Nasal Polyp in Children with Allergic Rhinitis: A Case Report

Teuku Husni

1,2

Doctoral Program in Mathematics Science Application, Syiah Kuala University, Banda Aceh, Indonesia

Division of Rhinology, Department of Ear, Nose, Throat, Head & Neck Surgery, Faculty of Medicine, Zainoel Abidin

General Hospital, Banda Aceh, Indonesia

Keywords: Nasal Polyp In Chidren, Rare Case, Allergic Rhinitis, Endoscopic Sinus Surgery, Polypectomy

Abstract: Nasal polyp are soft, painless, non cancerous growths, semi-translucent edematous masses with a broad or

slim base usually arising from the mucosal lining of paranasal sinuses or on the lining of nasal passages. In

most cases, polyps are considered to be manifestation of chronic inflammation due to asthma, recurring

infection, allergies, drug sensitivity or certain immune disorders. Nasal polyp are very rare in children, the

incidence is 0.1% of all nasal polyp case. Thirty three percent of all nasal polyp case in children are

antrochoanal type. Multiple polyp can occur in children with chronic sinusitis, allergic rhinitis, cystic

fibrosis or allergic fungal sinusitis. Medication like steroid can often shrink or eliminate nasal polyps, but

surgery is sometimes needed to remove them. Even after successful treatment, nasal polyp often return. In

this case report we present a 5 years old boy with nasal polyp sinistra with allergic rhinitis and necessitating

endoscopic surgical intervention.

1 INTRODUCTION

Nasal polyp is a soft mass containing alot of fluid in

nasal cavity, white greyish in color, due to mucous

inflammation. Nasal polyp can occur in male and

female, from young age to elderly person. If nasal

polyp occur in children below 2 years, need to rule

out possibilty of meningocel or

meningoencephalocele. (Soepardi, 2012).

Nasal polyp mostly associated with chronic

inflammation, otonom nerve dysfunction, and

genetic disproportion. According to Bernstein

theory, change in nasal mucous due to inflammation

or airflow turbulence, mostly in narrow area in

osteomeatal complex. Submucousal prolaps occur

that followed by re-epitelization dan new gland

formation. Also increasing natrium absorbtion by

ephitel surface that cause water retention and create

nasal polyp. Another theory confirm due to

imbalance vasomotor nerve, increase capiler

permeability and vascular regulation that cause

releasing cytokin from mast cell, and cause edema

and in long time will cause nasal polyp. (Soepardi,

2012).

Mackay dividing nasal polyp into 4 stadium:

(Budiman, 2010)

‐ Stadium 0 : no nasal polyp

‐ Stadium 1 : polyp only in meatus media,not

in nasal cavity, can’t be seen by anterior

rhinoscopy but can be seen by

nasoendoscopy

‐ Stadium 2 : polyp out of meatus media and

seen in nasal cavity, but not fullfil the nasal

cavity

‐ Stadium 3 : nasal polyp fullfil the nasal

cavity

Hellquist dividing nasal polyp based on the

histologic type: (Budiman, 2010)

‐ Type I : Allergic polyp with

dominant eosinophilic

‐ Type II : Fibroinflamatoric polyp

with neutrofil dominant

‐ Type III : Polyp with hyperplasia

seromusinosa gland

‐ Type IV : Polyp with atipical stroma

Chmielik dividing polyp based on hystologic into

3 type: eosinophilic polyp, inflammatory polyp, and

atipical stroma. (Chmielik, 2011)

Clinical manifestations of nasal polyp depend on

their extent and may consist of obstructed nasal

breathing, hyposmia or anosmia (due to obstruction

of the olfactory groove), headache (due to impaired

228

Husni, T.

Nasal Polyp in Children with Allergic Rhinitis: A Case Report.

DOI: 10.5220/0008792302280232

In Proceedings of the 2nd Syiah Kuala International Conference on Medicine and Health Sciences (SKIC-MHS 2018), pages 228-232

ISBN: 978-989-758-438-1

ventilation and draination in the paranasal sinuses),

snoring, rhinophonia clausa, and frequent throat

clearing due to associated postnasal drainage. Spread

to the lower airways can lead to laryngitis with

hoarseness and bronchitic symptoms. (Probst, 2006).

Masive nasal polyp can cause nose deformity

and widening of nasal bridge. On anterior

rhinoscopy nasal polyp seen as a pale mass that

came out from meatus medius and mobile.

(Soepardi, 2012).

