Difference between revisions of "Nasal polyps"

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#redirect [[Head_and_neck_pathology#Nasal_polyps]]
'''Nasal polyps''' are a common [[head and neck pathology|head and neck]] lesion.  They are typically benign but may be [[malignant]].
 
==Overview==
DDx (benign - multiple):<ref name=emedicine994274>URL: [http://emedicine.medscape.com/article/994274-overview http://emedicine.medscape.com/article/994274-overview]. Accessed on: 16 March 2011.</ref>
*Autoimmune/idiopathic:
**Asthma.
**Allergic rhinitis.
**[[Churg-Strauss syndrome]] (AKA ''allergic granulomatous angiitis'').
***Features: [[asthma]], eosinophilia, granulomatous inflammation, necrotizing systemic [[vasculitis]], and necrotizing glomerulonephritis.<ref name=emedicine333492>[http://emedicine.medscape.com/article/333492-overview http://emedicine.medscape.com/article/333492-overview]</ref>
**Nonallergic rhinitis with eosinophilia syndrome (NARES).
*Infectious:
**Fungal infection (with allergic component - ''AFS'' = allergic fungal sinusitis).
**Chronic rhinosinusitis.
*Genetic:
**Primary ciliary dyskinesia.
**[[Cystic fibrosis]].
*Associations:
**Alcohol intolerance ~ 50%.
**Aspirin intolerance - upto ~ 25%.
*Tumours:
**Juvenile [[nasopharyngeal angiofibroma]] - young males.
**[[Nasopharyngeal carcinoma]]s.
**[[Sarcoma]]s.
**[[Hemangioma]].
**[[Schneiderian papilloma]].
**Other.
 
Memory devices:
*''GAIT'' = '''G'''enetic, '''A'''llergic/idiopathic, '''I'''nfectious, '''T'''umours.
*Allergic causes '''A'''s - '''a'''llergic, '''a'''sthma, '''a'''llergic granulomatous angiitis ([[Eosinophilic granulomatosis with polyangiitis|Churg-Strauss syndrome]]), non'''a'''llergic rhinitis with eosinophilia.
 
===Epidemiology===
*More commonly assoc. with nonallergic conditions.<ref name=emedicine994274/>
 
===Treatment===
*Recurrent polyps: functional endoscopic sinus surgery (FESS).
 
==Inflammatory polyps with neutrophils==
===General===
*Histologic findings are non-specific; DDx includes:<ref name=emedicine994274dx>URL: [http://emedicine.medscape.com/article/994274-diagnosis http://emedicine.medscape.com/article/994274-diagnosis]. Accessed on: 16 March 2011.</ref>
**[[Cystic fibrosis]].
**Primary ciliary dyskinesia syndrome.
**Young syndrome
 
===Microscopic===
Features:
*Neutrophil predominant.
*Edema.
*+/-Mucus-impaction (dilated glands with mucus).
**Suggestive of cystic fibrosis.<ref name=pmid15554502>{{cite journal |author=Beju D, Meek WD, Kramer JC |title=The ultrastructure of the nasal polyps in patients with and without cystic fibrosis |journal=J. Submicrosc. Cytol. Pathol. |volume=36 |issue=2 |pages=155–65 |year=2004 |month=April |pmid=15554502 |doi= |url=}}</ref>
 
===Sign out===
<pre>
A. Nasal sinus tissue, right, excision:
- Inflamed edematous sinonasal mucosa with abundant neutrophils.
- Negative for malignancy.
 
B. Nasal sinus tissue, left, excision:
- Inflamed edematous sinonasal mucosa with abundant neutrophils and fragments of bone.
- Negative for malignancy.
</pre>
 
====Alternate====
<pre>
A. Contents of Left Ethmoid Sinus, Excision:
    - Mildly inflamed sinonasal mucosa with bone and fibrous tissue.
    - NEGATIVE for malignancy.
 
