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Patient Story
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A 14-year-old boy complains of unilateral nasal obstruction for the past several months of gradual onset. On examination of the nose, a nasal polyp is found (Figure 25-1).

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FIGURE 25-1

Nasal polyp in left middle meatus with normal surrounding mucosa. (Used with permission from William Clark, MD.)

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Introduction
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Nasal polyps are benign lesions arising from the mucosa of the nasal passages including the paranasal sinuses. They are most commonly semitransparent and pale in appearance.

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Epidemiology1
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  • Prevalence of 0.1 percent of children of all races and classes.

  • Nasal polyps are rare in children younger than 10 years old; peak age of onset is age 20 to 40 years.

  • Associated with the following conditions:

    • Nonallergic and allergic rhinitis and rhinosinusitis.

    • Asthma—In 20 percent to 50 percent of patients with polyps.

    • Cystic fibrosis.

    • Aspirin intolerance—In 8 percent to 26 percent of patients with polyps.

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Etiology and Pathophysiology
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  • Nasal polyposis is an inflammatory process. The precise cause is unknown, but genetic associations have been identified.2

  • Infectious agents causing desquamation of the mucous membrane can play a triggering role. Presence of Helicobacter pylori was identified in nasal flora in all 25 patients in one case series.3

  • Activated epithelial cells appear to be the major source of mediators that induce an influx of inflammatory cells, including eosinophils prominently; these in turn lead to proliferation and activation of fibroblasts.4 Cytokines and growth factors play a role in maintaining the mucosal inflammation associated with polyps.

  • Food allergies including milk allergy are strongly associated with nasal polyps.

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Diagnosis
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Clinical Features
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  • The appearance is usually smooth and rounded (Figure 25-1).

  • Moist and translucent (Figure 25-2).

  • Variable size.

  • Color ranging from nearly none to deep erythema.

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FIGURE 25-2

Nasal polyp in right nasal cavity in a patient with inflamed mucosa from allergic rhinitis. (Used with permission from William Clark, MD.)

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Typical Distribution
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  • Nasal polyps arise most commonly from the ethmoid sinus and middle meatus.

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Laboratory and Imaging
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  • Consider allergy testing.

  • In children with multiple polyps, order sweat test to rule out cystic fibrosis.

  • A competed tomography (CT) of the nose and paranasal sinuses may be indicated to evaluate extent of lesion(s) (Figure 25-3).

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FIGURE 25-3

Computed tomography (CT) scan showing polyps (asterisk) and bilateral opacified maxillary sinuses (MS). Note the nasal polyp appears to be coming from the left maxillary sinus and is above the inferior turbinate. (Used with permission from Richard P. ...

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