Nasal Polyps

I. Introduction & Definition

• Definition: Non-neoplastic, pedunculated, edematous hypertrophy of the nasal or sinus mucosa.
• Characteristics: Typically pale, pearly white, glistening, insensate (pain-free on probing), and non-tender.
• Pediatric Rule: While common in adults, polyps are rare in children <10 years.
  • Red Flag: The presence of bilateral ethmoidal polyps in a child necessitates a work-up for Cystic Fibrosis.

II. Classification

Broadly classified into two types based on origin and presentation.

III. Etiology and Associations

1. Infection (Main cause of ACP): Chronic maxillary sinusitis leads to venous stasis and edema at the ostium.
2. Cystic Fibrosis (CF): Most common cause of bilateral polyps in children.
3. Allergic Fungal Rhinosinusitis (AFRS): Common in adolescents; characterized by thick "peanut-butter" mucin and fungal debris.
4. Primary Ciliary Dyskinesia (Kartagener's): Due to poor mucociliary clearance.
5. Samter’s Triad: Aspirin sensitivity + Bronchial Asthma + Nasal Polyps (Rare in children, more common in adults).

IV. Clinical Features

1. Nasal Obstruction:
   • Unilateral (ACP) or Bilateral (Ethmoidal).
   • Progressive and persistent.
2. Rhinorrhea: Mucoid or mucopurulent discharge.
3. Voice Changes: Hyponasal speech (Rhinolalia clausa).
4. Mass in Throat: Large AC polyps may hang down behind the soft palate into the oropharynx.
5. Facial Deformity:
   • "Frog Face" deformity: Broadening of the nasal bridge and hypertelorism seen in massive, neglected ethmoidal polyposis (Woakes' Syndrome).

V. Diagnosis

1. Anterior Rhinoscopy:
   • Visualization of a smooth, pale, greyish mass.
   • Probe Test: Probe can be passed all around the polyp (unlike turbinate hypertrophy) and it is insensitive to touch.
2. Diagnostic Nasal Endoscopy (DNE):
   • Confirms origin (middle meatus vs. sphenoethmoidal recess).
   • Assesses extent of disease.
3. CT Scan Paranasal Sinuses (PNS): Gold Standard.
   • ACP: Opacification of maxillary sinus widening the ostium and extending into the nasopharynx.
   • Ethmoidal: Generalized opacification.
   • AFRS: "Double density" sign (central hyperdensity due to fungal elements).

VI. Differential Diagnosis (The "Dangerous" Polyps)

Before biopsy/surgery in a child, rule out:

1. Meningocele/Encephalocele: Pulsatile, cough impulse (+), reducible. Do not biopsy!
2. Juvenile Nasopharyngeal Angiofibroma (JNA): Adolescent male, bleeds profusely on touch.
3. Rhabdomyosarcoma: Rapidly growing, destructive.

VII. Management

A. Medical Management

Primarily for Ethmoidal Polyps (Systemic disease).

1. Corticosteroids:
   • Topical: Fluticasone/Mometasone sprays (First line for small polyps).
   • Systemic: Short course oral steroids to reduce size before surgery.
2. Antihistamines/Antibiotics: Treatment of underlying allergy or infection.
3. Anti-fungals: Only if AFRS is confirmed.

B. Surgical Management

Indicated for Antrochoanal Polyps (Always) and refractory Ethmoidal Polyps.

1. Functional Endoscopic Sinus Surgery (FESS):
   • The standard of care.
   • For ACP: Removal of the nasal and choanal part + widening of maxillary ostium + removal of antral attachment (using microdebrider) to prevent recurrence.
   • For Ethmoidal: Uncapping of ethmoid air cells (Polypectomy).
2. Simple Polypectomy: High recurrence rate (avoid if possible).
3. Caldwell-Luc Operation: Generally avoided in children due to risk of damaging tooth buds and facial growth centers.

VIII. Prognosis

• ACP: Excellent prognosis; recurrence is rare if the antral base is cleared.
• Ethmoidal: High recurrence rate due to underlying systemic factors (Allergy/CF).