|Year : 2013 | Volume
| Issue : 2 | Page : 113-115
Multiple nasal polyps in an 11 year old asthmatic child: A case report
Ibrahim Aliyu, Akhiwu O Helen
Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University, Kano, Nigeria
|Date of Web Publication||25-Dec-2013|
Department of Paediatrics, Aminu Kano Teaching Hospital, Kano
Childhood asthma is a common chronic respiratory disease; it may be associated with other co-morbidities which may influence its severity. Among these is chronic rhino sinusitis, conjunctivitis, or gastroesophageal reflux disease. However, nasal polyps are rare in asthmatic children, being more common in those more than 20 years. Its exact cause is not completely understood and it has been associated with sensitivity to non-steroidal anti-inflammatory drugs. In this communication we report a case of a 11-year-old boy with multiple nasal polyps and difficult to manage asthma.
يعتبر الربو عند الأطفال من أمراض الجهاز التنفسي المزمنة والشائعة والتي قد ترتبط بأمراض أخرى تؤثر على حدتها؛ ومن هذه: التهاب الجيوب الأنفية، التهاب الملتحمة والارتجاع المعدي المريئى. يندر حدوث اللحميات الأنفية عند الأطفال المصابين بالربو ولا يعرف سببها على وجه التحديد، ولكنها قد ترتبط بالحساسية للأدوية المضادة للالتهابات. يعرض الباحثان تقريرا عن حالة لطفل في الحادية عشرة من العمر يعاني من اللحميات الأنفية المتعددة أدت إلى صعوبة علاجه من الربو.
Keywords: Asthma, childhood, nasal polyps, non-steroidal anti-inflammatory drugs
|How to cite this article:|
Aliyu I, Helen AO. Multiple nasal polyps in an 11 year old asthmatic child: A case report. Saudi J Med Med Sci 2013;1:113-5
| Introduction|| |
Nasal polyps are semi-translucent edematous masses with a broad or slim base usually arising from the mucosal linings of the paranasal sinuses. In most cases, polyps are considered to be the manifestation of chronic inflammation.  A strong association has been observed between nasal polyposis and asthma with the incidence most common in individuals older than 20 years especially those above 40 years of age. , Most patients respond to the use of steroids and a few require surgical intervention.  Furthermore, nasal polyposis with asthma may be associated with other multisystemic diseases like Churg Strauss syndrome which is rare in children. In this communication we present an 11-year-old asthmatic boy presenting with multiple nasal polyps necessitating surgical intervention.
| Case Report|| |
A 11-year-old boy presented to the pediatrics cardiopulmonary clinic for the first time in 2010 with complaints of recurrent cough and difficulty in breathing with associated wheezing since the previous year. There was a positive maternal history of asthma. Symptoms were usually worse at night and abort spontaneously or with nebulization at the emergency pediatrics unit. Common triggers elicited were cold, upper respiratory tract infection, and dust, but no sensitivity to drugs like non-steroidal anti-inflammatory drugs (NSAIDs). He occasionally required oral steroid to control his symptoms. His chest x-ray and blood counts were essentially normal. The full blood count showed a total white cell count of 12,900 cells/mm 3 with an eosinophil count of 1300 cells/mm 3 . He was then followed up as a case of moderate persistent asthma on salbutamol inhaler (for rescue therapy) and medium dose fluticasone and salmeterol combination as controller medication. He had several acute asthmatic exacerbation over the following 2 years especially when he ran out of his drugs.
In 2011, he complained of progressive nasal blockage with snoring and noisy breathing with hyposmia, rhinolalia, and recurrent otorrhea. His nasal endoscopy showed multiple nasal polyps more on the right, originating from the middle meatus displacing the middle turbinate medially and the nasal septum. The inferior turbinates were bilaterally engorged. Repeat chest x-rays showed increasing perihaliar opacities [Figure 1] and [Figure 2] and he was negative for ANCA. His CT-scan of the paranasal sinuses showed opacification of both maxillary sinuses and nasal cavities [Figure 3]. He was prescribed steroid nasal spray with no significant improvement and subsequently had endoscopic sinus surgery for removal of the polyps. He was discharged home 6 days after the surgery.
|Figure 1: Chest X-ray PA view taken a year later showing increasing opacities in both lung fields|
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|Figure 2: Chest X-ray PA view taken in 2011 showing prominent perihaliar shadows|
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|Figure 3: CT scan of the paranasal sinuses pre-operation showing opacification of the paranasal sinuses|
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The histopathology of the excised polyps showed fibromuscular stoma exhibiting intense lymphoplasmacytic cells infiltrates admixed with eosinophilic mucous glands of which some were dilated in addition to areas of granulation tissue. Hence, the diagnosis of childhood asthma with multiple benign nasal polyps was made. He is still being followed up at the respiratory clinic.
| Discussion|| |
Nasal polyps are the result of several disease processes involving the nose and paranasal sinuses. It may follow an inflammatory, infective, or neoplastic process.  Its exact pathogenesis is not clear though it has been linked to chronic inflammation, autonomic nervous system dysfunction, and genetic predisposition.  It is seen mostly in adults with a mean age of 34 years, , but the index case developed symptom at 11 years of age. The duration from onset of asthma to development of nasal polyp is quoted as 9-13 years.  However, this index case developed symptoms within 2 years of diagnosis of asthma and the progression was so rapid that by the second year of illness the size of the polyps was so large as to necessitate surgical intervention.
This patient had frequent acute exacerbation of asthma despite the use of inhaled glucocorticoid controller medication which is typical of patients with asthma, concomitant chronic rhino-sinusitis, and nasal polyps. Despite the surgery and steroid nasal spray the patient still required intermittent oral steroid therapy. Considering the patients symptom complex of asthma (which was difficult to control on inhaled steroid), rhino-sinusitis and peripheral eosinophilia, Churg Strauss syndrome could be a possibility, even though he did not completely fulfill the diagnostic criteria as stipulated by the American College of Rheumatology or the Lanham criteria. , Furthermore, Churg Strauss syndrome often progresses in phases thus all the features may not be present at the same time. Though not common at this age, time will tell if features of vasculitis will eventually set in. No other history could be elicited as associations with other disorder like aspirin sensitivity or sensitivity to other NSAIDS. Above disorder has been observed among 20-40% of glucocorticoid-dependent asthmatics and asthmatic with chronic rhino-sinusitis and nasal polyps. 
| Conclusion|| |
We have reported a rather uncommon presentation of rapidly developing multiple benign nasal polyps and peripheral eosinophilia in a 11-year-old asthmatic patient in whom no other abnormal associations were detected. However, the need to follow up this patient well into adulthood cannot be over emphasized in order to ensure early detection of any other disorder which may arise.
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[Figure 1], [Figure 2], [Figure 3]