Sinonasal polyposis

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Disclosures - updated 6 Apr 2022:

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Sinonasal polyposis refers to the presence of multiple benign polyps in the nasal cavity and paranasal sinuses.

Epidemiology

It is most commonly encountered in adults and rare in children. Polyps are the most common expansile lesions of the nasal cavity ⁸.

Associations

Conditions known to be associated with polyps include ¹⁰:

Clinical presentation

Clinical symptoms of sinonasal polyposis may include progressive nasal obstruction, rhinorrhoea, facial pain, headache, anosmia, etc. ³. It can also cause a particular pattern of chronic sinusitis as a result of obstruction of the drainage pathways of the paranasal sinuses.

Pathology

Polyps are formed by the influx of fluid into the lamina propria of the sinonasal Schneiderian mucosa ^8,9.

Grading

The Meltzer grading system is a clinical grading system that is as follows ^ref:

grade 0 ~~= no~~: no visible polyposis
grade 1 =: single polyp confined to the middle meatus
grade 2 =: multiple polyps in the middle meatus
grade 3 =: extending beyond the middle meatus
grade 4 =: nasal cavity obstruction

Radiographic features

CT

extensive mucosal polyps occupying and obliterating the nasal cavity and the paranasal sinuses
- usually, they are hypodense but may be hyperdense due to increased protein content or fungal infection
associated local benign bone remodelling or erosion (as opposed to a mucocele where the entire sinus is expanded ⁶)
- enlargement of infundibula
- attenuation of the ethmoid sinus walls and nasal septum
- occasionally sparing the inferior nasal meatus
- truncation of middle turbinate ⁴
opacified ethmoid sinuses with convex lateral walls and gas-fluid levels
a concurrent fungal sinus infection may be present

Complications

Differential diagnosis

sinonasal retention cyst
- can be indistinguishable
- usually spares the nasal cavity
allergic fungal sinusitis
- commonly associated with polyps
- hyperdense central areas
- MRI may show low T1 and T2 signal
granulomatosis with polyangiitis
- centred in the nasal cavity

