Isolated polyp of the ethmoid sinus. (Rhinoscopic Clinic).

A 64-year-old man had a 6-month history of dull, right-sided frontal headaches. He also had recurrent sinusitis and experienced difficulty breathing through his nose. He denied any history of allergy, asthma, or anosmia.

Nasal examination revealed a rightward deviation of the nasal septum, bilateral hypertrophy of the turbinates, and generally reactive nasal mucosa. Coronal thin-section computed tomography (CT) of the sinuses revealed a right-sided ethmoid polyp in the region near the frontal sinuses (figure, A). The ostiomeatal complex was markedly narrowed on the right side. A further posterior CT scan cut showed a paradoxically bent middle turbinate on the right side (figure, B). The other sinuses were clear. No bony destruction was noted.

The patient was taken to the operating room. Nasal endoscopy revealed that the anterior end of the right middle turbinate was edematous and polypoid and that the middle turbinate was indeed paradoxically bent (figure, B, inset). The left middle turbinate was hypertrophied. The edematous right middle turbinate was retracted medially with a Killian nasal speculum. Telescopy revealed that a gray, smooth, polypoid mass, had protruded into the middle meatus and obstructed the ostiomeatal complex (figure, C). This mass was grasped with a 30[degrees] upward medium-sized cup forceps; as it was carefully pulled, the entire polypoid lesion was removed in continuity as a single specimen (figure, C, inset). The lesion had originated in the medial wall of the expanded ethmoid sinus near the entrance of the frontal sinus (figure, D). A branch of the anterior ethmoid artery was observed along the posterior wall of this cavity (figure, D). Right anterior ethmoidectomy, bilateral partial turbinectomy, and septoplasty were com pleted. No other lesion was identified. The diagnosis of an inflammatory polyp was confirmed by pathologic examination. Three years later, the patient reported complete relief of his symptoms and he had no further evidence of recurrent polyps.

Nasal polyps are usually multiple and bilateral. According to Stammberger, they usually originate much more frequently in fissures and narrow spaces of the ethmoid than from ethmoidal cells themselves. (1) Some attribute this anatomic predilection to the effects of mucosal contact (1) or chronic infection and inflammation at these sites. (2) According to Larsen and Tos, the lateral wall of the anterior middle meatus is the most common site of origin of nasal polyps. (2) One wonders how the polyp can reach from the ethmoid sinus to the middle meatus. From their cadaver study, Larsen and Tos demonstrated that polyps do originate from the edge of the ostium to the ethmoid sinus. (2) Yanagisawa et al endoscopically demonstrated that nasal polyps can originate in the uncinate process, the ethmoid infundibulum or bulla, the frontal recess, the suprabullar and retrobullar recess, the hiatus semilunaris, the turbinates, and the mucosa of the septum. (3,4) This report illustrates an isolated nasal polyp originating in an anterior ethmoid cell.

References

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

(2.) Larsen PL, Tos M. Origin of nasal polyps. Laryngoscope 1991; 101:305-12.

(3.) Yanagisawa E, Christmas DA, Yanagisawa R. Endoscopic view of the sites of origin of nasal polyps. Ear Nose Throat J 2000;79: 490-2.

(4.) Yanagisawa E. Atlas of Rhinoscopy: Endoscopic Sinonasal Anatomy and Pathology. San Diego: Singular Publishing, 2000.