http://emedicine.medscape.

com/article/994274-overview
Nasal Polyps
Author: John E McClay, MD; Chief Editor: Glenn C Isaacson, MD, FACS, FAAP
Background
Broadly defined, nasal olys are a!nor"al lesions that ori#inate fro" any ortion of the nasal
"ucosa or aranasal sinuses$ Polys are an end result of %aryin# disease rocesses in the nasal
ca%ities$ &he "ost co""only discussed olys are !eni#n se"itransarent nasal lesions 'see the
i"a#es !elo() that arise fro" the "ucosa of the nasal ca%ity or fro" one or "ore of the
aranasal sinuses, often at the outflo( tract of the sinuses$
Rigid endoscopic view of the left nasal cavity, showing
the septum on the left. olyps with some !lood and hemorrhage are on top of them
in the center portion. "he rim of white from # o$cloc% to 4 o$cloc% indicates the
lateral nasal wall vesti!ule. "he polyps cover the inferior tur!inate, which is partially
visi!le at 4 and & o$cloc%. 'ndoscopic view of the left
nasal cavity, showing a polyp protruding from the uncinate process. "he middle
tur!inate is to the left. ( suction is visi!le on top of the inferior portion of the
uncinate process and inferior portion of the polyp. "he lateral nasal wall is on the far
right. "he polyp is directly in the center and is pale, glistening, and white.
'ndoscopic view of the left middle meatus. "he septum
is on the far left. "he middle tur!inate is ne)t to the septum on the left. ( large,
glistening, translucent polyp is visi!le in the center of the screen ne)t to the middle
tur!inate. "he lateral nasal wall is on the right side of the screen. "he inferior
tur!inate nu! posteriorly is in the !ottom right hand corner.
Multile olys can occur in children (ith chronic sinusitis, aller#ic rhinitis, cystic fi!rosis 'CF),
or aller#ic fun#al sinusitis 'AFS)$ An indi%idual oly could !e an antral*choanal oly, a !eni#n
"assi%e oly, or any !eni#n or "ali#nant tu"or 'e#, encehaloceles, #lio"as, he"an#io"as,
aillo"as, +u%enile nasoharyn#eal an#iofi!ro"as, rha!do"yosarco"a, ly"ho"a,
neuro!lasto"a, sarco"a, chordo"a, nasoharyn#eal carcino"a, in%ertin# aillo"a)$ E%aluate
all children (ith !eni#n "ultile nasal olyosis for CF and asth"a$
Pathophysiology
&he atho#enesis of nasal olyosis is un,no(n$ Poly de%elo"ent has !een lin,ed to chronic
infla""ation, autono"ic ner%ous syste" dysfunction, and #enetic redisosition$ Most theories
consider olys to !e the ulti"ate "anifestation of chronic infla""ation; therefore, conditions
leadin# to chronic infla""ation in the nasal ca%ity can lead to nasal olys$
&he follo(in# conditions are associated (ith "ultile !eni#n olys:
*ronchial asthma - +n 2,-&,- of patients with polyps
./ - olyps in 0-41- of patients with ./
(llergic rhinitis
(/2 - olyps in 1&- of patients with (/2
.hronic rhinosinusitis
rimary ciliary dys%inesia
(spirin intolerance - +n 1-20- of patients with polyps
(lcohol intolerance - +n &,- of patients with nasal polyps
.hurg-2trauss syndrome - 3asal polyps in &,- of patients with .hurg-2trauss
syndrome
4oung syndrome 5ie, chronic sinusitis, nasal polyposis, a6oospermia7
3onallergic rhinitis with eosinophilia syndrome 53(R'27 - 3asal polyps in 2,-
of patients with 3(R'2
Most studies su##est that olys are associated "ore stron#ly (ith nonaller#ic disease than (ith
aller#ic disease$ Statistically, nasal olys are "ore co""on in atients (ith nonaller#ic asth"a
'-./) than (ith aller#ic asth"a '0/), and only 1$0/ of .111 atoic indi%iduals ha%e nasal
olys$
Se%eral theories ha%e !een ostulated to e2lain the atho#enesis of nasal olys, althou#h none
see"s to account fully for all the ,no(n facts$ So"e researchers !elie%e that olys are an
e2%a#ination of the nor"al nasal or sinus "ucosa that fills (ith ede"atous stro"a; others !elie%e
olys are a distinct entity arisin# fro" the "ucosa$ Based on a re%ie( of the literature and
se%eral intricate studies of the !ioelectric roerties of olys, Bernstein deri%ed a con%incin#
