Ballenger's Manual of Otorhinolaryngology Head & Neck Surger

Andrew P. Lane, MD
David W. Kennedy, MD
Page 295-296
2002
BC Decker
Hamilton • London

POLYPOSIS
Nasal polyps are associated with a number of systemic diseases
including aspirin intolerance, intrinsic asthma, primary
ciliary dyskinesia, and cystic fibrosis. They are frequently
observed in chronic rhinosinusitis, including allergic rhinosinusitis,
and other chronic sinonasal inflammatory states.
Overall, the mechanisms behind polyp formation are believed
to be multifactorial. A variety of environmental and genetic
factors play a role in the pathogenesis of inflammatory polyps,
and the role of proinflammatory cytokines, chemokines, and
chemotactic mediators is increasingly being appreciated.
When significant intranasal polyposis is present, polyps can
easily be seen by anterior rhinoscopy. Grossly, they are
translucent to pale gray, pear shaped, smooth, soft, and freely
278 Otorhinolaryngology
mobile. Polyps arise from the lateral nasal wall and, in many
cases, are limited to the middle meatus, where they can only be
visualized endoscopically. The typical complaints associated
with polyposis are nasal congestion, rhinorrhea, and olfactory
dysfunction. Unilateral polyps should raise concern for allergic
fungal sinusitis or inverted papilloma. A single, unilateral
polyp originating high in the nasal cavity or with a stalk that
is not clearly visible may represent an encephalocele or
meningocele. As a rule, if the intranasal mass does not have
the characteristic appearance of a polyp, is unilateral, bleeds
easily, or has a stalk that is not clearly identified, imaging studies
are indicated before proceeding with management.
The most important element in the treatment of nasal
polyposis is medical therapy with corticosteroids. Both oral
corticosteroids and topical nasal corticosteroids are effective
in shrinking polyps and controlling their recurrence. Topical
corticosteroids are first-line therapy that should be employed
prior to considering surgical intervention. Unless there is a
contraindication, a trial of a tapering course of oral corticosteroids
is also frequently used prior to surgical resection.
Should surgery eventually become necessary, topical corticosteroids
and occasionally oral corticosteroids may be
needed for long-term maintenance. Surgery for polyps is indicated
when medical management fails to give symptomatic
improvement or if complications develop. Successful treatment
ultimately depends on a commitment by both the patient
and the doctor to an intensive postoperative course, which
may be quite prolonged and involve multiple débridements.