~~-<li><a href="/articles/acute-sinusitis">infectious rhinosinusitis</a></li>~~
~~-<li><a href="/articles/cystic-fibrosis">cystic fibrosis</a></li>~~
~~-<li><a href="/articles/allergic-fungal-sinusitis">allergic fungal sinusitis</a></li>~~
~~-<li><a href="/articles/asthma-summary">asthma</a></li>~~
~~-<li><a href="/articles/asthma-summary">nickel exposure</a></li>~~
~~-<li><a title="Eosinophilic granulomatosis with polyangiitis" href="/articles/eosinophilic-granulomatosis-with-polyangiitis">eosinophilic granulomatosis with polyangiitis</a></li>~~
-</ul><h4>Clinical presentation</h4>Clinical symptoms of sinonasal polyposis may include progressive nasal obstruction, rhinorrhoea, facial pain, headache, <a href="/articles/anosmia">anosmia</a>, etc. 3. It can also cause a particular <a href="/articles/patterns-of-sinonasal-obstruction">pattern</a> of <a href="/articles/chronic-sinusitis">chronic sinusitis</a> as a result of obstruction of the drainage pathways of the paranasal sinuses.<h4>Pathology</h4>Polyps are formed by the influx of fluid into the lamina propria of the sinonasal Schneiderian mucosa 8,9.<h5>Grading</h5>The <a href="/articles/meltzer-grading-system">Meltzer grading system</a> is a clinical grading system that is as follows <ul>
~~-<li>grade 0 = no visible polyposis</li>~~
~~-<li>grade 1 = single polyp confined to the middle meatus</li>~~
~~-<li>grade 2 = multiple polyps in the middle meatus</li>~~
~~-<li>grade 3 = extending beyond the middle meatus</li>~~
~~-<li>grade 4 = nasal cavity obstruction</li>~~
+<li><a href="/articles/acute-sinusitis">infectious rhinosinusitis</a></li>
+<li><a href="/articles/cystic-fibrosis">cystic fibrosis</a></li>
+<li><a href="/articles/allergic-fungal-sinusitis">allergic fungal sinusitis</a></li>
+<li><a href="/articles/asthma-summary">asthma</a></li>
+<li><a href="/articles/asthma-summary">nickel exposure</a></li>
+<li><a href="/articles/eosinophilic-granulomatosis-with-polyangiitis" title="Eosinophilic granulomatosis with polyangiitis">eosinophilic granulomatosis with polyangiitis</a></li>
+</ul><h4>Clinical presentation</h4>Clinical symptoms of sinonasal polyposis may include progressive nasal obstruction, rhinorrhoea, facial pain, headache, <a href="/articles/anosmia">anosmia</a>, etc. 3. It can also cause a particular <a href="/articles/patterns-of-sinonasal-obstruction">pattern</a> of <a href="/articles/chronic-sinusitis">chronic sinusitis</a> as a result of obstruction of the drainage pathways of the paranasal sinuses.<h4>Pathology</h4>Polyps are formed by the influx of fluid into the lamina propria of the sinonasal Schneiderian mucosa 8,9.<h5>Grading</h5>The <a href="/articles/meltzer-grading-system">Meltzer grading system</a> is a clinical grading system that is as follows ref:<ul>
+<li>grade 0: no visible polyposis</li>
+<li>grade 1: single polyp confined to the middle meatus</li>
+<li>grade 2: multiple polyps in the middle meatus</li>
+<li>grade 3: extending beyond the middle meatus</li>
+<li>grade 4: nasal cavity obstruction</li>
