Nasal Polyps Clinical Presentation
- Author: John E McClay, MD; Chief Editor: Ravindhra G Elluru, MD, PhD more...
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.
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.
In a retrospective study, McClay et al reported that 42% 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 neurologic symptoms, even those that extend into the intracranial cavity.
The patient's facial appearance may vary, depending on the underlying condition (see the images below).
Begin physical examination for nasal polyps with an anterior rhinoscopy procedure (see the images 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 via anterior rhinoscopy if the child is cooperative and if no significant mucosal edema or secretions are present in the anterior nasal cavity.
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 computed tomography (CT) of the sinuses, rather than performing a rigid or flexible endoscopic procedure that may distress a young patient and the parents. However, rigid or flexible endoscopy is the best method for examining the nasal cavity and nasopharynx to fully assess the nasal anatomy and to determine the extent and location of nasal polyps. (See the images below.)
In small children, a flexible fiberoptic nasopharyngoscope is often used because it is less traumatic for young patients who may move their heads from anxiety or discomfort. In older cooperative children and adolescents, a rigid endoscope 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.
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