Q:

12/22/2011
On a sinus CT, will nasal polyps look different than a mass (i.e. possible oncologic process)? Is there any reason that I would need to send a patient with "polyp or cyst" read on sinus CT for a biopsy? Thank you.

A:

Thank you for your inquiry.

I will try to answer your question as best I can, but I am slightly confused by the terminology. The term “cyst” usually is not used to describe a nasal polyp, but is occasionally used to refer to a polypoid lesion in the sinuses, most commonly in the maxillary antra. This type of lesion is benign and does not need to be evaluated for a neoplastic process. These again are usually referred to an maxillary mucoceles or maxillary cysts. Occasionally you see the term “polypoid lesions of the maxillary antra” as well.

As noted, these are benign and do not require biopsy. They are only of clinical significance if they grow to fill the entire maxillary antra at which time they may cause mechanical problems.

Nasal polyps are distinct and are not, at least in my experience, referred to as cysts. That is the reason I cited the above information about maxillary mucoceles.

A CT scan is not sufficient to distinguish a nasal tumor from a nasal polyp. There are a few distinguishing features that would lead to a further evaluation. First of all, the majority of polyps arise in the ethmoids, and are almost always bilateral. On the other hand, tumors are unilateral. The only exception is polyps (choanal polyps) that arise from the maxillary antra and can be unilateral.

The other distinguishing features are noted on physical examination, and any polyp lesion seen in the nose, especially those that are unilateral, should be visualized. Polyps have a distinct mucoid appearance. They do not have pain fibers and therefore they can be touched and pushed with a Q-tip without pain. They are usually not friable and show no bleeding on the external surface. On the other hand, tumors can be painful when touched, are usually not as mobile as a polyp, and show bleeding.

I would turn again to the term “cyst,” and I am wondering if you are speaking of a concha bullosa which is air in a turbinate, and is a "cystic" lesion.

If, however, you are speaking of nasal polyps, yes, they do need to be visualized. This is especially true, as noted, if they are unilateral. The visualization of the polyp can oftentimes determine whether or not the polyp may be malignant.

Thus, if you aren’t able to visualize the polyp yourself and make a reasonable distinction on physical examination, the patient should be referred to an otolaryngologist for visualization.

For your interest, I have copied below an abstract discussing unilateral polyps.

Thank you again for your inquiry and we hope this response is helpful to you.

Am J Otolaryngol. 2008 Jul-Aug;29(4):230-2. Epub 2008 Mar 17.
Unilateral nasal polyposis: clinical presentation and pathology.
Tritt S, McMains KC, Kountakis SE.
Source
Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia, Augusta, GA 30912, USA.
Abstract
Objectives: The aim of this study is to determine the clinical presentation and pathology of unilateral nasal polyposis (UNP).
Study Design: Retrospective chart review.
Methods: A retrospective analysis was completed on 301 consecutive patients with nasal polyposis that underwent functional endoscopic sinus surgery from 1995 to 2004. Of the charts reviewed, 46 patients were identified with UNP. In this group, there were 28 males and 18 females with a mean age at presentation of 34.85 years. Pathologic diagnosis was not available for 2 patients, so there were 44 UNP patient records for analysis. Presenting symptoms, surgical findings, and pathology were analyzed.
Results: All 44 patients underwent surgical management for their symptoms, and specimens were sent for pathologic evaluation. There were 17 cases of chronic rhinosinusitis, 15 of allergic fungal sinusitis, 7 of inverting papilloma, 2 of squamous cell carcinoma, 1 of esthesioneuroblastoma, 1 of mucocele, and 1 of human papilloma virus polyp-type papilloma. The only presenting symptom that correlated with the presence of inverted papilloma or neoplastic process in our patients with UNP was epistaxis.
Conclusions: Chronic rhinosinusitis, allergic fungal sinusitis, inverting papilloma, and other neoplasms account for most UNP cases and must be considered when a patient presents with symptoms of unilateral polyps. A careful history and endoscopic examination play a key role in identifying possible disease processes and proper management.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology