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Clinical Challenge
July 2015

Massive Sinonasal Polyposis

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas
JAMA Otolaryngol Head Neck Surg. 2015;141(7):669-670. doi:10.1001/jamaoto.2015.0798

A man in his 30s presented to the emergency department with a worsening sinus infection and vision loss. His medical history was significant for previous nasal endoscopy with biopsy of nasal polyps 6 years previously, with a finding of benign nasal polyps by surgical pathology. The patient had then been lost to follow-up. He now complained of nasal drainage, severe headaches, and long-standing visual loss. There had been no acute worsening of headaches or visual loss in the previous months. Physical examination showed severe left proptosis, telecanthus, purulent nasal drainage, and nasal polypsis filling the bilateral nasal cavities. Ophthalmology consultation revealed no evidence of restriction of gaze or papilledema, and a recommendation was made for endoscopic sinus surgery to remove the source of infection. Computed tomographic imaging revealed extensive nasal polyposis, bony remodeling consistent with long-standing inflammation, and massive erosion of the bilateral skull base and orbits (Figure 1A). The patient underwent endoscopic sinus surgery. Nasal polyps were present and had a typical appearance superficially (Figure 1B). However, on deeper dissection, they became increasingly difficult to remove even with powered instrumentation, and an atypical, fibrotic endoscopic appearance was noted (Figure 1C). Tissue was sent for histologic evaluation. Following this, the dissection was terminated.

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