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 polyps are abnormal lesions that originate from any portion of the nasal
mucosa or paranasal sinuses. Polyps are an end result of varying disease processes in the nasal
cavities. The most commonly discussed polyps are benign semitransparent nasal lesions (see the
images below) that arise from the mucosa of the nasal cavity or from one or more of the
paranasal sinuses, often at the outflow tract of the sinuses.

Rigid endoscopic view of the left nasal cavity, showing

the septum on the left. Polyps with some blood and hemorrhage are on top of them
in the center portion. The rim of white from 1 o'clock to 4 o'clock indicates the
lateral nasal wall vestibule. The polyps cover the inferior turbinate, which is partially

visible at 4 and 5 o'clock.

Endoscopic view of the left
nasal cavity, showing a polyp protruding from the uncinate process. The middle
turbinate is to the left. A suction is visible on top of the inferior portion of the
uncinate process and inferior portion of the polyp. The lateral nasal wall is on the far

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

Endoscopic view of the left middle meatus. The septum

is on the far left. The middle turbinate is next to the septum on the left. A large,
glistening, translucent polyp is visible in the center of the screen next to the middle
turbinate. The lateral nasal wall is on the right side of the screen. The inferior
turbinate nub posteriorly is in the bottom right hand corner.

Multiple polyps can occur in children with chronic sinusitis, allergic rhinitis, cystic fibrosis (CF),
or allergic fungal sinusitis (AFS). An individual polyp could be an antral-choanal polyp, a benign
massive polyp, or any benign or malignant tumor (eg, encephaloceles, gliomas, hemangiomas,
papillomas, juvenile nasopharyngeal angiofibromas, rhabdomyosarcoma, lymphoma,
neuroblastoma, sarcoma, chordoma, nasopharyngeal carcinoma, inverting papilloma). Evaluate
all children with benign multiple nasal polyposis for CF and asthma.

Pathophysiology
The pathogenesis of nasal polyposis is unknown. Polyp development has been linked to chronic
inflammation, autonomic nervous system dysfunction, and genetic predisposition. Most theories
consider polyps to be the ultimate manifestation of chronic inflammation; therefore, conditions
leading to chronic inflammation in the nasal cavity can lead to nasal polyps.
The following conditions are associated with multiple benign polyps:

Bronchial asthma - In 20-50% of patients with polyps

CF - Polyps in 6-48% of patients with CF

Allergic rhinitis

AFS - Polyps in 85% of patients with AFS

Chronic rhinosinusitis

Primary ciliary dyskinesia

Aspirin intolerance - In 8-26% of patients with polyps

Alcohol intolerance - In 50% of patients with nasal polyps

Churg-Strauss syndrome - Nasal polyps in 50% of patients with Churg-Strauss

syndrome

Young syndrome (ie, chronic sinusitis, nasal polyposis, azoospermia)

Nonallergic rhinitis with eosinophilia syndrome (NARES) - Nasal polyps in 20%

of patients with NARES

Most studies suggest that polyps are associated more strongly with nonallergic disease than with
allergic disease. Statistically, nasal polyps are more common in patients with nonallergic asthma
(13%) than with allergic asthma (5%), and only 0.5% of 3000 atopic individuals have nasal
polyps.
Several theories have been postulated to explain the pathogenesis of nasal polyps, although none
seems to account fully for all the known facts. Some researchers believe that polyps are an
exvagination of the normal nasal or sinus mucosa that fills with edematous stroma; others believe
polyps are a distinct entity arising from the mucosa. Based on a review of the literature and
several intricate studies of the bioelectric properties of polyps, Bernstein derived a convincing
theory on the pathogenesis of nasal polyps, building on other theories and information from Tos.
[1, 2]