theory on the atho#enesis of nasal olys, !uildin# on other theories and infor"ation fro" &os$
3-, 45
In Bernstein6s theory, infla""atory chan#es first occur in the lateral nasal (all or sinus "ucosa
as the result of %iral*!acterial host interactions or secondary to tur!ulent airflo($ In "ost cases,
olys ori#inate fro" contact areas of the "iddle "eatus, esecially the narro( clefts in the
anterior eth"oid re#ion that create tur!ulent airflo(, and articularly (hen narro(ed !y "ucosal
infla""ation$ 7lceration or rolase of the su!"ucosa can occur, (ith reeitheliali8ation and
ne( #land for"ation$ Durin# this rocess, a oly can for" fro" the "ucosa !ecause the
hei#htened infla""atory rocess fro" eithelial cells, %ascular endothelial cells, and fi!ro!lasts
affects the !ioelectric inte#rity of the sodiu" channels at the lu"inal surface of the resiratory
eithelial cell in that section of the nasal "ucosa$ &his resonse increases sodiu" a!sortion,
leadin# to (ater retention and oly for"ation$
9ther theories in%ol%e %aso"otor i"!alance or eithelial ruture$ &he %aso"otor i"!alance
theory ostulates that increased %ascular er"ea!ility and i"aired %ascular re#ulation cause
deto2ification of "ast*cell roducts 'e#, hista"ine)$ &he rolon#ed effects of these roducts
(ithin the oly stro"a result in "ar,ed ede"a 'esecially in the oly edicle) that is (orsened
!y %enous draina#e o!struction$ &his theory is !ased on the cell*oor stro"a of the olys, (hich
is oorly %asculari8ed and lac,s %asoconstrictor inner%ation$
&he eithelial ruture theory su##ests that ruture of the eitheliu" of the nasal "ucosa is
caused !y increased tissue tur#or in illness 'e#, aller#ies, infections)$ &his ruture leads to
rolase of the la"ina roria "ucosa, for"in# olys$ &he defects are ossi!ly enlar#ed !y
#ra%itational effects or %enous draina#e o!struction, causin# the olys$ &his theory, althou#h
si"ilar to Bernstein6s, ro%ides a less con%incin# e2lanation for oly enlar#e"ent than the
sodiu" flu2 theory suorted !y Bernstein6s data$ :either theory co"letely defines the
infla""atory tri##er$
Patients (ith CF ha%e a defecti%e s"all chloride conductance channel, re#ulated !y cyclic
adenosine "onohoshate 'cAMP), (hich causes a!nor"al chloride transort across the aical
cell "e"!rane of eithelial cells$ &he atho#enesis of nasal olyosis in atients (ith CF could
!e associated (ith this defect$
Epidemiology
Frequency
United States
&he o%erall incidence of nasal olys in children is 1$-/; the incidence in children (ith CF is ;*
<=/$ A"on# adults, the incidence is -*</ o%erall, (ith a ran#e of 1$4*4=/$
International
>orld(ide incidence is the sa"e as the incidence in the 7nited States$
Mortality/Morbidity
:o si#nificant "ortality is associated (ith nasal olyosis$ Mor!idity is usually associated (ith
altered ?uality of life, nasal o!struction, anos"ia, chronic sinusitis, headaches, snorin#, and
ostnasal draina#e$ In certain situations, nasal olys can alter the craniofacial s,eleton !ecause
unre"o%ed olys can e2tend intracranially and into the or!ital %aults$
Race
:asal olys occur in all races and social classes$
Sex
Althou#h the "ale*to*fe"ale ratio is 4*<:- in adults, the ratio in children is unreorted$ A re%ie(
of articles reortin# on children (hose nasal olyosis re?uired sur#ery sho(ed aarently e?ual
re%alence in !oys and #irls, althou#h the data are inconclusi%e$
3.5
&he reorted re%alence is
e?ual in atients (ith asth"a$
Age
Beni#n "ultile nasal olyosis usually "anifests in atients older than 41 years and is "ore
co""on in atients older than <1 years$ :asal olys are rare in children youn#er than -1 years$
History
&he "anifestation of nasal olys deends on the si8e of the oly$ S"all olys "ay not
roduce sy"to"s and "ay !e identified only durin# routine e2a"ination (hen they are anterior
to the anterior ed#e of the "iddle tur!inate$ Polys located osterior to the site are not tyically