-<li>extensive mucosal polyps occupying and obliterating the nasal cavity and the paranasal sinuses<ul><li>usually, they are hypodense but may be hyperdense due to increased protein content or fungal infection</li></ul>
~~-</li>~~
~~-<li>associated local benign bone remodelling or erosion (as opposed to a <a href="/articles/mucocele-general">mucocele</a> where the entire sinus is expanded 6)<ul>~~
~~-<li>enlargement of infundibula</li>~~
~~-<li>attenuation of the ethmoid sinus walls and nasal septum</li>~~
~~-<li>occasionally sparing the inferior nasal meatus</li>~~
~~-<li>truncation of middle turbinate 4~~
+<li>
+extensive mucosal polyps occupying and obliterating the nasal cavity and the paranasal sinuses
+<ul><li>usually, they are hypodense but may be hyperdense due to increased protein content or fungal infection</li></ul>
+<li>
+associated local benign bone remodelling or erosion (as opposed to a <a href="/articles/mucocele-general">mucocele</a> where the entire sinus is expanded 6)
+<ul>
+<li>enlargement of infundibula</li>
+<li>attenuation of the ethmoid sinus walls and nasal septum</li>
+<li>occasionally sparing the inferior nasal meatus</li>
+<li>truncation of middle turbinate 4</li>
~~-<li>opacified ethmoid sinuses with convex lateral walls and gas-fluid levels</li>~~
~~-<li>a concurrent <a href="/articles/fungal-sinusitis">fungal sinus infection</a> may be present</li>~~
+<li>opacified ethmoid sinuses with convex lateral walls and gas-fluid levels</li>
+<li>a concurrent <a href="/articles/fungal-sinusitis">fungal sinus infection</a> may be present</li>
~~-<li>~~
~~-<a href="/articles/osseous-metaplasia">osseous metaplasia</a> 11~~
~~-</li>~~
~~-<li><a title="Aspirin-induced asthma" href="/articles/non-steroidal-anti-inflammatory-drug-exacerbated-respiratory-disease">aspirin exacerbated respiratory disease (AERD)</a></li>~~
+<li><a href="/articles/osseous-metaplasia">osseous metaplasia</a> 11</li>
+<li><a href="/articles/non-steroidal-anti-inflammatory-drug-exacerbated-respiratory-disease" title="Aspirin-induced asthma">aspirin exacerbated respiratory disease (AERD)</a></li>
~~-<a href="/articles/paranasal-sinuses-retention-cysts">sinonasal retention cyst</a><ul>~~
~~-<li>can be indistinguishable </li>~~
~~-<li>usually spares the nasal cavity</li>~~
+<a href="/articles/paranasal-sinuses-retention-cysts">sinonasal retention cyst</a>
+<ul>
+<li>can be indistinguishable </li>
+<li>usually spares the nasal cavity</li>
~~-<a href="/articles/allergic-fungal-sinusitis">allergic fungal sinusitis</a><ul>~~
~~-<li>commonly associated with polyps </li>~~
~~-<li>hyperdense central areas </li>~~
~~-<li>MRI may show low T1 and T2 signal</li>~~
+<a href="/articles/allergic-fungal-sinusitis">allergic fungal sinusitis</a>
+<ul>
+<li>commonly associated with polyps </li>
+<li>hyperdense central areas </li>
+<li>MRI may show low T1 and T2 signal</li>
~~-<a href="/articles/granulomatosis-with-polyangiitis">granulomatosis with polyangiitis</a><ul><li>centred in the nasal cavity</li></ul>~~
+<a href="/articles/granulomatosis-with-polyangiitis">granulomatosis with polyangiitis</a>
+<ul><li>centred in the nasal cavity</li></ul>

