Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Nasal Polyps

  • Author: John E McClay, MD; Chief Editor: Ravindhra G Elluru, MD, PhD  more...
 
Updated: Jun 17, 2016
 

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 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.

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. Educating patients about the chronicity of the disease is important to make them aware of the recurrent nature of the problem.

Next

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 6-44% of patients with CF [1]
  • 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.[2, 3]

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.

Previous
Next

Etiology

As noted (see 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, or any of the following congenital lesions or benign or malignant tumors:

  • Nasolacrimal duct cysts
  • Encephaloceles
  • Gliomas
  • Dermoid tumors
  • Hemangiomas
  • Papillomas
  • Juvenile nasopharyngeal angiofibromas
  • Rhabdomyosarcoma
  • Lymphomas
  • Neuroblastomas
  • Sarcomas
  • Chordomas
  • Nasopharyngeal carcinomas
  • Inverting papillomas

Evaluate all children with benign nasal polyposis for CF and asthma.

Previous
Next

Epidemiology

In the United States, the overall incidence of nasal polyps in children is 0.1%; the incidence in children with CF is 6-48%. Among adults, the incidence is 1-4% overall, with a range of 0.2-28%. Worldwide incidence is the same as the incidence in the United States.

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. 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.[4] The reported prevalence is equal in patients with asthma. Nasal polyps occur in all races and social classes.

Previous
Next

Prognosis

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.

Polyposis recurrence is common following treatment with medical or surgical therapy if multiple benign polyps are present (see Treatment, Surgical Care). Single large polyps (eg, antral-choanal polyps) are less likely to recur. The literature contains sparse data comparing treatments. Endoscopic sinus surgery appears to improve both olfaction and quality of life in chronic rhinosinusitis patients with nasal polyps.[5, 6]

Previous
 
 
Contributor Information and Disclosures
Author

John E McClay, MD Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical Center

John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Alan D Murray, MD Pediatric Otolaryngologist, ENT for Children; Full-Time Staff, Medical City Dallas Children's Hospital; Consulting Staff, Department of Otolaryngology, Children's Medical Center at Dallas, Cook Children's Medical Center; Full-Time Staff, Texas Pediatric Surgery Center, Cook Children's Pediatric Surgery Center Plano

Alan D Murray, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, American Academy of Pediatrics, American College of Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Ravindhra G Elluru, MD, PhD Professor, Wright State University, Boonshoft School of Medicine; Pediatric Otolaryngologist, Department of Otolaryngology, Dayton Children's Hospital Medical Center

Ravindhra G Elluru, MD, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, Association for Research in Otolaryngology, Society for Ear, Nose and Throat Advances in Children, Triological Society, American Society for Cell Biology

Disclosure: Nothing to disclose.

Acknowledgements

Orval Brown, MD Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas

Orval Brown, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Nothing to disclose.

References
  1. Babinski D, Trawinska-Bartnicka M. Rhinosinusitis in cystic fibrosis: not a simple story. Int J Pediatr Otorhinolaryngol. 2008 May. 72(5):619-24. [Medline].

  2. Bernstein JM, Gorfien J, Noble B. Role of allergy in nasal polyposis: a review. Otolaryngol Head Neck Surg. 1995 Dec. 113(6):724-32. [Medline].

  3. Tos M, Sasaki Y, Ohnishi M, Larsen P, Drake-Lee AB. Fireside conference 2. Pathogenesis of nasal polyps. Rhinol Suppl. 1992. 14:181-5. [Medline].

  4. Stammberger H. Surgical treatment of nasal polyps: past, present, and future. Allergy. 1999. 54 Suppl 53:7-11. [Medline].

  5. Lind H, Joergensen G, Lange B, Svendstrup F, Kjeldsen AD. Efficacy of ESS in chronic rhinosinusitis with and without nasal polyposis: a Danish cohort study. Eur Arch Otorhinolaryngol. 2016 Apr. 273 (4):911-9. [Medline].

  6. Andrews P, Poirrier AL, Lund VJ, Choi D. Outcomes in Endoscopic Sinus Surgery : Olfaction, NOSE scale and Quality of Life in a Prospective Cohort Study. Clin Otolaryngol. 2016 Apr 27. [Medline].

