Nasal polyps are pale grey pedunculated masses often prolaps- ing from the sinuses into the nasal cavity. They most commonly Plain sinus radiographs have no role
in the routine investigation of chronic rhinosinusitis, because abnormalities are present in up to 40% of the normal population.
Clinical insight
Nasal polyps in a child indicate cystic fibrosis until proved otherwise.
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arise from ethmoid air cells and less frequently from the maxil- lary sinuses, turbinates or septum.
Pathogenesis
Chronic inflammation of the nasal and sinus mucosa leads to oedema and reactive hyperplasia; this can progress and lead to polyp formation. There are many theories as to the exact pathogenesis, and it is incompletely understood why some people develop the disorder. In many cases the pol- yps are related to allergy and are sometimes attributed to chronic sinus infection, which may be bacterial or fungal. They are nearly always bilateral; if unilateral, neoplasia must be suspected. Inflammatory polyps themselves are not premalignant.
In children polyps can be related to cystic fibrosis. Asthma, aspirin sensitivity and nasal polyposis often occur together (Samter’s triad).
Clinical features
Progressive nasal obstruction, rhinorrhoea, postnasal drip and anosmia are the most common symptoms.
Otological symptoms from Eustachian tube obstruction, recurrent sinusitis and occasionally headaches or facial
Medical Surgical
• Corticosteroids. Usually topical (fluticasone, mometasone, betamethasone). For severe cases, systemic steroids may be considered for short period • Saline nasal douching • Macrolide antibiotic (e.g. azithromycin or clarithromycin) for 12 weeks • Antihistamine for allergic rhinitis • Allergen avoidance and good asthma control • Functional endoscopic sinus surgery to restore adequate ventilation and drainage of sinuses and remove polyps • Balloon sinuplasty: a relatively
new procedure that can help cases with localised limited disease
discomfort may occur. Nasal blockage may lead to snoring and obstructive sleep apnoea. Nasal polyps may exacerbate coexisting asthma.
Rarely, distortion of the facial skeleton occurs secondary to chronic pressure from long-standing and extensive polyposis, but actual erosion of bone, either clinically or radiologically, should raise suspicion of malignancy. Inflammatory polyps are not usually bloody.
Antrochoanal polyps are less common and arise from the maxillary antrum on one side. They extend through the sinus ostium and extend posteriorly to block the posterior choana.
Investigation
Anterior rhinoscopy and nasal endoscopy should be performed. Smooth, translucent pale blue/grey pedunculated masses which can be single or multiple are seen. They are insensitive, but are usually mobile around their stalks.
Investigation of bilateral inflammatory polyps is not always necessary. If polypectomy with functional endoscopic sinus surgery is being considered, or if any sinister features such as bleeding, unilateral polyp, orbital signs and symptoms are present, then a CT scan of the sinuses including 3– to 4– mm coronal cuts should be obtained. This is used both to assess the extent and nature of the disease and as an anatomical ‘road map’ for endoscopic surgery.
Allergy testing by serological radioallergosorbent test (RAST) or allergy skin prick testing should be considered if suggested by the history. It’s important to exclude CF in children, so a chloride sweat test or genetic testing for CF is usually indicated.
Differential diagnosis
Large polypoidal inferior turbinates may mimic nasal polyps but are vascular, sensate, and attached to the lateral nasal wall (Figure 4.4). Other nasal masses that may mimic the symptoms/ appearance of inflammatory nasal polyps include primary malignant tumours (usually squamous cell carcinoma – SCC), inverted papilloma, neurogenic lesions, e.g. olfactory neuro- blastoma, and juvenile nasopharyngeal angiofibroma.
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Sinonasal neoplasia may be suspected in patients having unilateral polyps with serosanguineous discharge, and nasal obstruction with or without sinus, dental or orbital symptoms. Suspected neoplasia should be investigated with both CT and MRI scanning of the sinuses for bony and soft tissue detail (see Figure 4.8). However, most multiple bilateral nasal polyps are benign, inflammatory or allergic in nature.
Management
Medical
Topical nasal steroid drops/ sprays and/or oral corticoste- roids are effective treatment for nasal polyps. Corticoste- roids can be used to shrink polyps before surgery, to reduce the rate of regrowth after surgery, or as a primary treatment modality.
