xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

447

Orlandi et al.

and extends into the choana through an accessory maxil lary sinus ostium. 1335 NPs can be associated with comorbid diseases includ ing aspirin intolerance, asthma, AR, CF, and PCD. 1336–1340 Because NPs are often secondary to continued inflam mation caused by these comorbid diseases, the clinician should evaluate underlying conditions in order to more effectively treat NPs. X.B.3 Cost-Effective Work Up of CRSwNP Because of limited data, CRSsNP and CRSwNP are com bined in Section IX.B.3 . X.C Pathophysiology of CRSwNP X.C.1 Associated Factors in CRSwNP: Asthma The association of CRSwNP and asthma has been sup ported by numerous studies showing similarities between both diseases. 1341–1343 CRSwNP is present in 2%-4% of the adult population, 26,164 often associated with other respira tory diseases such as asthma, 1344 aspirin sensitivity, 1345 and idiopathic bronchiectasis. 1346 The prevalence of asthma in the general population is around 5% while it scales to 25% in patients with CRS and between 20% and 45% in patients with CRSwNP. 196,1347 Two perspectives need to be considered: patients with CRSwNP suffering from asthma and asthmatic patients developing CRSwNP. An England National CRS Epidemiology Study included 221 controls, 553 CRSsNP, 651 CRSwNP, and 45 AFRS patients. The prevalence of asthma was 9.95, 21.16, 46.9, and 73.3%, respectively. 196 Similarly, the GA 2 LENRS cohort involved 52,000 subjects demonstrating that almost 50% of CRSwNP patients developed asthma. 195 In non atopic asthma and late-onset asthma, CRSwNP was found frequently, reaching 15% to 26% depending on the study. 149 Even more, in severe asthmatic patients the prevalence of CRSwNP can reach up to 40.6%. 1348 The typical patients with CRSwNP and asthma are older, with longer duration of symptoms, higher incidence of allergic rhinitis, bronchial obstruction, higher CT score, total polyp scores (TPS), and higher number of sinonasal surgeries. 195,1349 Similarly, the presence of asthma has been related to worse paranasal sinus disease, signifi cantly higher endoscopy and CT severity scores as well as higher absolute eosinophil counts and total IgE levels. 167 Lin et al. 1350 found that patients with moderate-to-severe asthma displayed worse sinus disease than those with mild asthma, with significantly higher mean CT-scores.

TABLE X-2 Differential diagnosis of nasal polyps Benign Mucus retention cyst Antrochoanal polyp Mucocele Dacryocystocele Nasal dermoid Glioma Encephalocele Osteoma Respiratory epithelial adenomatoid hamartoma (REAH) Schneiderian papilloma Juvenile nasopharyngeal angiofibroma

Hemangiopericytoma Capillary hemangioma Cavernous hemangioma Vascular malformation Granulomatosis with polyangiitis

Sarcoidosis Malignant

Squamous cell carcinoma Adenoid cystic carcinoma Adenocarcinoma Esthesioneuroblastoma

Chordoma Lymphoma Melanoma

Rhabdomyosarcoma Fibrous histiocytoma

Juvenile angiofibroma should be suspected in adolescent males. Malignant tumors simulating polyps include squa mous cell carcinoma, salivary gland-type carcinoma, olfac tory neuroblastoma and lymphoma, among others. Key features distinguishing sinonasal tumors from NPs are unilateral disease, 1333 lack of sinus inflammation in some cases and surface features, such as easy bleeding and ulcer ation. Encephaloceles can masquerade as NPs. 1334 This lesion typically arises in the midline nasal and anterior skull base and can cause nasal obstruction. Characteristic signs are pulsation and expansion of the mass with crying or com pression of the jugular vein. Biopsy or nasal polypectomy based on the misdiagnosis as NP can cause intracranial complications. Intracranial connection should therefore be ruled out before any intervention in cases of a unilat eral nasal mass, especially in pediatric cases. Unilateral nasal obstruction or rhinorrhea in the pediatric population should also raise suspicion for a foreign body. 534 An antrochoanal polyp differs from other NPs in that it tends to be a large unilateral single mass comprised of cystic and solid components. Removal of the base may decrease the chance of recurrence. It usually originates from the posterior or inferior walls of the maxillary sinus