seen durin# routine anterior rhinoscoy e2a"ination erfor"ed (ith an otoscoe and are "issed
unless the child is sy"to"atic$ S"all olys in areas (here olys nor"ally arise 'ie, the
"iddle "eatus) "ay roduce sy"to"s and !loc, the outflo( tract of the sinuses, causin#
chronic or recurrent acute sinusitis sy"to"s$
Sy"to"*roducin# olys can cause nasal air(ay o!struction, ostnasal draina#e, dull
headaches, snorin#, and rhinorrhea$ Associated hyos"ia or anos"ia "ay !e a clue that olys,
rather than chronic sinusitis alone, are resent$ Eista2is that does not arise fro" irritation of the
anterior nasal setu" 'ie, @iessel!ach area) usually does not occur (ith !eni#n "ultile olys
and "ay su##est other, "ore serious, nasal ca%ity lesions$
Massi%e olyosis or a sin#le lar#e oly 'e#, antral*choanal oly 3see the i"a#es !elo(5 that
o!structs the nasal ca%ities, nasoharyn2, or !oth) can cause o!structi%e slee sy"to"s and
chronic "outh !reathin#$
Rigid endoscopic view of the left nasal cavity, showing
the septum on the left, inferior tur!inate on the right, middle tur!inate superiorly,
and antral-choanal polyp among the 8oor of the nose.
Rigid endoscopic view of the left anterior nasal cavity, showing the septum on the
left, a suction pushing the inferior tur!inate on the right, and the clear antral-
choanal polyp at the center of the endoscopic view.
.lose-up of the middle meatus, showing the stal% of the antral-choanal polyp
emanating from the ma)illary sinus !ehind the uncinate process on the !ottom
right-hand side of the picture. "he left side of the picture shows the septum and the
middle tur!inate !eing pushed over via suction. ()ial ."
scan section through the ma)illary sinuses showing opaci9cation of the left
ma)illary sinus with antral-choanal polyp in the posterior nasal cavity and choana
e)iting from !eneath the middle tur!inate in the area of the ostiomeatal comple)
unit. 2cale is in centimeters. .oronal ." scan through the
anterior sinuses showing opaci9cation of the left ma)illary sinus with opaci9cation
of the inferior half of the nasal cavity on the left, 9lled !y the antral-choanal polyp.
"he rest of the sinuses are clear. .oronal ." scan section
through the posterior nasopharyn) showing the sphenoid sinus superiorly and the
antral-choanal polyp 9lling the nasopharyn) in the center of the scan.
:ral cavity and oropharyngeal view of antral-choanal
polyp 9lling the posterior oral pharyn) and pushing the soft palate anterior and
inferiorly. "he polyp is visi!le !ehind the uvula and the soft palate.
2cale is in inches. "he left side of the lesion was the
portion of the polyp in the nasal cavity. "he right was a stal% attached to the medial
ma)illary wall. 'ndoscopic view of the left middle
meatus, showing the septum on the left, the middle tur!inate in the center
superiorly, and a large ma)illary antrostomy with a curved suction on the right. "his
is following antral-choanal polyp removal.
Aarely, atients (ith cystic fi!rosis 'CF) and atients (ith aller#ic fun#al sinusitis 'AFS) ha%e
"assi%e olyoses$ &hese can alter the craniofacial structure and cause rotosis, hyerteloris",
and diloia$ See the i"a#es !elo($
Rigid endoscopic view of the left nasal cavity, showing
the septum on the left. olyps with some !lood and hemorrhage are on top of them
in the center portion. "he rim of white from # o$cloc% to 4 o$cloc% indicates the
lateral nasal wall vesti!ule. "he polyps cover the inferior tur!inate, which is partially
visi!le at 4 and & o$cloc%. 'ndoscopic view of the left
nasal cavity, showing a polyp protruding from the uncinate process. "he middle
tur!inate is to the left. ( suction is visi!le on top of the inferior portion of the
uncinate process and inferior portion of the polyp. "he lateral nasal wall is on the far
right. "he polyp is directly in the center and is pale, glistening, and white.