B. Contents of Right Ethmoid Sinus, Excision:
    - Mildly inflamed sinonasal mucosa with bone and fibrous tissue.
    - NEGATIVE for malignancy.
</pre>
 
==Allergic nasal polyp==
===General===
*People with allergies.
**Same type of polyps seen in those without allergies.<ref name=pmid8441521>{{Cite journal  | last1 = Davidsson | first1 = A. | last2 = Hellquist | first2 = HB. | title = The so-called 'allergic' nasal polyp. | journal = ORL J Otorhinolaryngol Relat Spec | volume = 55 | issue = 1 | pages = 30-5 | month =  | year = 1993 | doi =  | PMID = 8441521 }}</ref>
 
===Gross===
*Polypoid mass - several millimetres to centimetres in size.
**Translucent.{{fact}}
 
===Microscopic===
Features:<ref>{{Ref Klatt|144}}</ref>
*Normal respiratory epithelium.
*Stroma with:
**Edema.
**Eosinophils.
**+/-Other inflammatory cells (plasma cells, lymphocytes, neutrophils).
 
DDx:
*Inflammatory nasal polyp with abundant neutrophils.
*[[Vasculitis]].
**[[Wegener's granulomatosis]].
**[[Churg-Strauss syndrome]].
*[[Biphenotypic sinonasal sarcoma]] - has hypercellular stroma.
 
===Sign out===
<pre>
A. Left Nasal Polyp, Excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils.
- NEGATIVE for malignancy.
 
B. Right Nasal Polyp, Excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils and fragments of bone.
- NEGATIVE for malignancy.
</pre>
 
<pre>
A. Nasal sinus tissue, right, excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils.
- Negative for malignancy.
 
B. Nasal sinus tissue, left, excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils and fragments of bone.
- Negative for malignancy.
</pre>
 
====Block letters====
<pre>
A. NASAL SINUS TISSUE, RIGHT, EXCISION:
- INFLAMED EDEMATOUS SINONASAL MUCOSA WITH ABUNDANT EOSINOPHILS.
- NEGATIVE FOR MALIGNANCY.
 
B. NASAL SINUS TISSUE, LEFT, EXCISION:
- INFLAMED EDEMATOUS SINONASAL MUCOSA WITH ABUNDANT EOSINOPHILS AND FRAGMENTS OF BONE.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
==Schneiderian papilloma==
*[[AKA]] ''Schneiderian polyp''.
*[[AKA]] ''sinonasal papilloma''.<ref>URL: [http://emedicine.medscape.com/article/862677-overview http://emedicine.medscape.com/article/862677-overview]. Accessed on: 19 November 2011.</ref>
===General===
*Lumpers vs. splitters debate about whether it is one entity or three.<ref name=pmid11904343>{{cite journal |author=Barnes L |title=Schneiderian papillomas and nonsalivary glandular neoplasms of the head and neck |journal=Mod. Pathol. |volume=15 |issue=3 |pages=279–97 |year=2002 |month=March |pmid=11904343 |doi=10.1038/modpathol.3880524 |url=http://www.nature.com/modpathol/journal/v15/n3/full/3880524a.html}}</ref>
 
[http://www.nature.com/modpathol/journal/v15/n3/fig_tab/3880524t1.html#figure-title Subclassification]:<ref name=pmid11904343/>
*Inverted (Schneiderian) - most common ~60-65%.
*Fungiform (Schneiderian) - less common ~30-35%.
*Oncocytic (Schneiderian) - least common ~5%.
====Inverted====
*[[AKA]] ''[[inverted papilloma]]''.<ref name=pmid8189990>{{Cite journal  | last1 = Vrabec | first1 = DP. | title = The inverted Schneiderian papilloma: a 25-year study. | journal = Laryngoscope | volume = 104 | issue = 5 Pt 1 | pages = 582-605 | month = May | year = 1994 | doi =  | PMID = 8189990 }}</ref>
*Usually lateral wall (as the septum as little soft tissue to grow into).<ref name=pmid11904343/>
*May transform to carcinoma.
 
====Fungiform====
*[[AKA]] exophytic papilloma, [[AKA]] septal papilloma.<ref name=pmid11904343/>
*Low risk of malignant transformation.
 