In Bernstein's theory, inflammatory changes first occur in the lateral nasal wall or sinus mucosa
as the result of viral-bacterial host interactions or secondary to turbulent airflow. In most cases,
polyps originate from contact areas of the middle meatus, especially the narrow clefts in the
anterior ethmoid region that create turbulent airflow, and particularly when narrowed by mucosal
inflammation. Ulceration or prolapse of the submucosa can occur, with reepithelialization and
new gland formation. During this process, a polyp can form from the mucosa because the
heightened inflammatory process from epithelial cells, vascular endothelial cells, and fibroblasts
affects the bioelectric integrity of the sodium channels at the luminal surface of the respiratory
epithelial cell in that section of the nasal mucosa. This response increases sodium absorption,
leading to water retention and polyp formation.
Other theories involve vasomotor imbalance or epithelial rupture. The vasomotor imbalance
theory postulates that increased vascular permeability and impaired vascular regulation cause
detoxification of mast-cell products (eg, histamine). The prolonged effects of these products
within the polyp stroma result in marked edema (especially in the polyp pedicle) that is worsened
by venous drainage obstruction. This theory is based on the cell-poor stroma of the polyps, which
is poorly vascularized and lacks vasoconstrictor innervation.
The epithelial rupture theory suggests that rupture of the epithelium of the nasal mucosa is
caused by increased tissue turgor in illness (eg, allergies, infections). This rupture leads to
prolapse of the lamina propria mucosa, forming polyps. The defects are possibly enlarged by
gravitational effects or venous drainage obstruction, causing the polyps. This theory, although
similar to Bernstein's, provides a less convincing explanation for polyp enlargement than the
sodium flux theory supported by Bernstein's data. Neither theory completely defines the
inflammatory trigger.

Patients with CF have a defective small chloride conductance channel, regulated by cyclic
adenosine monophosphate (cAMP), which causes abnormal chloride transport across the apical
cell membrane of epithelial cells. The pathogenesis of nasal polyposis in patients with CF could
be associated with this defect.

Epidemiology
Frequency
United States

The overall incidence of nasal polyps in children is 0.1%; the incidence in children with CF is 648%. Among adults, the incidence is 1-4% overall, with a range of 0.2-28%.
International

Worldwide incidence is the same as the incidence in the United States.

Mortality/Morbidity

No significant mortality is associated with nasal polyposis. Morbidity is usually associated with
altered quality of life, nasal obstruction, anosmia, chronic sinusitis, headaches, snoring, and
postnasal drainage. In certain situations, nasal polyps can alter the craniofacial skeleton because
unremoved polyps can extend intracranially and into the orbital vaults.
Race

Nasal polyps occur in all races and social classes.

Sex

Although the male-to-female ratio is 2-4:1 in adults, the ratio in children is unreported. A review
of articles reporting on children whose nasal polyposis required surgery showed apparently equal
prevalence in boys and girls, although the data are inconclusive.[3] The reported prevalence is
equal in patients with asthma.
Age

Benign multiple nasal polyposis usually manifests in patients older than 20 years and is more
common in patients older than 40 years. Nasal polyps are rare in children younger than 10 years.

History
The manifestation of nasal polyps depends on the size of the polyp. Small polyps may not
produce symptoms and may be identified only during routine examination when they are anterior
to the anterior edge of the middle turbinate. Polyps located posterior to the site are not typically
seen during routine anterior rhinoscopy examination performed with an otoscope and are missed
unless the child is symptomatic. Small polyps in areas where polyps normally arise (ie, the
middle meatus) may produce symptoms and block the outflow tract of the sinuses, causing
chronic or recurrent acute sinusitis symptoms.
Symptom-producing polyps can cause nasal airway obstruction, postnasal drainage, dull
headaches, snoring, and rhinorrhea. Associated hyposmia or anosmia may be a clue that polyps,
rather than chronic sinusitis alone, are present. Epistaxis that does not arise from irritation of the
anterior nasal septum (ie, Kiesselbach area) usually does not occur with benign multiple polyps
and may suggest other, more serious, nasal cavity lesions.
Massive polyposis or a single large polyp (eg, antral-choanal polyp [see the images below] that
obstructs the nasal cavities, nasopharynx, or both) can cause obstructive sleep symptoms and
chronic mouth breathing.

Rigid endoscopic view of the left nasal cavity, showing

the septum on the left, inferior turbinate on the right, middle turbinate superiorly,

and antral-choanal polyp among the floor of the nose.

Rigid endoscopic view of the left anterior nasal cavity, showing the septum on the
left, a suction pushing the inferior turbinate on the right, and the clear antral-

choanal polyp at the center of the endoscopic view.

Close-up of the middle meatus, showing the stalk of the antral-choanal polyp
emanating from the maxillary sinus behind the uncinate process on the bottom
right-hand side of the picture. The left side of the picture shows the septum and the

middle turbinate being pushed over via suction.

Axial CT
scan section through the maxillary sinuses showing opacification of the left
maxillary sinus with antral-choanal polyp in the posterior nasal cavity and choana
exiting from beneath the middle turbinate in the area of the ostiomeatal complex

unit. Scale is in centimeters.

