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.
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. [9] 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.
Physical Examination
The patient's facial appearance may vary, depending on the underlying condition (see the images below).
A 3-month-old infant with hypertelorism and bulging of the nasal dorsum, secondary to encephalocele.
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.
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.
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.
Physical examination for nasal polyps should begin 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.
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.
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.
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.)
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.
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.
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.
Anterior nasal papilloma arising from the septum. The skin of the nasal vestibule is seen surrounding the papilloma in the center of the image.
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.
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.
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.
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.
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. Adequate decongestion and anesthesia of the nasal cavities are necessary before an endoscopic procedure in 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).
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.
Otoscopic examinations are warranted 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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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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A 3-month-old infant with hypertelorism and bulging of the nasal dorsum, secondary to encephalocele.
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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.
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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.
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Anterior nasal papilloma arising from the septum. The skin of the nasal vestibule is seen surrounding the papilloma in the center of the image.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Lateral view of a preteenaged child showing infected nasal dermoid. Note the protrusion of the dorsum of the nose.
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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.
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Frontal view of a 5-month-old infant, showing hypertelorism and protrusion in the glabellar region secondary to a small nasal dermoid.
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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.
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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.
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An interoperative view of dermoid removal from a 5-month-old infant.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Nine-year-old girl with allergic fungal sinusitis displaying telecanthus and asymmetrical positioning of her eyes and globes.