====Oncocytic====
*[[AKA]] ''cylindrical cell papilloma''.<ref>{{Cite journal  | last1 = Bravo Domínguez | first1 = O. | last2 = Vela Cortina | first2 = M. | last3 = Ramírez Ruiz | first3 = RD. | last4 = Ros Vergara | first4 = A. | last5 = Dinarés Jaumeandreu | first5 = D. | last6 = Encina Ruiz | first6 = L. | last7 = Arias Cuchí | first7 = G. | last8 = Ardíaca Bosch | first8 = MC. | last9 = Cánovas Robles | first9 = E. | title = [Oncocytic schneiderian papilloma. A case report]. | journal = An Otorrinolaringol Ibero Am | volume = 32 | issue = 2 | pages = 115-23 | month =  | year = 2005 | doi =  | PMID = 15929584 }}</ref>
*Lateral nasal wall.<ref name=pmid11904343/>
 
===Microscopic===
====Inverted Schneiderian papilloma====
Features:<ref name=pmid11904343/>
*Well-demarcated epithelial islands in the stroma.
*Squamous +/-surface keratinization ''or'' respiratory type epithelium (with cilia).
*+/-Neutrophils.
*+/-Goblet cells.
 
Notes:
*May mimic invasive SCC.
 
=====Images=====
*[http://path.upmc.edu/cases/case32.html Inverted papilloma & verrucous carcinoma (upmc.edu)].
<gallery>
Image:Sinonasal_papilloma_-_very_low_mag.jpg | Schneiderian papilloma - very low mag. (WC)
Image:Sinonasal_papilloma_-_cropped_-_very_high_mag.jpg | Schneiderian papilloma - very high mag. (WC)
</gallery>
 
====Fungiform Schneiderian papilloma====
Features:
*Exophytic growth pattern - '''key feature'''.
 
====Oncocytic Schneiderian papilloma====
Features:
*Oncocytes - '''key feature'''.
*Exophytic or endophytic growth pattern.
 
==Antrochoanal polyp==
*Abbreviated ''ACP''.
===General===
*Benign.<ref name=pmid15626248>{{cite journal |authors=Maldonado M, Martínez A, Alobid I, Mullol J |title=The antrochoanal polyp |journal=Rhinology |volume=42 |issue=4 |pages=178–82 |date=December 2004 |pmid=15626248 |doi= |url=}}</ref>
*Relative common ~5% of nasal polyps.<ref name=pmid19609378>{{cite journal |authors=Frosini P, Picarella G, De Campora E |title=Antrochoanal polyp: analysis of 200 cases |journal=Acta Otorhinolaryngol Ital |volume=29 |issue=1 |pages=21–6 |date=February 2009 |pmid=19609378 |pmc=2689564 |doi= |url=}}</ref>
 
Epidemiology:
*"Almost always" recur if incompletely excised.<ref name=pmid19609378/>
*Originates from maxillary sinus and extends to choana.<ref name=pmid23179936>{{cite journal |authors=Balikci HH, Ozkul MH, Uvacin O, Yasar H, Karakas M, Gurdal M |title=Antrochoanal polyposis: analysis of 34 cases |journal=Eur Arch Otorhinolaryngol |volume=270 |issue=5 |pages=1651–4 |date=May 2013 |pmid=23179936 |doi=10.1007/s00405-012-2274-2 |url=}}</ref>
 
===Microscopic===
Features:<ref>{{cite journal |authors=Min YG, Chung JW, Shin JS, Chi JG |title=Histologic structure of antrochoanal polyps |journal=Acta Otolaryngol |volume=115 |issue=4 |pages=543–7 |date=July 1995 |pmid=7572133 |doi=10.3109/00016489509139364 |url=}}</ref>
*Respiratory epithelium.
*Relatively pauciglandular - when compared to inflammatory nasal polyps.
*Typically few eosinophils.
 
DDx:
*Inflammatory nasal polyps.
 
===Sign out===
<pre>
Ethmoid Sinus Contents (Right), Excision:
    - Benign nasal polyp (antrochoanal type) and mildly inflamed sinonasal mucosa.
    - NEGATIVE for malignancy.
</pre>
 
==See also==
*[[Head and neck pathology]].
*[[Tonsillar lymphangiomatous polyp]].
 
