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DIAGNOSTIC EXAM

Laboratory Studies

Children with polyposis that is associated with allergic rhinitis should have an

evaluation for their allergies; this may include a serological radioallergosorbenttest (RAST) or some form of allergic skin testing. Mabry et al showed a decrease

in the recurrence rate of polyps in children treated with immunotherapy directed

at all antigens for which they are allergic, especially molds;4therefore, allergytesting and treatment may be important in treating allergic fungal sinusitis (AFS).

Perform a sweat chloride test or genetic testing for cystic fibrosis (CF) in any

child with multiple benign nasal polyps.

A nasal smear for eosinophils may differentiate allergic from nonallergic sinus

diseases and indicate whether the child may be responsive to glucocorticoids. The

presence of neutrophils may indicate chronic sinusitis.

Imaging Studies

The criterion standard to evaluate nasal lesions, especially nasal polyposis orsinusitis, is a thin-cut (1-3 mm) CT scan of the maxillofacial area, the sinuses

axially, and the coronal plane. Perform a compatible CT scan if an intraoperative

image-guided system is used. Plain film radiography has no significant value afterpolyps are diagnosed.

Also perform MRI in patients with possible intracranial involvement or extension

of benign nasal polyps.

CT scan findings and MRI findings can help diagnose the polyp or polyps; definethe extent of the lesion in the nasal cavities, sinuses, and beyond; and narrow the

differential diagnosis of an unusual polyp or clinical presentation.

Physical

Begin physical examination for nasal polyps with an anterior rhinoscopy procedure (see

the image below). For small children, a handheld otoscope and otologic speculum are

typically used. An otoscope placed in the nasal cavity provides views of the inferiorturbinate, anterior septum, and areas in the nasal cavity extending to the anterior edge of

the middle turbinate and midportion of the septum. The middle meatus (ie, the area under

the middle turbinate laterally) can often be seen using anterior rhinoscopy if the child iscooperative and if no significant mucosal edema or secretions are present in the anterior

nasal cavity.

For benign nasal polyps, the middle meatus is the most common location. If adequately

visible, views of the middle meatus can reveal whether sufficient pathology is present to

warrant ordering a CT scan of the sinuses, rather than preforming a rigid or flexible

endoscopic procedure that may distress a young patient and the parents. However, rigidor flexible endoscopy is the best method to examine the nasal cavity and nasopharynx to

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fully assess the nasal anatomy (see the images below) and to determine the extent and

location of nasal polyps.

For small children, a flexible fiberoptic nasopharyngoscope is often used because it isless traumatic for children who may move their heads from anxiety or discomfort. In

older cooperative children and adolescents, a rigid endoscopy can be used to assess themiddle meatus and the sphenoethmoid recess. Perform adequate decongestion and

anesthesia of the nasal cavities before an endoscopic procedure for any child older than 6months. Video documentation of the procedure decreases the amount of time necessary

for the procedure and later enhances patient and parent education.

For children, evaluating the posterior wall of the oral cavity also can indicate the

symptomatology of polyposis (eg, postnasal drainage concomitant with chronic sinusitis).Large polyps or lesions of the nasal cavity may also protrude into the posterior

oropharynx from the nasopharynx; these may occur as a lesion behind the palate and

uvula or may depress the palate inferiorly and anteriorly (see the image below). Perform

otoscopic examinations because extensive polyposis that causes eustachian tubedysfunction can cause fluid and infection in the middle ear space. Careful examination of

the innervated systems of the cranial nerves and of the craniofacial structure helps definea nasal lesion's potential expansion into surrounding vital structures.

Endoscopy (pronounced /n d skpi/) means looking inside and typically refers to looking

inside the body for medical reasons using an endoscope (pronounced /ndskop/), an

instrument used to examine the interior of a hollow organ or cavity of the body. Unlike

most other medical imaging devices, endoscopes are inserted directly into the organ.

Endoscopy can also refer to using aborescopein technical situations where direct line-of-sight observation is not feasible.

The respiratory tract

The nose (rhinoscopy)

After the endoscopy

After the procedure the patient will be observed and monitored by a qualified individualin the endoscopy room or a recovery area until a significant portion of the medication has

worn off. Occasionally the patient is left with a mild sore throat, which may respond tosaline gargles, or chamomile tea. It may last for weeks or not happen at all. The patientmay have a feeling of distention from the insufflated air that was used during the

procedure. Both problems are mild and fleeting. When fully recovered, the patient will be

instructed when to resume their usual diet (probably within a few hours) and will be

allowed to be taken home. Because of the use of sedation, most facilities mandate that thepatient is taken home by another person and does not drive or handle machinery for the

remainder of the day.

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