  7. McClay JE, Marple B, Kapadia L, Biavati MJ, Nussenbaum B, Newcomer M, et al. Clinical presentation of allergic fungal sinusitis in children. Laryngoscope. 2002 Mar. 112 (3):565-9. [Medline].

  8. Mabry RL, Marple BF, Folker RJ, Mabry CS. Immunotherapy for allergic fungal sinusitis: three years' experience. Otolaryngol Head Neck Surg. 1998 Dec. 119(6):648-51. [Medline].

  9. Zhu CJ, Fruth K, Schneider A, Mann WJ, Brieger J. Impact of ozone exposure on prostaglandin release in nasal polyps. Eur Arch Otorhinolaryngol. 2011 Dec 1. [Medline].

  10. Lund VJ, Mackay IS. Staging in rhinosinusitus. Rhinology. 1993 Dec. 31 (4):183-4. [Medline].

  11. Lund VJ, Kennedy DW. Quantification for staging sinusitis. The Staging and Therapy Group. Ann Otol Rhinol Laryngol Suppl. 1995 Oct. 167:17-21. [Medline].

  12. Mackay IS, Lund VJ. Imaging and staging. Mygind N, Lildholdt T, eds. Nasal Polyposis: An Inflammatory Disease and Its Treatment. Copenhagen: Munksgaard; 1997. 137-44.

  13. Malm L. Assessment and staging of nasal polyposis. Acta Otolaryngol. 1997 Jul. 117 (4):465-7. [Medline].

  14. Wongsritrang K, Ruttanaphol S. Clinical efficacy of a short course of systemic steroids in nasal polyposis. Rhinology. 2011 Dec. 49(5):525-32. [Medline].

  15. Naclerio RM, Pinto J, Baroody F. Evidence-based approach to medical and surgical treatment of nasal polyposis. J Allergy Clin Immunol. 2013 Dec. 132 (6):1461-1462.e3. [Medline]. [Full Text].

  16. Bachert C, Zhang L, Gevaert P. Current and future treatment options for adult chronic rhinosinusitis: Focus on nasal polyposis. J Allergy Clin Immunol. 2015 Dec. 136 (6):1431-40; quiz 1441. [Medline].

  17. Holmstrom M. Clinical performance of fluticasone propionate nasal drops. Allergy. 1999. 54 Suppl 53:21-5. [Medline].

  18. Rudmik L, Schlosser RJ, Smith TL, Soler ZM. Impact of topical nasal steroid therapy on symptoms of nasal polyposis: A Meta-Analysis. Laryngoscope. 2012 Mar 12. [Medline].

  19. Lund VJ, Flood J, Sykes AP, Richards DH. Effect of fluticasone in severe polyposis. Arch Otolaryngol Head Neck Surg. 1998 May. 124(5):513-8. [Medline].

 
Previous
Next
 
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.
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.
An anterior endoscopic view of the nasal cavity in a 5-month-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.
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 3-month-old infant with hypertelorism and bulging of the nasal dorsum, secondary to encephalocele.
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.
Anterior nasal papilloma arising from the septum. The skin of the nasal vestibule is seen surrounding the papilloma in the center of the image.
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.
Endoscopic view of the left nasal cavity posteriorly, showing a polyp emanating from the sphenoid sinus in the center of the picture and purulence above and below the polyp. On the left is the septum. On the right is the lateral aspect of the middle turbinate.
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.
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.
An interoperative view of dermoid removal from a 5-month-old infant.
A surgical microdebrider entering the middle meatus. The septum is on the far left. The middle turbinate is in the left center. The surgical microdebrider is on the inferior center. Inferior turbinate is seen on the bottom right. Some blood overlying the ethmoid cavity is noted where polyps were present in the center of the picture.
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.
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.
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 coronal CT scan section through the orbit to maxillary sinus. The medial maxillary walls bulge medially, which is a typical CT scan view of cystic fibrosis. The ethmoid sinuses have scattered disease.
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 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.
Nine-year-old girl with allergic fungal sinusitis displaying telecanthus and asymmetrical positioning of her eyes and globes.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.