Chapter 94

Tumors and Polyps of the Nose

Emily Karwacki Sheff, Jason Lucey, Patricia A. Reidy, Catherine M. Franklinh, Daniel E. Kane, Kerry A. Decker, Margaret Ann Mahoney, Patrice K. Nicholas

Nasal Tumors and Polyps

Definition and Epidemiology

Primary sites for malignant tumors can occur in the nose, nasopharynx, and paranasal sinuses. The broad spectrum of malignant lesions that occur in the nose and paranasal sinuses includes carcinomas, lymphomas, sarcomas, and melanomas. The most common, however, is squamous cell carcinoma.

The most common type of benign tumor is an inverted papilloma, which arises from the common wall between the nose and maxillary sinuses. A highly vascular benign tumor, the juvenile angiofibroma, is common in adolescent boys, bleeds easily, and can cause nasal obstruction. These tumors are nonmalignant, but they can cause considerable problems as they spread through the nasopharynx.¹

Nasal polyps represent an inflammatory disorder of the nose and paranasal sinuses that can result in chronic nasal obstruction and a diminished sense of smell. The cause of these pale, edematous masses is unknown, but the lesions are commonly seen in patients with allergic rhinitis, which predisposes them to polyp formation, and in patients with acute or chronic infections.² Nasal polyps occur in up to one third of patients and children with cystic fibrosis, and a majority of cystic fibrosis patients have some form of sinus disease.³

Pathophysiology

The pathophysiology of benign and malignant tumors of the nasopharynx is varied and makes diagnosis difficult. However, a basic understanding of the different pathologic conditions can assist in diagnosis. Squamous cell carcinomas arise from the keratinocytes of the epithelium. This cancer develops in normal skin, in preexisting actinic keratosis, or in a patch of leukoplakia. The incidence is higher in men and can be associated with smoking, alcohol consumption, and sunlight exposure.⁴ The inverted cell papillomas develop from the squamous cells in which the epithelium is invaginated into the vascular connective tissue stroma. They are invasive and behave in a locally malignant manner. Potentially serious complications involve invasion of the orbit or cranial vault.⁴ Juvenile or nasopharyngeal angiofibromas are vascular and may actually hemorrhage. These tumors may be associated with familial adenomatous polyps and almost exclusively occur in adolescent males who often have red hair and fair skin.⁴ They also act in a locally malignant manner. They spread from the nasopharynx to the nasal cavity, the sphenoid, and the parasinuses and may extend extradurally.

Nasal polyps originate mostly from the mucous membrane linings of the maxillary sinuses and prolapse into the nasal cavity. Polyps may be classified into four types: antrochoanal (non-eosinophilic, unilateral masses), idiopathic (unilateral or bilateral eosinophilic without lower airway involvement), eosinophilic (associated with asthma or aspirin sensitivity), and polyps with underlying systemic disease (e.g., cystic fibrosis, Churg-Strauss syndrome, Kartagener syndrome).²

Clinical Presentation

Malignant tumors can occur in the nose, nasopharynx, and paranasal sinuses. In general, these malignant neoplasms remain asymptomatic until late in their course. Early symptoms are nonspecific, mimicking those of rhinitis or sinusitis. Unilateral nasal obstruction and discharge accompanied by pain, recurrent hemorrhage, headache, or visual or olfactory changes suggest the presence of cancer. For this reason, any patient with unilateral or persistent nasal symptoms requires thorough evaluation.

Benign nasal tumors are associated with nasal obstruction, discharge, or facial swelling. These tumors can bleed easily and cause recurrent epistaxis. The tumor is usually easily visualized because of its growth and spread.

Symptoms of nasal polyps include nasal obstruction, hyposmia or anosmia, recurrent sinusitis, headache, and postnasal drip. In some patients, nasal polyps are accompanied by intrinsic asthma and intolerance to acetylsalicylic acid.¹ A developing polyp is teardrop shaped; when mature, it resembles a peeled seedless grape.

Physical Examination

A complete examination of the head and nasopharynx is essential. The vestibules should be inspected with a penlight while the patient’s head is tipped back. The use of a nasal speculum and/or a topical vasoconstrictor spray such as phenylephrine (if available) can improve visualization of intranasal structures.⁵ Each naris should be inspected for erythema, edema, discharge, bleeding, or tumor. Further examination includes pharyngeal inspection, sinus palpation, and determination of lymph node involvement.

Diagnostics

Diagnostic testing for benign tumors and nasal polyps can include sinus x-ray studies for information about fluid levels and bone involvement, but computed tomography (CT) scan or magnetic resonance imaging (MRI) is usually indicated if tumor is suspected. Endoscopic evaluation and biopsy are the gold standard for definitive diagnosis and treatment of suspected tumors.⁵ Complete blood studies are necessary to determine the presence of anemia or other hematologic disease.

Diagnostics

Nasal Tumors and Polyps

Laboratory

Imaging

Other

CBC, complete blood count.

Differential Diagnosis

The differential diagnosis for tumors and polyps includes mucoceles; granulomas without systemic involvement; and granulomatosis with polyangiitis (GPA) (Wegener granulomatosis), a systemic vasculitis of unknown cause associated with granulomatous changes. GPA is associated with glomerulonephritis and granulomatous lesions in the upper and lower respiratory tract. Other organ systems can also be affected.

Differential Diagnosis

Nasal Tumors and Polyps