aspirin should be avoided because it may precipitate a severe episode of bronchospasm, known as triad asthma (Samter triad). Such patients may have an immunologic salicylate sensitivity.

Use of topical intranasal corticosteroids improves the quality of life in patients with nasal polyposis and chronic rhinosinusitis. Initial treatment with topical nasal corticosteroids (see Allergic Rhinitis section for specific medications) for 1–3 months is usually successful for small polyps and may reduce the need for operation. A short course of oral corticosteroids (eg, prednisone, 6-day course using 21 [5-mg] tablets: 6 tablets [30 mg] on day 1 and tapering by 1 tablet [5 mg] each day) may also be of benefit, but when polyps are massive or medical management is unsuccessful obstructing polyps may be removed surgically. Polyps may readily be removed using endoscopic sinus surgery techniques. It may be necessary to remove polyps from the ethmoid, sphenoid, and maxillary sinuses to provide longer-lasting relief and open the affected sinuses. Intranasal corticosteroids should be continued following polyp removal to prevent recurrence, and the clinician should consider allergen testing to determine the offending allergen and avoidance measures.

B. Inverted Papillomas

Inverted papillomas are benign tumors caused by HPV that usually arise on the lateral nasal wall. They present with unilateral nasal obstruction and occasionally hemorrhage. They are often easily seen on anterior rhinoscopy as cauliflower-like growths in or around the middle meatus. Because squamous cell carcinoma is seen in about 10% of inverted or schneiderian papillomas, complete excision is strongly recommended. This usually requires an endoscopic medial maxillectomy. While rare, very extensive disease may require an open inferior or total maxillectomy for complete removal. Because recurrence rates for inverted papillomas are reported to be as high as 20%, subsequent clinical and radiologic follow-up is imperative. All excised tissue (not just a portion) should be carefully reviewed by the pathologist to be sure no carcinoma is present.

2. MALIGNANT NASOPHARYNGEAL & PARANASAL SINUS TUMORS

Though rare, malignant tumors of the nose, nasopharynx, and paranasal sinuses are quite problematic because they tend to remain ...