Paranasal sinuses radiologic (waters, AP,

caldwell and lateral view) show mucous thickening

and air fluid level in sinus, but less helpful in polyp

case. CT scan investigation very helpful to see nasal

cavity and sinuses clearly if there any inflammation

process, anatomy abnormality, polyp or obstruction

in osteomeatal complex. CT scan mostly indicated

for nasal polyp case that fail to be treated with

medication, for sinusitis complication dan planning

for endoscopic surgery. (Soepardi, 2012).

Main purpose for nasal polyp treatment is to heal

the complain, avoid the complication dan avoid the

polyp recurrent. Corticosteroid treatment for nasal

polyp called medication polypectomy. Can be given

as topical or sistemic. Eosinophilic polyp give better

response with intransal corticosteroid compare with

neutrophilic polyp. For nasal polyp that not improve

with medication or for masive nasal polyp, surgery

is suggested. The surgery can be done by polyp

extraction (polypectomy) with polyp wire or forcep

with local anagesic, intranasal ethmoidectomy or

extranasal ethmoidectomy for ethmoid polyp,

Caldwell-luc surgery for maxillary sinus. If

endoscopi facility avaialable, then the best option is

to do Functional Endoscopic Sinus Surgery (FESS).

(Probst, 2006).

2 CASE REPORT

A 5 years old boy came to ENT clinic of Zainoel

Abidin General Hospital (ZAGH) on end of April

2018 referral from district ENT specialist with major

complaint obstruction of left nose since 2 years ago

and getting worse in the last 3 months. Patient

complaining permanent obstruction, and only on the

left nose. There’s a history of nasal bleeding twice.

Currently patient complaining pain on the left nose.

Patient has an dust allergic and history of recurrent

runny nose.

On physical examination, patient in good

condition, fully alert, cooperative, and well nutrition

status. On Ear examination, within normal limit. On

nasal examination, looked asymetric due to mass

compression on left nose. On left nares seen white

gelatinous mass. On anterior rhinoscopy seen left

nasal cavity fullfil with white gelatinous mass,

inferior concha can’t be seen due to mass. Right

nasal cavity narrowing due to inferior concha

hypertrophy, pale mucous, no rhinorea and septal

deviation found. On oropharingeal examination

within normal limit and found caries dentis. Normal

neck examination. Patient diagnosed with left nasal

polyp with allergic rhinitis. Then we conduct some

examination such as laboratory, paranasal sinused

CT scan without contrast dan chest x-ray. After all

the examination result available, we refer patient to

pediatric and anesthesia department to obtain the

surgery approval for polypectomy under general

anesthesia. The surgery plan to be done on 22 May

2018.

Figure 1: First picture of patient before the surgery

Figure 2: Paranasal sinus CT scan axial view showed

polyp mass on left nasal cavity

Nasal Polyp in Children with Allergic Rhinitis: A Case Report

229

Figure 3: Paranasal sinus CT scan coronal view showed

polyp mass on left nasal cavity

On 22 May 2018, the polypectomy endoscopic

surgery done within general anesthesia. The surgery

start with patient lay on the surgery table under

general anesthesia. Pack was placed in the mouth.

Aseptic and antiseptic procedure was done on the

surgery field. Then xylocain adrenalin package was

placed on both nasal cavity for 15-20 minutes. After

the nasal packages removed, the left nasal cavity

was observed with 0

scope, white greyish

gelatinous mass seen fullfil the left nasal cavity dan

seen redness on the posterior side, mobile, and seem

came out from meatus media, inferior and media

nasal concha eutrophy, meatus media blocked by the

polyp mass. Extirpation nasal polyp was done by

cutting forcep until all the nasal polyp in left nasal

cavity was removed. And then nasal cavity was

evaluated until nasopharyng area. No active bleeding

found and nasopharyng area seem clear. Right nasal

cavity also evaluated with 0

scope, no mass seen,

inferior and media nasal concha eutrophy,

nasopharyng within normal limit. Bleeding on left

nose was controlled with handscoon nasal package.

Pack in the mouth was removed. Surgery has

finished. Polyp tissue was sent to anatomic

pathology laboratory to find out what type of nasal

polyp. Patient was returned to ward after fully alert.

Post surgery treatment patient was given cefotaxime

injection 500mg twice a day, paracetamol 250mg

twice a day dan tranexamic acid 250mg thrice a day.

On the first post operation day, patient still

complaining pain on the surgery site, but no more

active bleeding found on the left nose. Anterior nasal

package was still applied, no blood seepage seen, no

blood seen on pharyngeal area.

On second post operation day, pain on the

surgery site has reduced. Anterior nasal package was

removed, and then left nasal cavity was evaluated.

No active bleeding, sinechia, or nasal polyp found.

