Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Patient Story Download Section PDF Listen ++ 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 30-1). ++Figure 30-1Graphic Jump LocationView Full Size||Download Slide (.ppt)Nasal polyp in left middle meatus with normal surrounding mucosa. (Courtesy of William Clark, MD.) + Introduction Download Section PDF Listen ++ Nasal polyps are benign lesions arising from the mucosa of the nasal passages including the paranasal sinuses. They are most commonly semitransparent. + Epidemiology Download Section PDF Listen ++ See reference 1. ++ Prevalence of 1% to 4% of adults; 0.1% of children of all races and classes.The male-to-female ratio in adults is approximately 2:1.Peak age of onset is 20 to 40 years old; rare in children younger than 10 years old.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 Download Section PDF Listen ++ 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 Download Section PDF Listen +++ Clinical Features ++ The appearance is usually smooth and rounded (Figure 30-1).Moist and translucent (Figure 30-2).Variable size.Color ranging from nearly none to deep erythema. ++Figure 30-2Graphic Jump LocationView Full Size||Download Slide (.ppt)Nasal polyp in right nasal cavity in a patient with inflamed mucosa from allergic rhinitis. (Courtesy of William Clark, MD.) +++ Typical Distribution ++ The middle meatus is the most common location. +++ 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 30-3). ++Figure 30-3Graphic Jump LocationView Full Size||Download Slide (.ppt)CT scan showing polyps (asterisk) and bilateral opacified maxillary sinuses (MS). Note the nasal polyp appears to be coming from the left maxillary sinus and is above the inferior turbinate. (Courtesy of Richard P. Usatine, MD.) +++ Biopsy ++ Not usually indicated. Histology typically shows pseudostratified ciliary epithelium, edematous stroma, epithelial basement membrane, and proinflammatory cells with eosinophils present in 80% to 90% of cases. + Differential Diagnosis Download Section PDF Listen ++ Many relatively rare conditions can cause an intranasal mass including (in adults): ++ Papilloma—About 1% of nasal tumors, affecting 1 in 100,000 adults per year. Locally invasive, these tend to recur especially if excision is not complete. Papillomas are of unknown etiology but are associated with chronic sinusitis, air pollution, and viral infections. They are irregular and friable in appearance and bleed easily.3Meningoencephalocele—Grayish gelatinous appearance.4Nasopharyngeal carcinoma—Firm, often ulcerated.Pyogenic granuloma—Relatively common benign vascular neoplasm of skin and mucous membranes (see Chapter 161, Pyogenic Granuloma).5Chordoma—Locally invasive neoplasms with gelatinous appearance that arise from notochordal (embryonic) remnants. Occurs in all age groups (mean age: 48 years).6Glioblastoma—Rare manifestation of the most common kind of brain tumor in adults. ++ Conditions that may mimic nasal polyp in children include: ++ Rhabdomyosarcoma—Malignant tumor of childhood originating from striated muscle.Dermoid tumor—Inclusion cysts of ectodermal epithelial elements, usually manifest before 20 years of age. May grow slowly.Hemangioma—Congenital, abnormal proliferation of blood vessels that may occur in any vascularized tissue (see Chapter 109, Childhood Hemangiomas and Vascular Malformations).Neuroblastoma—Unusual presentation of relatively common malignancy of childhood.Meningoencephalocele—Grayish gelatinous appearance.Angiofibroma—Locally invasive neoplasm that appears as a firm grayish mass. Bleeds easily. Occurs in adolescent males ages 14 to 18 years. Undetermined etiology.7Pyogenic granuloma (see Chapter 161, Pyogenic Granuloma).5 + Management Download Section PDF Listen +++ Medications ++ Medical treatment consists of intranasal corticosteroids.8 SOR AAn initial short course (2 to 4 weeks) of oral steroids may be considered in severe cases.9,10 SOR ASteroid treatment reduces polyp size, but does not generally resolve them. Corticosteroid treatment is also useful preoperatively to reduce polyp size.Oral doxycycline 100 mg daily for 20 days was shown to decrease polyp size, providing benefit for 12 weeks in one randomized controlled trial.11 SOR BTopical nasal decongestants may provide some symptom relief, but do not reduce polyp size.12 SOR BMontelukast reduces symptoms when used as an adjunct to oral and inhaled steroid therapy in patients with bilateral nasal polyposis.13 SOR B +++ Procedures ++ Surgical excision is often required to relieve symptoms.Consider immunotherapy for patients with allergies. + Prognosis Download Section PDF Listen ++ Lesions are benign and tend to recur. + Follow-Up Download Section PDF Listen ++ Periodic reevaluation is recommended because recurrence rates are high.14 + Patient Education Download Section PDF Listen ++ Patients should be informed about the benign nature of nasal polyps and their tendency to recur. +++ Patient Resources ++ http://www.mayoclinic.com/health/nasal-polyps/DS00498.http://www.nlm.nih.gov/medlineplus/ency/article/001641.htm. +++ Provider Resources ++ http://emedicine.medscape.com/article/994274.http://emedicine.medscape.com/article/861353. + References Download Section PDF Listen ++1. McClay JE. Nasal Polyps. http://emedicine.medscape.com/article/994274. Accessed July 20, 2011. ++2. Pawliczak R, Lewandowska-Polak A, Kowalski ML. Pathogenesis of nasal polyps: an update. Curr Allergy Asthma Rep. 2005;5:463-471. [PubMed: 16216171] ++3. Sadeghi N. Sinonasal Papillomas. http://emedicine.medscape.com/article/862677. Accessed July 20, 2011. ++4. Kumar KK, Ganapathy K, Sumathi V, et al. Adult meningoencephalocele presenting as a nasal polyp. J Clin Neurosci. 2005;12:594-596. [PubMed: 15936196] ++5. Hoving EW. Nasal encephaloceles. Childs Nerv Syst. 2000;16:702-706. [PubMed: 11151720] ++6. Palmer CA. Chordoma. http://emedicine.medscape.com/article/250902. Accessed July 20, 2011. ++7. Tewfik TL. Angiofibroma. http://emedicine.medscape.com/article/872580. Accessed July 20, 2011. ++8. Joe SA, Thambi R, Huang J. A systematic review of the use of intranasal steroids in the treatment of chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2008;139(3):340-347. [PubMed: 18722209] ++9. Martinez-Devesa P, Patiar S. Oral steroids for nasal polyps. Cochrane Database Syst Rev. 2011;6(7):CD005232. ++10. Vaidyanathan S, Barnes M, Williamson P, et al. Treatment of chronic rhinosinusitis with nasal polyposis with oral steroids followed by topical steroids: a randomized trial. Ann Intern Med. 2011;154(5):293-302. [PubMed: 21357906] ++11. Van Zele T, Gevaert P, Holtappels G, et al. Oral steroids and doxycycline: two different approaches to treat nasal polyps. J Allergy Clin Immunol. 2010;125(5):1069-1076.e4. ++12. Johansson L, Oberg D, Melem I, Bende M. Do topical nasal decongestants affect polyps? Acta Otolaryngol. 2006:126:288-290. ++13. Stewart RA, Ram B, Hamilton G, et al. Montelukast as an adjunct to oral and inhaled steroid therapy in chronic nasal polyposis. Otolaryngol Head Neck Surg. 2008;139(5):682-687. [PubMed: 18984264] ++14. Vento SI, Ertama LO, Hytonen ML, et al. Nasal polyposis: clinical course during 20 years. Ann Allergy Asthma Immunol. 2000;85:209-214. [PubMed: 11030275]