'ndoscopic view of the left middle meatus. "he septum
is on the far left. "he middle tur!inate is ne)t to the septum on the left. ( large,
glistening, translucent polyp is visi!le in the center of the screen ne)t to the middle
tur!inate. "he lateral nasal wall is on the right side of the screen. "he inferior
tur!inate nu! posteriorly is in the !ottom right hand corner.
;iew <ust inside the nasal vesti!ule of a 9fteen-year-old
adolescent !oy with allergic fungal sinusitis showing di=used polyposis e)tending
into the anterior nasal cavity and vesti!ule> the septum is on the right, and the right
lateral vesti!ular wall 5nasal ala7 is on the left. "he polyps are all in the center. "he
polyps almost hang out of the nasal vesti!ule. .oronal
section through the ethmoid ma)illary sinuses and or!its. "his is a 2-year-old child
with cystic 9!rosis, showing complete opaci9cation of the ma)illary and ethmoid
sinuses. *ulging in the medial ma)illary walls is o!served.
.oronal section showing soft tissue windows rather than
!ony windows. +t indicates the infection !y the thic% mucus in the ma)illary and
ethmoid cavities !y the heterogeneity of the opaci9cation in the sinuses. 3ote that
the nasal cavity is completely o!literated !y polyp disease.
.oronal ." scan showing e)tensive allergic fungal
sinusitis involving the right side with mucocele a!ove the right or!it and e)pansion
of the sinuses on the right. .oronal ." scan showing
typical unilateral appearance of allergic sinusitis with hyperintense areas and
inhomogeneity of the sinus opaci9cation> the hyperintense areas appear whitish in
the center of the allergic mucin. .oronal ?R+ scan showing
e)pansion of the sinuses with allergic mucin and polypoid disease> the hypointense
!lac% areas in the nasal cavities are the actual fungal elements and de!ris. "he
density a!ove the right eye is the mucocele. "he fungal elements and allergic mucin
in allergic fungal sinusitis always loo% hypointense on ?R+ scanning and can !e
mista%en for a!sence of disease. /ifteen year-old
adolescent !oy with allergic fungal sinusitis causing right proptosis, telecanthus,
and malar 8attening> position of his eyes is asymmetrical, and his nasal ala on the
right is pushed inferiorly compared with the left. 3ine-
year-old girl with allergic fungal sinusitis displaying telecanthus and asymmetrical
positioning of her eyes and glo!es.
In an article su!"itted for u!lication, the author has reorted <1/ of children (ith AFS
resented (ith craniofacial a!nor"alities, co"ared (ith -1/ of adults (ith AFS$ Massi%e
olyosis rarely causes enou#h e2trinsic co"ression on the otic ner%e to decrease %isual
acuity$ Further"ore, !ecause they #ro( slo(ly, "assi%e olyoses usually cause no neurolo#ical
sy"to"s, e%en those that e2tend into the intracranial ca%ity$
Physical
Be#in hysical e2a"ination for nasal olys (ith an anterior rhinoscoy rocedure 'see the
i"a#e !elo()$ For s"all children, a handheld otoscoe and otolo#ic seculu" are tyically used$
An otoscoe laced in the nasal ca%ity ro%ides %ie(s of the inferior tur!inate, anterior setu",
and areas in the nasal ca%ity e2tendin# to the anterior ed#e of the "iddle tur!inate and
"idortion of the setu"$ &he "iddle "eatus 'ie, the area under the "iddle tur!inate laterally)
can often !e seen usin# anterior rhinoscoy if the child is cooerati%e and if no si#nificant
"ucosal ede"a or secretions are resent in the anterior nasal ca%ity$
(n anterior endoscopic view of the nasal cavity in a &-
month-old infant. "he vesti!ule is seen in the periphery of the picture. +n the center
of the picture, the septum is visi!le to the left, and the inferior tur!inate is to the
right. "hese structures are reddish in hue. 2ome congestion in the nasal cavity is
usually present. "hese are often structures that can !e seen only !y anterior
rhinoscopy. +f the area is decongested, the area of the middle meatus can
occasionally !e seen.
