Endoscopic views of nasal septal polyps.

Nasal polyps most often originate in the lateral wall of the nasal cavity, specifically, in the anterior ethmoid region. In a study of 200 patients, Stammberger found that the most common sites of polyp origin were the contact areas of the uncinate process, the middle turbinate, and the ethmoid infundibulum. [1] Almost two-thirds of those patients had polyps originating in the anterior aspect of the ethmoid bulla. Medially based nasal polyps are rare. Stammberger mentioned that only three patients had polyps originating in the posterior nasal septum. [1] Likewise, the senior author (E.Y.) found only three cases of septal polyps in 200 consecutive sinonasal surgical cases.

Patient 1. The first patient, whose chief complaint was nasal obstruction, underwent a septoplasty and partial turbinectomy. The patient was found to have a single polyp arising from the posterior midportion of the nasal septum on the right side (figure, A), which was removed with a microdebrider. There were no other polyps.

Patient 2. The second patient was a 40-year-old woman who had undergone sinonasal surgery (polypectomy) for nasal polyposis approximately 10 years earlier. She developed recurrent nasal polyps bilaterally and underwent a powered endoscopic polypectomy and ethmoidectomy. Nasal endoscopy at surgery revealed multiple polyps arising from the lateral nasal wall bilaterally (figure, B). Another polyp was found arising from the midportion of the nasal septum on the right. After removal of these polyps, yet another polyp was found arising from the posterosuperior portion of the nasal septum on the same side (figure, C).

Patient 3. The third patient, who had a history of recurrent sinusitis, had extensive bilateral nasal polyposis. Preoperative sinus computed tomography showed pansinusitis, with cloudiness of the right sphenoid sinus. After the excision of numerous polyps that had originated in the lateral nasal wall, patient 3 was found to have a polypoid lesion with a wide base arising from the posterosuperior portion of the nasal septum on the right side (figure, D). The polyps extended medially, close to the natural opening of the sphenoid sinus. The polyp was excised with a microdebrider.

Polypoid nasal mucosa is a common pathologic condition that is poorly understood. Polyps manifest with a wide range of clinical appearances; some are glassy, edematous, and cystic, while others are coarse and fibrotic. [1] The most common clinical presentations include nasal obstruction, sinusitis, and anosmia. [2] Asthma and cystic fibrosis have been associated with nasal polyps, but their definitive etiology has not yet been determined. Nasal polyps begin as a localized submucosal edema. Over time, gravity causes the edematous tissue to aggregate. Air currents in the nasal cavity affect the mucosa by creating areas of negative pressure. Together, gravity and pressure act to elongate the edematous mucosa and enlarge its base, and a polyp eventually forms. [3]

One of the major questions about polyps that remains to be answered is, What is the origin of the initial mucosal edema? Two possible initial stimuli are allergy and inflammation. Two localized phenomena that might lead to polyp formation are pressure1 and turbulent air flow.4 These phenomena are most likely to occur along the lateral aspect of the nasal cavity, which perhaps helps explain the general distribution of nasal polyps. In the medial aspect of the nasal cavity, there are fewer pressure points to stimulate foci of inflammation. Pressure points can be found in patients who have massive polyposis. In these patients, polyps from other areas can impinge on the septum and create an area of edema (figure, B and D).

Partly because of the lack of medial pressure points and contact areas, cases of septal polyps have been relatively rare. Even so, it is possible that they will become increasingly recognized in the future as a result of improvements in visualization techniques. Telescopic endoscopy allows for a thorough inspection of the entire nasal cavity, including the posterior septum. When they are detected, septal polyps are best excised endoscopically with a microdebrider.

From the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group and the Section of Otolaryngology, Hospital of St. Raphael (Dr. Yanagisawa), and the Section of Otolaryngology, Yale University School of Medicine (Dr. Yanagisawa and Dr. Klenoff), New Haven, Coon.

References

(1.) Stammberger HR. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia, B.C. Decker, 1991.

(2.) Drake-Lee AB, Lowe D, Swanston A, Grace A. Clinical profile and recurrence of nasal polyps. J Laryngol Otol 1984;98:783-93.

(3.) Ogawa H. A possible role of aerodynamic factors in nasal polyp formation. Acta Otolaryngol Suppl 1986;430:18-20.

(4.) Bernstein JM, Gorfien J, Noble B. Role of allergy in nasal polyposis: A review. Otolaryngol Head Neck Surg 1995;113:724-32.