Nasal, oral and pharyngeal diseases: Pathology review

While in the ENT Clinic, two people present with trouble breathing through the nose and have frequent nose bleeds. One of them is a 25 year old individual named Andrew, and the other one is an 18 year old individual named Sarah. Andrew says the problems appeared gradually and feels like something is stuck in the nose. Andrew also has a history of aspirin allergy. On examination, everything seems normal, except for a decrease in the sense of smell. Sarah, on the other hand, has noted these problems ever since childhood. Sarah also mentioned that the symptoms get worse during the spring or proximity to flowers. On examination, presentation is nasal congestion and red, itchy, swollen eyes with frequent bouts of sneezing. Blood tests were normal in both individuals.

Now, from what we can gather, both have some type of nasal, oral, or pharyngeal disease. But first, a bit of anatomy. The nasopharynx is an open chamber located below the base of the skull and behind the nasal cavity. The nasopharynx contains structures like the adenoids, also known as the pharyngeal tonsils; the Waldeyer's tonsillar ring, which is a ring-like arrangement of lymphoid tissue in both the nasopharynx and oropharynx; the Rosenmüller fossa, which is part of the lateral recess of the nasopharynx and a common site of nasopharyngeal cancers; and the eustachian tube orifices. Now, the nasopharynx connects the nasal cavity and oropharynx, which is posterior to the oral cavity that contains structures like the salivary glands, soft and hard palate, tongue, and tonsils.

Ok, so we can begin with nasal polyps. Now, remember that a nasal polyp is a clump of epithelial cells that undergo hyperplasia and form a growth of tissue along the lining of the nasal cavity. This is most often caused by seasonal allergies, recurrent infections, frequent asthma exacerbations, chronic sinusitis, or acetyl-salicylic acid and nonsteroidal anti-inflammatory drug sensitivity. There are some genetic causes too; that’s high yield. Remember that it’s associated with cystic fibrosis and primary ciliary dyskinesia. You also need to know that usually, nasal polyps form in the ethmoid or maxillary sinuses and are typically non-cancerous. As polyps enlarge, they often obstruct the airflow as well as the mucus drainage, allowing pathogens to linger in the sinuses and cause recurrent infections. For symptoms, know that this leads to progressive nose breathing difficulties, nose foreign body sensation, the loss of the sense of smell, or anosmia, and bouts of fevers and headaches due to infections. In young infants, it can cause hypoxia, which gives a bluish tinge to their skin color, called cyanosis. This specifically happens in infants because they are obligate nose breathers, meaning they really prefer breathing through their nose. If bilateral obstruction occurs, a period of cyanosis occurs, then the infant cries and breathes through the mouth, resolving the cyanosis. So on the exam, look for an infant with periodic bouts of cyanosis, resolved by crying. Now, regarding diagnosis, all you need to recall is that nasal endoscopy or CT can help diagnose nasal polyps, and determine the size, location, and number. The treatment is to shrink them using nasal steroids, which work by decreasing the inflammation and swelling of the polyp. Those unresponsive to steroids are removed by endoscopic sinus surgery.