References changed:

1. Heinz Stammberger, Wolfgang Kopp, Gino Hasler. Functional Endoscopic Sinus Surgery. (1991) ISBN: 9780941158961 - <a href="http://books.google.com/books?vid=ISBN9780941158961">Google Books</a>
2. Hussain S, Woo E, Connor S. Sinonasal Imaging. Imaging. 2013;22(1):20110001. <a href="https://doi.org/10.1259/imaging.20110001">doi:10.1259/imaging.20110001</a>
3. Drutman J, Harnsberger H, Babbel R, Sonkens J, Braby D. Sinonasal Polyposis: Investigation by Direct Coronal CT. Neuroradiology. 1994;36(6):469-72. <a href="https://doi.org/10.1007/BF00593686">doi:10.1007/BF00593686</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/7991094">Pubmed</a>
4. Liang E, Lam W, Woo J, Van Hasselt C, Metreweli C. Another CT Sign of Sinonasal Polyposis: Truncation of the Bony Middle Turbinate. Eur Radiol. 1996;6(4):553-6. <a href="https://doi.org/10.1007/BF00182492">doi:10.1007/BF00182492</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/8798041">Pubmed</a>
5. Drutman J, Babbel R, Harnsberger H, Sonkens J, Braby D. Sinonasal Polyposis. Semin Ultrasound CT MR. 1991;12(6):561-74. - <a href="https://www.ncbi.nlm.nih.gov/pubmed/1786179">Pubmed</a>
6. Nasal Polyposis: Pathogenesis, Medical, and Surgical Treatment. (2010) ISBN: 9783642114113 - <a href="http://books.google.com/books?vid=ISBN9783642114113">Google Books</a>
7. Wolfgang Dähnert. Radiology Review Manual. (2011) ISBN: 9781609139438 - <a href="http://books.google.com/books?vid=ISBN9781609139438">Google Books</a>
8. Huang B, Lloyd K, DelGaudio J, Jablonowski E, Hudgins P. Failed Endoscopic Sinus Surgery: Spectrum of CT Findings in the Frontal Recess. Radiographics. 2009;29(1):177-95. <a href="https://doi.org/10.1148/rg.291085118">doi:10.1148/rg.291085118</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/19168844">Pubmed</a>
9. Lester D. R. Thompson. Head and Neck Pathology E-Book. (2012) ISBN: 9781455737826 - <a href="http://books.google.com/books?vid=ISBN9781455737826">Google Books</a>
10. Wolfgang F. Dahnert. Radiology Review Manual. (2017) ISBN: 9781496360694 - <a href="http://books.google.com/books?vid=ISBN9781496360694">Google Books</a>
11. Ramachandran K, Thomas M, Denholm R. Osseous Metaplasia of a Nasal Polyp. J Otolaryngol. 2005;34(1):72-3. <a href="https://doi.org/10.2310/7070.2005.04007">doi:10.2310/7070.2005.04007</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15966483">Pubmed</a>
12. Kshirsagar R, Chou D, Wei J, Liang J. Aspirin-Exacerbated Respiratory Disease: Longitudinal Assessment of a Large Cohort and Implications of Diagnostic Delay. Int Forum Allergy Rhinol. 2020;10(4):465-73. <a href="https://doi.org/10.1002/alr.22516">doi:10.1002/alr.22516</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/32104978">Pubmed</a>
1. Stammberger H. Functional endoscopic sinus surgery. Mosby-Year Book. ISBN:0941158969. <a href="http://books.google.com/books?vid=ISBN0941158969">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0941158969">Find it at Amazon</a>
2. HUSSAIN S, WOO E, CONNOR S. Imaging. 2013;22 (1): . <a href="http://dx.doi.org/10.1259/imaging.20110001">doi:10.1259/imaging.20110001</a>
3. Drutman J, Harnsberger HR, Babbel RW et-al. Sinonasal polyposis: investigation by direct coronal CT. Neuroradiology. 1995;36 (6): 469-72. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7991094">Pubmed citation</a>
4. Liang EY, Lam WW, Woo JK et-al. Another CT sign of sinonasal polyposis: truncation of the bony middle turbinate. Eur Radiol. 1996;6 (4): 553-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/8798041">Pubmed citation</a>
5. Drutman J, Babbel RW, Harnsberger HR et-al. Sinonasal polyposis. Semin. Ultrasound CT MR. 1992;12 (6): 561-74. <a href="http://www.ncbi.nlm.nih.gov/pubmed/1786179">Pubmed citation</a>
6. Nasal Polyposis: Pathogenesis, Medical and Surgical Treatment. Springer. ISBN:B00F75GZFC. <a href="http://books.google.com/books?vid=ISBNB00F75GZFC">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/B00F75GZFC">Find it at Amazon</a>
7. Dähnert W. Radiology Review Manual. LWW. (2011) ISBN:1609139437. <a href="http://books.google.com/books?vid=ISBN1609139437">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/1609139437">Find it at Amazon</a>
8. 13. Huang BY, Lloyd KM, DelGaudio JM, Jablonowski E, Hudgins PA. Failed endoscopic sinus surgery: spectrum of CT findings in the frontal recess. (2009) Radiographics : a review publication of the Radiological Society of North America, Inc. 29 (1): 177-95. <a href="https://doi.org/10.1148/rg.291085118">doi:10.1148/rg.291085118</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/19168844">Pubmed</a>
9. Lester D. R. Thompson. Head and Neck Pathology. (2012) p.4 <a href="https://books.google.co.uk/books?vid=ISBN9781455737826">ISBN: 9781455737826</a>
10. Wolfgang F. Dahnert. Radiology Review Manual. (2020) <a href="https://books.google.co.uk/books?vid=ISBN9781496360694">ISBN: 9781496360694</a>
11.Ramachandran K, Thomas M, Denholm R. Osseous Metaplasia of a Nasal Polyp. J Otolaryngol. 2005;34(1):72-3. <a href="https://doi.org/10.2310/7070.2005.04007">doi:10.2310/7070.2005.04007</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15966483">Pubmed</a>
12. Kshirsagar R, Chou D, Wei J, Liang J. Aspirin‐exacerbated Respiratory Disease: Longitudinal Assessment of a Large Cohort and Implications of Diagnostic Delay. Int Forum Allergy Rhinol. 2020;10(4):465-73. <a href="https://doi.org/10.1002/alr.22516">doi:10.1002/alr.22516</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/32104978">Pubmed</a>