Coronal CT scan through the
anterior sinuses showing opacification of the left maxillary sinus with opacification
of the inferior half of the nasal cavity on the left, filled by the antral-choanal polyp.

The rest of the sinuses are clear.

Coronal CT scan section
through the posterior nasopharynx showing the sphenoid sinus superiorly and the
antral-choanal polyp filling the nasopharynx in the center of the scan.

Oral cavity and oropharyngeal view of antral-choanal

polyp filling the posterior oral pharynx and pushing the soft palate anterior and
inferiorly. The polyp is visible behind the uvula and the soft palate.

Scale is in inches. The left side of the lesion was the

portion of the polyp in the nasal cavity. The right was a stalk attached to the medial

maxillary wall.
Endoscopic view of the left middle
meatus, showing the septum on the left, the middle turbinate in the center
superiorly, and a large maxillary antrostomy with a curved suction on the right. This
is following antral-choanal polyp removal.

Rarely, patients with cystic fibrosis (CF) and patients with allergic fungal sinusitis (AFS) have
massive polyposes. These can alter the craniofacial structure and cause proptosis, hypertelorism,
and diplopia. See the images below.

Rigid endoscopic view of the left nasal cavity, showing

the septum on the left. Polyps with some blood and hemorrhage are on top of them
in the center portion. The rim of white from 1 o'clock to 4 o'clock indicates the
lateral nasal wall vestibule. The polyps cover the inferior turbinate, which is partially

visible at 4 and 5 o'clock.

Endoscopic view of the left
nasal cavity, showing a polyp protruding from the uncinate process. The middle
turbinate is to the left. A suction is visible on top of the inferior portion of the

uncinate process and inferior portion of the polyp. The lateral nasal wall is on the far
right. The polyp is directly in the center and is pale, glistening, and white.

Endoscopic view of the left middle meatus. The septum

is on the far left. The middle turbinate is next to the septum on the left. A large,
glistening, translucent polyp is visible in the center of the screen next to the middle
turbinate. The lateral nasal wall is on the right side of the screen. The inferior
turbinate nub posteriorly is in the bottom right hand corner.

View just inside the nasal vestibule of a fifteen-year-old

adolescent boy with allergic fungal sinusitis showing diffused polyposis extending
into the anterior nasal cavity and vestibule; the septum is on the right, and the right
lateral vestibular wall (nasal ala) is on the left. The polyps are all in the center. The

polyps almost hang out of the nasal vestibule.

Coronal
section through the ethmoid maxillary sinuses and orbits. This is a 2-year-old child

with cystic fibrosis, showing complete opacification of the maxillary and ethmoid
sinuses. Bulging in the medial maxillary walls is observed.

Coronal section showing soft tissue windows rather than

bony windows. It indicates the infection by the thick mucus in the maxillary and
ethmoid cavities by the heterogeneity of the opacification in the sinuses. Note that
the nasal cavity is completely obliterated by polyp disease.

Coronal CT scan showing extensive allergic fungal

sinusitis involving the right side with mucocele above the right orbit and expansion

of the sinuses on the right.

Coronal CT scan showing
typical unilateral appearance of allergic sinusitis with hyperintense areas and
inhomogeneity of the sinus opacification; the hyperintense areas appear whitish in

the center of the allergic mucin.

Coronal MRI scan showing
expansion of the sinuses with allergic mucin and polypoid disease; the hypointense
black areas in the nasal cavities are the actual fungal elements and debris. The
density above the right eye is the mucocele. The fungal elements and allergic mucin
in allergic fungal sinusitis always look hypointense on MRI scanning and can be

mistaken for absence of disease.

Fifteen year-old
adolescent boy with allergic fungal sinusitis causing right proptosis, telecanthus,
and malar flattening; position of his eyes is asymmetrical, and his nasal ala on the

right is pushed inferiorly compared with the left.

Nineyear-old girl with allergic fungal sinusitis displaying telecanthus and asymmetrical
positioning of her eyes and globes.

In an article submitted for publication, the author has reported 40% of children with AFS
presented with craniofacial abnormalities, compared with 10% of adults with AFS. Massive

polyposis rarely causes enough extrinsic compression on the optic nerve to decrease visual
acuity. Furthermore, because they grow slowly, massive polyposes usually cause no neurological
symptoms, even those that extend into the intracranial cavity.