Short courses of oral steroids are commonly used without significant side effects in carefully selected individuals. The effects are, however, nearly always short-lasting. A history of diabetes, TB, glaucoma, gastric ulceration/gastritis and os- teoporosis are among the contraindications to this regimen.
Figure 4.4 Hypertrophied nasal turbinate.
Polypoidal inferior turbinates (Figure
4.4) can be differentiated from nasal
polyps (see Figure 4.2) by the application of topical nasal decongestant spray, which shrinks the vascular turbinates but rarely affects nasal polyps.
Nasal steroid drops/sprays can shrink smaller polyps and are useful for slowing recurrence.
Some patients also show benefit from oral leukotriene recep- tor antagonists or macrolide antibiotics.
Surgical
This consists of polypectomy, usually together with resection of ethmoid air cells, and is nearly always performed endoscopi- cally. A microdebrider can make this much simpler. Nasal polyps removed during surgery are sent for histology. A CT scan should be taken prior to surgery.
Prognosis
Despite surgical excision nasal polyps tend to recur, although this can be reduced by the use of long-term medical therapy (topical corticosteroid).
4.5 Epistaxis
Epistaxis is an acute haemorrhage from the nasal cavity or nasopharynx. This may be classified as anterior or posterior, depending on the location of bleeding from the nasal cavity.
Epidemiology
The lifelong incidence in the general population is around 60%, with <10% seeking medical attention. Incidence is bimodal, peak- ing at ages 2–10 and 50–80 years. The sexes are equally affected.
Causes
In most cases a cause is not identified; episodes tend to be self-limiting and harmless. Causes may be classified as local or general (Table 4.5), and include the autosomal dominant disease hereditary haemorrhagic telangiectasia (Osler-Weber- Rendu disease; Figure 4.5).
Pathogenesis
Bleeding typically occurs from Little’s area (anterior nasal septum) in around 90% of cases, as blood vessels here are superficial and easily traumatised. This area has Kiesselbach’s
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plexus of vessels, with a confluence of branches from the internal and external carotid artery systems. Posterior epi- staxis usually originates from branches of the sphenopalatine artery.
Clinical features
Most anterior epistaxis presents as unilateral bleeding from the nares. In posterior epistaxis blood will also pass down into the
Local causes General causes
• Nasal trauma, e.g. nose picking, blunt or sharp injury
• Foreign body • Nasal surgery or instrumentation • Inflammation, e.g. rhinitis, sinusitis, Wegener’s granulomatosis • Drugs, e.g. steroid nasal spray • Recreational drugs, e.g. cocaine • Tumours, e.g. sinonasal malignancy, angiofibroma • Vascular, e.g. hereditary haemorrhagic telangiectasia (HHT) (Figure 4.5), arteriovenous malformation, endometriosis • Hypertension • Drugs, e.g. warfarin, heparin, aspirin • Haematological disorder, e.g. haemophilia, thrombocytopenia • Elevated venous system
pressure, e.g. mitral stenosis • Environmental e.g. temperature,
humidity, altitude • Liver disease • Excessive alcohol
Table 4.5 Causes of epistaxis
Figure 4.5 Hereditary haemorrhagic telangiectasia.
pharynx and may compromise the airway. Blood may be spat out from the mouth and vomited up if swallowed.
If haemorrhage is severe and prolonged the patient is at risk of developing symptoms and signs of hypovolaemic shock. Recurrent epistaxis may lead to iron deficiency anaemia.
Investigation
Laboratory investigations are not normally required but are recommended for recurrent epistaxis, for major haemorrhage, or depending on the clinical picture, e.g. easy bruising suggest- ing a coagulopathy. Blood tests are indicated for the following situations:
• Recurrent epistaxis or patients with systemic conditions (e.g. neoplasia or platelet disorder): FBC, coagulation studies, hepatic and renal function
• Persistent heavy bleeding: FBC, haematocrit count, type and cross-match (for possible transfusion), coagulation studies • Patients on warfarin: FBC, coagulation studies.
Diagnosis
Diagnosis is on clinical grounds, but special investigations and an appropriate specialist opinion may be required if an unusual cause is suspected.