For !eni#n nasal olys, the "iddle "eatus is the "ost co""on location$ If ade?uately %isi!le,
%ie(s of the "iddle "eatus can re%eal (hether sufficient atholo#y is resent to (arrant
orderin# a C& scan of the sinuses, rather than refor"in# a ri#id or fle2i!le endoscoic
rocedure that "ay distress a youn# atient and the arents$ Bo(e%er, ri#id or fle2i!le
endoscoy is the !est "ethod to e2a"ine the nasal ca%ity and nasoharyn2 to fully assess the
nasal anato"y 'see the i"a#es !elo() and to deter"ine the e2tent and location of nasal olys$
( rigid rhinoscopy photograph of the left anterior nasal
cavity of a 0-wee%-old infant. "he middle tur!inate is superiorly in the midline, and
the inferior tur!inate is to the right. "he septum is to the left.
( rigid rhinoscopy photograph ta%en in the midportion of
the left nasal cavity of a 0-wee%-old infant showing the septum on the left, the
inferior tur!inate on the right, and the middle tur!inate superiorly. "he choanae is
seen in the dar% area in the center. ( rigid rhinoscopy
photograph ta%en two thirds of the way !ac% along the 8oor of the nose of the left
nasal cavity of a 0-wee%-old infant. "his photograph shows the septum on the left,
the choanae straight ahead, and the posterior portion inferior tur!inate to the right.
( rigid rhinoscopy photograph of the the nasal cavity of a
0-wee%-old infant ta%en all the way !ac% into the choanae of the left nasal cavity.
"he photograph shows the septum on the left, the small adenoids on the posterior
superior wall of the nasopharyn) in the center, and the eustachian tu!e ori9ce on
the right.
For s"all children, a fle2i!le fi!erotic nasoharyn#oscoe is often used !ecause it is less
trau"atic for children (ho "ay "o%e their heads fro" an2iety or disco"fort$ In older
cooerati%e children and adolescents, a ri#id endoscoy can !e used to assess the "iddle "eatus
and the shenoeth"oid recess$ Perfor" ade?uate decon#estion and anesthesia of the nasal
ca%ities !efore an endoscoic rocedure for any child older than ; "onths$ Cideo docu"entation
of the rocedure decreases the a"ount of ti"e necessary for the rocedure and later enhances
atient and arent education$
For children, e%aluatin# the osterior (all of the oral ca%ity also can indicate the
sy"to"atolo#y of olyosis 'e#, ostnasal draina#e conco"itant (ith chronic sinusitis)$ Dar#e
olys or lesions of the nasal ca%ity "ay also rotrude into the osterior oroharyn2 fro" the
nasoharyn2; these "ay occur as a lesion !ehind the alate and u%ula or "ay deress the alate
inferiorly and anteriorly 'see the i"a#e !elo()$ Perfor" otoscoic e2a"inations !ecause
e2tensi%e olyosis that causes eustachian tu!e dysfunction can cause fluid and infection in the
"iddle ear sace$ Careful e2a"ination of the inner%ated syste"s of the cranial ner%es and of the
craniofacial structure hels define a nasal lesion6s otential e2ansion into surroundin# %ital
structures$
:ral cavity and oropharyngeal view of antral-choanal
polyp 9lling the posterior oral pharyn) and pushing the soft palate anterior and
inferiorly. "he polyp is visi!le !ehind the uvula and the soft palate.
auses
As descri!ed in Pathohysiolo#y, chronic infla""ation 'fro" (hate%er source) aarently has
an initial role in the atho#enesis of nasal olys$ Multile olys occur in children (ith chronic
sinusitis, aller#ic rhinitis, CF, and AFS$ An isolated oly could !e an antral*choanal oly, a
!eni#n "assi%e oly, a nasolacri"al duct cyst 'as sho(n !elo(), or any con#enital lesion or
!eni#n or "ali#nant tu"or listed !elo($
3asolacrimal duct cysts /rontal view of a 2-day-old
infant with swelling in the inferior medial canthal area on !oth sides. "he
right side appears more prominent on this picture. ." scan showed infected
nasal lacrimal duct cysts. Rigid endoscopic view of
the left nasal cavity. "he septum is on the left, and the lateral nasal wall is on
the right. "he inferior tur!inate is in the center of the picture, and the middle
tur!inates are visi!le in the superior midsection of the picture. "he nasal
lacrimal duct cyst is the yellow dilated lesion underneath the inferior
tur!inate. ()ial ." scan section through the or!it,
showing the dilated nasal lacrimal ducts in the medial anterior area
compared to the or!its. 2cale on the !ottom right is in centimeters.