Physical
Begin physical examination for nasal polyps with an anterior rhinoscopy procedure (see the
image below). For small children, a handheld otoscope and otologic speculum are typically used.
An otoscope placed in the nasal cavity provides views of the inferior turbinate, anterior septum,
and areas in the nasal cavity extending to the anterior edge of the middle turbinate and
midportion of the septum. The middle meatus (ie, the area under the middle turbinate laterally)
can often be seen using anterior rhinoscopy if the child is cooperative and if no significant
mucosal edema or secretions are present in the anterior nasal cavity.

An anterior endoscopic view of the nasal cavity in a 5month-old infant. The vestibule is seen in the periphery of the picture. In the center
of the picture, the septum is visible to the left, and the inferior turbinate is to the
right. These structures are reddish in hue. Some congestion in the nasal cavity is
usually present. These are often structures that can be seen only by anterior
rhinoscopy. If the area is decongested, the area of the middle meatus can
occasionally be seen.

For benign nasal polyps, the middle meatus is the most common location. If adequately visible,
views of the middle meatus can reveal whether sufficient pathology is present to warrant
ordering a CT scan of the sinuses, rather than preforming a rigid or flexible endoscopic
procedure that may distress a young patient and the parents. However, rigid or flexible
endoscopy is the best method to examine the nasal cavity and nasopharynx to fully assess the
nasal anatomy (see the images below) and to determine the extent and location of nasal polyps.

A rigid rhinoscopy photograph of the left anterior nasal

cavity of a 6-week-old infant. The middle turbinate is superiorly in the midline, and
the inferior turbinate is to the right. The septum is to the left.

A rigid rhinoscopy photograph taken in the midportion of

the left nasal cavity of a 6-week-old infant showing the septum on the left, the
inferior turbinate on the right, and the middle turbinate superiorly. The choanae is

seen in the dark area in the center.

A rigid rhinoscopy
photograph taken two thirds of the way back along the floor of the nose of the left
nasal cavity of a 6-week-old infant. This photograph shows the septum on the left,
the choanae straight ahead, and the posterior portion inferior turbinate to the right.

A rigid rhinoscopy photograph of the the nasal cavity of a

6-week-old infant taken all the way back into the choanae of the left nasal cavity.
The photograph shows the septum on the left, the small adenoids on the posterior
superior wall of the nasopharynx in the center, and the eustachian tube orifice on
the right.

For small children, a flexible fiberoptic nasopharyngoscope is often used because it is less
traumatic for children who may move their heads from anxiety or discomfort. In older
cooperative children and adolescents, a rigid endoscopy can be used to assess the middle meatus
and the sphenoethmoid recess. Perform adequate decongestion and anesthesia of the nasal
cavities before an endoscopic procedure for any child older than 6 months. Video documentation
of the procedure decreases the amount of time necessary for the procedure and later enhances
patient and parent education.
For children, evaluating the posterior wall of the oral cavity also can indicate the
symptomatology of polyposis (eg, postnasal drainage concomitant with chronic sinusitis). Large
polyps or lesions of the nasal cavity may also protrude into the posterior oropharynx from the
nasopharynx; these may occur as a lesion behind the palate and uvula or may depress the palate
inferiorly and anteriorly (see the image below). Perform otoscopic examinations because
extensive polyposis that causes eustachian tube dysfunction can cause fluid and infection in the
middle ear space. Careful examination of the innervated systems of the cranial nerves and of the
craniofacial structure helps define a nasal lesion's potential expansion into surrounding vital
structures.

Oral cavity and oropharyngeal view of antral-choanal

polyp filling the posterior oral pharynx and pushing the soft palate anterior and
inferiorly. The polyp is visible behind the uvula and the soft palate.

Causes
As described in Pathophysiology, chronic inflammation (from whatever source) apparently has
an initial role in the pathogenesis of nasal polyps. Multiple polyps occur in children with chronic
sinusitis, allergic rhinitis, CF, and AFS. An isolated polyp could be an antral-choanal polyp, a
benign massive polyp, a nasolacrimal duct cyst (as shown below), or any congenital lesion or
benign or malignant tumor listed below.

Nasolacrimal duct cysts

Frontal view of a 2-day-old
infant with swelling in the inferior medial canthal area on both sides. The
right side appears more prominent on this picture. CT scan showed infected

nasal lacrimal duct cysts.