==References==
{{Reflist|2}}
 
[[Category:Head and neck pathology]]

Latest revision as of 22:30, 9 October 2021

Nasal polyps are a common head and neck lesion. They are typically benign but may be malignant.

Overview

DDx (benign - multiple):[1]

Memory devices:

  • GAIT = Genetic, Allergic/idiopathic, Infectious, Tumours.
  • Allergic causes As - allergic, asthma, allergic granulomatous angiitis (Churg-Strauss syndrome), nonallergic rhinitis with eosinophilia.

Epidemiology

  • More commonly assoc. with nonallergic conditions.[1]

Treatment

  • Recurrent polyps: functional endoscopic sinus surgery (FESS).

Inflammatory polyps with neutrophils

General

  • Histologic findings are non-specific; DDx includes:[3]

Microscopic

Features:

  • Neutrophil predominant.
  • Edema.
  • +/-Mucus-impaction (dilated glands with mucus).
    • Suggestive of cystic fibrosis.[4]

Sign out

A. Nasal sinus tissue, right, excision:
- Inflamed edematous sinonasal mucosa with abundant neutrophils.
- Negative for malignancy.

B. Nasal sinus tissue, left, excision:
- Inflamed edematous sinonasal mucosa with abundant neutrophils and fragments of bone.
- Negative for malignancy.

Alternate

A. Contents of Left Ethmoid Sinus, Excision:
     - Mildly inflamed sinonasal mucosa with bone and fibrous tissue.
     - NEGATIVE for malignancy.

B. Contents of Right Ethmoid Sinus, Excision:
     - Mildly inflamed sinonasal mucosa with bone and fibrous tissue.
     - NEGATIVE for malignancy.

Allergic nasal polyp

General

  • People with allergies.
    • Same type of polyps seen in those without allergies.[5]

Gross

  • Polypoid mass - several millimetres to centimetres in size.

Microscopic

Features:[6]

  • Normal respiratory epithelium.
  • Stroma with:
    • Edema.
    • Eosinophils.
    • +/-Other inflammatory cells (plasma cells, lymphocytes, neutrophils).

DDx:

Sign out

A. Left Nasal Polyp, Excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils.
- NEGATIVE for malignancy.

B. Right Nasal Polyp, Excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils and fragments of bone.
- NEGATIVE for malignancy.

A. Nasal sinus tissue, right, excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils.
- Negative for malignancy.

B. Nasal sinus tissue, left, excision:
- Inflamed edematous sinonasal mucosa with abundant eosinophils and fragments of bone.
- Negative for malignancy.

Block letters

A. NASAL SINUS TISSUE, RIGHT, EXCISION:
- INFLAMED EDEMATOUS SINONASAL MUCOSA WITH ABUNDANT EOSINOPHILS.
- NEGATIVE FOR MALIGNANCY.

B. NASAL SINUS TISSUE, LEFT, EXCISION:
- INFLAMED EDEMATOUS SINONASAL MUCOSA WITH ABUNDANT EOSINOPHILS AND FRAGMENTS OF BONE.
- NEGATIVE FOR MALIGNANCY.

Schneiderian papilloma

  • AKA Schneiderian polyp.
  • AKA sinonasal papilloma.[7]

General

  • Lumpers vs. splitters debate about whether it is one entity or three.[8]

Subclassification:[8]

  • Inverted (Schneiderian) - most common ~60-65%.
  • Fungiform (Schneiderian) - less common ~30-35%.
  • Oncocytic (Schneiderian) - least common ~5%.

Inverted

Fungiform

  • AKA exophytic papilloma, AKA septal papilloma.[8]
  • Low risk of malignant transformation.

Oncocytic

  • AKA cylindrical cell papilloma.[10]
  • Lateral nasal wall.[8]

Microscopic

Inverted Schneiderian papilloma

Features:[8]

  • Well-demarcated epithelial islands in the stroma.
  • Squamous +/-surface keratinization or respiratory type epithelium (with cilia).
  • +/-Neutrophils.
  • +/-Goblet cells.