()ial ." scan through the inferior nasal cavities,
showing the dilated nasal lacrimal duct cysts at the inferior location. 2cale on
the !ottom right is in centimeters. "he dilated cysts are in the center of the
image. ( frontal view of the decompressed nasal
lacrimal ducts following surgical marsupiali6ation. 2welling in the inferior
medial canthal areas prior to surgery is no longer seen.
'ncephaloceles 5see the image !elow7 ( @-month-
old infant with hypertelorism and !ulging of the nasal dorsum, secondary to
encephalocele.
Aliomas 5see the images !elow7 +nterior view of the
nose and nasal cavities. "o the right of the patient$s left nostril, the right nasal
cavity has no o!struction. :n the left of the picture, a reddish polyp is visi!le.
"he reddish mass is a nasal glioma. ( close-up
view of the right nasal cavity and polyp B& in a &-month-old infant. "he
o!structing reddish polyp is visi!le. "his is an intranasal glioma that was
arising from the attachment of the inferior tur!inate anteriorly> it was
transnasally removed.
Cermoid tumors 5see the images !elow7 Dateral
view of a preteenaged child showing infected nasal dermoid. 3ote the
protrusion of the dorsum of the nose. reteenaged
!oy with infected nasal dermoid. ( pith is visi!le over the superior portion of
the swelling !etween the eyes. 3asal pith is commonly seen with the nasal
dermoid. /rontal view of a &-month-old infant,
showing hypertelorism and protrusion in the gla!ellar region secondary to a
small nasal dermoid. ()ial ." scan 5!ony windows7
showing a &-month-old infant with nasal dermoid anterior to the nasal and
ma)illary !ones. 3o !ony dehiscence or !ony a!normalities are visi!le.
( coronal ?R+ scan through the nasal dermoid of a
&-month-old infant. "he scale on the left is 2 mm per small !ar and # cm per
tall !ar. "he arrow points to the lesion. "he lesion appears to !e
appro)imately 0-7 mm in this dimension. (n
interoperative view of dermoid removal from a &-month-old infant.
Eemangiomas
apillomas 5see the image !elow7 (nterior nasal
papilloma arising from the septum. "he s%in of the nasal vesti!ule is seen
surrounding the papilloma in the center of the image.
Fuvenile nasopharyngeal angio9!romas
Rha!domyosarcoma 5see the images !elow7 ()ial ?R+
scan of the or!its, posterior fossa, and nasal cavity. "he solid tumor is seen
9lling the posterior ethmoid comple), !rain stem, cavernous sinuses, and left
anterior cranial fossa. ()ial ." scan through the or!its
and ethmoid sinuses, showing the rha!domyosarcoma in the same areas,
including the posterior ethmoid comple), left middle fossa, and s%ull !ase of
cavernous sinuses. Rigid endoscopic view of left
nasal cavity, showing a polyp in the center of the picture, with e)tension of
the rha!domyosarcoma. "he septum is on the left and the middle tur!inate is
on the right.
Dymphomas
3euro!lastomas
2arcomas
.hordomas
3asopharyngeal carcinomas
+nverting papillomas
E%aluate all children (ith !eni#n nasal olyosis for CF and asth"a
!i"erentials
(sthma
.ystic /i!rosis
3euro!lastoma
3euro9!romatosis
Rha!domyosarcoma
2inusitis
#aboratory Studies
Cirect la!oratory studies at the pathological process !elieved responsi!le for
the nasal polyps.
.hildren with polyposis that is associated with allergic rhinitis should have an
evaluation for their allergies> this may include a serological
radioallergosor!ent test 5R(2"7 or some form of allergic s%in testing. ?a!ry 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>
G4H
therefore, allergy testing and treatment may !e important in treating
allergic fungal sinusitis 5(/27.
erform a sweat chloride test or genetic testing for cystic 9!rosis 5./7 in any
child with multiple !enign nasal polyps.
( nasal smear for eosinophils may di=erentiate allergic from nonallergic sinus
diseases and indicate whether the child may !e responsive to glucocorticoids.
"he presence of neutrophils may indicate chronic sinusitis.