Rigid endoscopic view of
the left nasal cavity. The septum is on the left, and the lateral nasal wall is on
the right. The inferior turbinate is in the center of the picture, and the middle
turbinates are visible in the superior midsection of the picture. The nasal
lacrimal duct cyst is the yellow dilated lesion underneath the inferior

turbinate.
Axial CT scan section through the orbit,
showing the dilated nasal lacrimal ducts in the medial anterior area
compared to the orbits. Scale on the bottom right is in centimeters.

Axial CT scan through the inferior nasal cavities,

showing the dilated nasal lacrimal duct cysts at the inferior location. Scale on
the bottom right is in centimeters. The dilated cysts are in the center of the

image.
A frontal view of the decompressed nasal
lacrimal ducts following surgical marsupialization. Swelling in the inferior
medial canthal areas prior to surgery is no longer seen.

Encephaloceles (see the image below)

A 3-monthold infant with hypertelorism and bulging of the nasal dorsum, secondary to
encephalocele.

Gliomas (see the images below)

Interior view of the
nose and nasal cavities. To the right of the patient's left nostril, the right nasal
cavity has no obstruction. On the left of the picture, a reddish polyp is visible.

The reddish mass is a nasal glioma.

A close-up
view of the right nasal cavity and polyp #5 in a 5-month-old infant. The
obstructing reddish polyp is visible. This is an intranasal glioma that was
arising from the attachment of the inferior turbinate anteriorly; it was
transnasally removed.

Dermoid tumors (see the images below)

Lateral
view of a preteenaged child showing infected nasal dermoid. Note the

protrusion of the dorsum of the nose.

Preteenaged
boy with infected nasal dermoid. A pith is visible over the superior portion of
the swelling between the eyes. Nasal pith is commonly seen with the nasal

dermoid.
Frontal view of a 5-month-old infant,
showing hypertelorism and protrusion in the glabellar region secondary to a

small nasal dermoid.

Axial CT scan (bony windows)
showing a 5-month-old infant with nasal dermoid anterior to the nasal and
maxillary bones. No bony dehiscence or bony abnormalities are visible.

A coronal MRI scan through the nasal dermoid of a

5-month-old infant. The scale on the left is 2 mm per small bar and 1 cm per
tall bar. The arrow points to the lesion. The lesion appears to be

approximately 6-7 mm in this dimension.

interoperative view of dermoid removal from a 5-month-old infant.

Hemangiomas

An

Papillomas (see the image below)

Anterior nasal
papilloma arising from the septum. The skin of the nasal vestibule is seen
surrounding the papilloma in the center of the image.

Juvenile nasopharyngeal angiofibromas

Rhabdomyosarcoma (see the images below)

Axial MRI
scan of the orbits, posterior fossa, and nasal cavity. The solid tumor is seen
filling the posterior ethmoid complex, brain stem, cavernous sinuses, and left

anterior cranial fossa.

Axial CT scan through the orbits
and ethmoid sinuses, showing the rhabdomyosarcoma in the same areas,
including the posterior ethmoid complex, left middle fossa, and skull base of

cavernous sinuses.
Rigid endoscopic view of left
nasal cavity, showing a polyp in the center of the picture, with extension of
the rhabdomyosarcoma. The septum is on the left and the middle turbinate is
on the right.

Lymphomas

Neuroblastomas

Sarcomas

Chordomas

Nasopharyngeal carcinomas

Inverting papillomas

Evaluate all children with benign nasal polyposis for CF and asthma

Differentials

Asthma
Cystic Fibrosis

Neuroblastoma

Neurofibromatosis

Rhabdomyosarcoma

Sinusitis

Laboratory Studies

Direct laboratory studies at the pathological process believed responsible for

the nasal polyps.
Children with polyposis that is associated with allergic rhinitis should have an
evaluation for their allergies; this may include a serological
radioallergosorbent test (RAST) or some form of allergic skin testing. Mabry et
al showed a decrease in the recurrence rate of polyps in children treated with

immunotherapy directed at all antigens for which they are allergic, especially
molds;[4] therefore, allergy testing and treatment may be important in treating
allergic fungal sinusitis (AFS).

Perform a sweat chloride test or genetic testing for cystic fibrosis (CF) in any
child with multiple benign nasal polyps.

A nasal smear for eosinophils may differentiate allergic from nonallergic sinus
diseases and indicate whether the child may be responsive to glucocorticoids.
The presence of neutrophils may indicate chronic sinusitis.