Patient was allowed to discharge with some

medication, cefixime syrup 60mg twice a day and

paracetamol syrup 250mg thrice a day and edvised

to do nasal wash at home.

Patient came for follow up review on ENT clinic

ZAGH on the 6

post operation day. Patient

complaining blockage on left nose and stated that

the nose washing has been done as instructed, 6

times a day. On physical examination found bloody

crustae on left nasal cavity, no sinechia found. And

then bloody crustae was extracted followed by nasal

washing until left nasal clear.

Figure 4: First follow up review post surgery, no more

mass seen on left nasal cavity

Next follow up review was done once every 2

days. Nasal blockage complaint has reduced. on

anterior rhinoscopy blood crusta was found less than

before. Patient has come for post operation follow

up review 4 times,and then stopped due to ramadhan

and idul fitri holiday. Patient’s family was advised to

go to the hospital if there’s any nasal bleeding or

nasal blockage happen.

On 4

weeks after surgery, patient’s family

informed that patient start to sneezing and have a

runny nose again, also nasal blockage at night. We

advised them to come to ENT clinic of ZAGH and

continue the nose wash, but patient has not come yet

to the ENT clinic.

The anatomy pathology from the polyp tissue

result come as nasal polyp, no malignancies sign

found.

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3 DISCUSSION

A nasal polyp case on 5 years old boy reported and

diagnosed by anamnesis, physical examination

through anterior rhinoscopy and radiologic

examination paranasal sinuses CT scan. Nasal polyp

in this case report found in 5 years old boy. This

appropriate with literature reported by Bestari Jaka

Budiman stated that nasal polyp occur more in male

than female, 2-4: 1, and rarely happen in children

with evidence number 0,1%. In Indonesia,

epidemiology study showed comparison between

male and female is 2-3:1 with prevalence 0,2%-

4,3%. Polyp of this patient is antrochoanal polyp,

and according to literature defined antrochoanal

polyp is nasal polyp of maxillary nasal origin, came

out through maxillary sinus ostium to nasal cavity

and extend to choana. Accroding to Khalid,

antrochoanal polyp is polyp that growth from

maxillary sinus mucous and came out through

ostium to nasal cavity. (Budiman, 2010)

The exact cause of antrochoanal polyp is not

known yet, but can caused by allergic facto, cystic

fibrosis infection and mechanical obstruction. In this

patient also found allergic rhinitis that can cause

nasal polyp. To find the type of allergen, patient

should perform the allergic test so patient can avoid

the allergen to decrease the recurrence rate.

(Budiman, 2010)

Surgery was the only feasible treatment for

antrochoanal polyp. Several surgical techniques

were described. In the past, Caldwell-Luc technique

was used. FESS is currently the glod standard

techniques. FESS is less invasive techniques which

permits to restrore drainage of the paranasal sinuses

and ventilation between the nose and sinus cavities

and allows shorter hopsital stay. The antral portion

of an antrochoanal should be removed, together with

the base of its origin, to minimize post-operative

recurrence. The use of micro-debrider may be

indicated, as complementary to endocsopic surgery.

Combining endoscopic surgery and trans-canine

sinuscopy is an alternative technique. The succes

rate was 76,9% in the trans-nasal endoscopic

approach. On the other hand, no recurrence could

happen after long-term follow up if there’s a

correction of a nasal associated nasal anatomic

variation at the time of surgery for antrochoanal

polyp removal. (Chlebna, 2017; Mandour, 2017)

Recurrence rate of nasal polyp after endoscopi

surgery was about 60%.

we have informed about

this to patient’s family before the surgery since the

recurrency rate was quite high, followed by some

advised to have a review at ENT clinic if there’s any

nasal blockage found. (Budiman, 2010)

The process of polyp formation due to chronic

inflammation is reversible, so the treatment of

rhinosinusitis should start very early with nasal

washing with saline solution, antibiotic and local

steroid. In the post-operative period the patient hs

been recommended to keep on doing frequent nasal

washing with saline solution. (Chlebna, 2017).

4 CONCLUSION

We described a case report of a 5 years old boy with

rhinitis allergic presenting with nasal polyp.

Diagnosed was made based on anamnesis, physical

examination and radiology (CT scan) finding. The

treatment was done by polypectomy surgery with

FESS technique. Since the recurrence rate quite

high, patient’s family has been advised to control the

rhinitis allergic symptom and seek for medical

treatment if there’s any nasal blockage reported by

patient.

ACKNOWLEDGEMENTS

This paper reports a rare case in children hopefully

can be additional information and knowledge in the

field Ear Nose Throat Head and Neck Surgery.

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