PANCE Blueprint EENT (7%)

Nasal polyps

Patient will present as → a 6-year old female who is being seen for a routine well-child exam is noted to have multiple teardrop-shaped growths partially obstructing the nasal passages. The child has a history of chronic sinusitis and recurring ear infections. As an astute PA, you order a sweat chloride test.

Nasal polyps appear as pale, boggy masses on the nasal mucosa.

  • Allergic rhinitis, acute and chronic infections, and cystic fibrosis all predispose to the formation of nasal polyps.
  • Finding nasal polyposis in a child is a “red flag” condition and should make the clinician suspicious of possible cystic fibrosis.
  • Often causes symptoms of blockage, discharge, or loss of smell.
  • Samter's triad: Asthma, Aspirin sensitivity and nasal polyps.

Diagnosis is clinical

  • Patients may complain of chronic congestion and a decreased sense of smell.

A 3-month course of topical nasal corticosteroid is the initial treatment choice. This is effective for small polyps and can reduce the need for surgical intervention. Oral steroids (6-day taper) can also help reduce size.

  • Surgical removal may be necessary if therapy is unsuccessful or if polyps are large.
Nasal Polyp

Nasal polyp in left nostril

Question 1
Which nasal condition, if found in young children, is suggestive of cystic fibrosis?
A
chronic rhinorrhea
B
nasal polyps
C
choanal atresia
D
perennial allergic rhinitis
E
acute sinusitis
Question 1 Explanation: 
Nasal polyps in a child should make the clinician suspicious for possible cystic fibrosis. Usually, this illness manifests itself in early childhood with predominantly lung involvement. Recurrent sinusitis and otitis media are also frequently seen. The onset of nasal polyps in these patients typically appears between the ages of 5 and 14 years. Diagnosis of cystic fibrosis is made by a sweat chloride test.
Question 2
When evaluating a newborn, the inability to pass a small catheter through the nasal cavity is most indicative of which of the following conditions?
A
choanal atresia
B
meconium ileus
Hint:
Meconium ileus, intestinal obstruction secondary to inspissated meconium, occurs in approximately 10% of newborns with cystic fibrosis.
C
nasal infection
Hint:
Nasal infections may occur secondary to a furuncle (infected hair follicle) in the anterior nares or as a nasal septal abscess following spread of a furuncle. Common causes of nasal infections include picking at the nose and pulling out nose hair.
D
nasal polyps
Hint:
Nasal polyps are uncommon in children younger than age 10, and when they do occur it is usually in older children and adults with allergic rhinitis.
Question 2 Explanation: 
Choanal atresia, whether unilateral or bilateral, is a nasal obstruction that occurs relatively rarely in newborns. If bilateral choanal atresia occurs at birth, it causes a respiratory distress that requires immediate treatment (due to infants being obligate nose breathers) by placing an oral airway and subsequent surgical correction. Unilateral choanal atresia can present as a chronic, single-sided, nasal discharge that may not appear until later in childhood. Meconium ileus, intestinal obstruction secondary to inspissated meconium, occurs in approximately 10% of newborns with cystic fibrosis. Cystic fibrosis affects approximately 1 in 2,500 live Caucasian births, and is a leading cause of death in young adults. Nasal infections may occur secondary to a furuncle (infected hair follicle) in the anterior nares or as a nasal septal abscess following spread of a furuncle. Common causes of nasal infections include picking at the nose and pulling out nose hair. Nasal polyps are uncommon in children younger than age 10, and when they do occur it is usually in older children and adults with allergic rhinitis.
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