Notes:

  • May mimic invasive SCC.
Images

  • Schneiderian papilloma - very low mag. (WC)

  • Schneiderian papilloma - very high mag. (WC)

Fungiform Schneiderian papilloma

Features:

  • Exophytic growth pattern - key feature.

Oncocytic Schneiderian papilloma

Features:

  • Oncocytes - key feature.
  • Exophytic or endophytic growth pattern.

Antrochoanal polyp

  • Abbreviated ACP.

General

  • Benign.[11]
  • Relative common ~5% of nasal polyps.[12]

Epidemiology:

  • "Almost always" recur if incompletely excised.[12]
  • Originates from maxillary sinus and extends to choana.[13]

Microscopic

Features:[14]

  • Respiratory epithelium.
  • Relatively pauciglandular - when compared to inflammatory nasal polyps.
  • Typically few eosinophils.

DDx:

  • Inflammatory nasal polyps.

Sign out

Ethmoid Sinus Contents (Right), Excision:
     - Benign nasal polyp (antrochoanal type) and mildly inflamed sinonasal mucosa.
     - NEGATIVE for malignancy.

See also

References

  1. ↑ 1.0 1.1 URL: http://emedicine.medscape.com/article/994274-overview. Accessed on: 16 March 2011.
  2. ↑ http://emedicine.medscape.com/article/333492-overview
  3. ↑ URL: http://emedicine.medscape.com/article/994274-diagnosis. Accessed on: 16 March 2011.
  4. ↑ Beju D, Meek WD, Kramer JC (April 2004). "The ultrastructure of the nasal polyps in patients with and without cystic fibrosis". J. Submicrosc. Cytol. Pathol. 36 (2): 155–65. PMID 15554502.
  5. ↑ Davidsson, A.; Hellquist, HB. (1993). "The so-called 'allergic' nasal polyp.". ORL J Otorhinolaryngol Relat Spec 55 (1): 30-5. PMID 8441521.
  6. ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 144. ISBN 978-1416002741.
  7. ↑ URL: http://emedicine.medscape.com/article/862677-overview. Accessed on: 19 November 2011.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Barnes L (March 2002). "Schneiderian papillomas and nonsalivary glandular neoplasms of the head and neck". Mod. Pathol. 15 (3): 279–97. doi:10.1038/modpathol.3880524. PMID 11904343. http://www.nature.com/modpathol/journal/v15/n3/full/3880524a.html.
  9. ↑ Vrabec, DP. (May 1994). "The inverted Schneiderian papilloma: a 25-year study.". Laryngoscope 104 (5 Pt 1): 582-605. PMID 8189990.
  10. ↑ Bravo Domínguez, O.; Vela Cortina, M.; Ramírez Ruiz, RD.; Ros Vergara, A.; Dinarés Jaumeandreu, D.; Encina Ruiz, L.; Arias Cuchí, G.; Ardíaca Bosch, MC. et al. (2005). "[Oncocytic schneiderian papilloma. A case report].". An Otorrinolaringol Ibero Am 32 (2): 115-23. PMID 15929584.
  11. ↑ Maldonado M, Martínez A, Alobid I, Mullol J (December 2004). "The antrochoanal polyp". Rhinology 42 (4): 178–82. PMID 15626248.
  12. ↑ 12.0 12.1 Frosini P, Picarella G, De Campora E (February 2009). "Antrochoanal polyp: analysis of 200 cases". Acta Otorhinolaryngol Ital 29 (1): 21–6. PMC 2689564. PMID 19609378. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689564/.
  13. ↑ Balikci HH, Ozkul MH, Uvacin O, Yasar H, Karakas M, Gurdal M (May 2013). "Antrochoanal polyposis: analysis of 34 cases". Eur Arch Otorhinolaryngol 270 (5): 1651–4. doi:10.1007/s00405-012-2274-2. PMID 23179936.
  14. ↑ Min YG, Chung JW, Shin JS, Chi JG (July 1995). "Histologic structure of antrochoanal polyps". Acta Otolaryngol 115 (4): 543–7. doi:10.3109/00016489509139364. PMID 7572133.
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