Sunday, September 18, 2016

A 32 Year Old Man Presents With Unilateral Nasal Obstruction - A Case Of Nasal Polyp

A 32-year-old man complains of unilateral nasal obstruction for the past several months of gradual onset. On examination of the nose, a nasal polyp is found.



Case Discussion

Nasal Polyp:
Introduction: Nasal polyps are benign lesions arising from the mucosa of the nasal passages including the paranasal sinuses. They are most commonly semitransparent.

Epidemiology: Prevalence of 1% to 4% of adults; 0.1% of children of all races and classes.
• The male-to-female ratio in adults is approximately 2:1.
• Peak age of onset is 20 to 40 years old; rare in children younger than 10 years old.

Associations: Associated with the following conditions:
~ Nonallergic and allergic rhinitis and rhinosinusitis.
~ Asthma—In 20% to 50% of patients with polyps.
~ Cystic fibrosis.
~ Aspirin intolerance—In 8% to 26% of patients with polyps.
~ Alcohol intolerance—In 50% of patients with polyps


Etiology And Pathophysiology:
• The precise cause of nasal polyp formation is unknown.
• Infectious agents causing desquamation of the mucous membrane may play a triggering role.
• 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. Cytokines and growth factors play a role in maintaining the mucosal inflammation associated with polyps.
• Food allergies are strongly associated with nasal polyps.

Clinical Features: 

• The appearance is usually smooth and rounded
• Moist and translucent
• Variable size.
• Color ranging from nearly none to deep erythema.
• The middle meatus is the most common location.

Laboratory testing And Diagnosis:

• Consider allergy testing.
• In children with multiple polyps, order sweat test to rule out cystic fibrosis.
• CT of the nose and paranasal sinuses may be indicated to evaluate extent of lesion(s)
• Biopsy is not usually indicated. If done histology typically shows pseudostratified ciliary epithelium, edematous stroma, epithelial basement membrane, and proinflammatory cells with eosinophils present in 80% to 90% of cases.

Management:
• Medical treatment consists of intranasal corticosteroids.
• An initial short course (2 to 4 weeks) of oral steroids may be considered in severe cases.
• Steroid treatment reduces polyp size, but does not generally resolve them. Corticosteroid treatment is also useful preoperatively to reduce polyp size.
• Oral doxycycline 100 mg daily for 20 days was shown to decrease polyp size, providing benefit for 12 weeks in one randomized controlled trial.
• Topical nasal decongestants may provide some symptom relief, but do not reduce polyp size.
• Montelukast reduces symptoms when used as an adjunct to oral and inhaled steroid therapy in patients with bilateral nasal polyposis.

• Surgical excision is often required to relieve symptoms.

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