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Anterior Nasal Cavity Mass in a Neonate

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A newborn twin girl was referred to the pediatric otolaryngology clinic at a tertiary pediatric hospital for evaluation of a left-sided nasal mass causing nasal obstruction and difficulty breathing, especially with feeding (Figure 1A). She was born at 36 weeks’ gestation and spent 10 days in the neonatal intensive care unit. Her parents noted that the lesion was present at birth and she always seemed congested on the left side. There was no report of clear drainage. Physical examination showed an approximately 1-cm, firm, pedunculated polypoid mass in the anterior nasal cavity at the vestibule. The base was located just anterior to the septum and encompassed nearly the entire left nasal cavity. There was no fluid in the mass, and there was a negative Furstenberg sign. Nasal endoscopy was performed in the clinic, and there were no additional masses or mucosal abnormalities. The choana was patent. The patient was also noted to have left eye ptosis and left preauricular branchial remnants but no other significant abnormalities on examination. Magnetic resonance imaging was performed (Figure 1B) and showed a 0.8 × 0.5–cm hyperintense mass on T1-weighted images, suggesting a fatty component and no intracranial tract.

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B. Hairy polyp

Congenital midline nasal masses are rare and occur in only 1 of 20 000 to 40 000 births.1 The differential diagnosis includes nasal dermoids, encephaloceles, and gliomas, which represent the most common causes. All of the previously listed masses may have intracranial extension.1 Hairy polyps are epithelial-lined polypoid masses that usually arise from the oropharynx or the nasopharynx.2

Hairy polyps have keratinizing squamous epithelium on the surface and surround underlying pilosebaceous units and a fibrofatty core (Figure 2A and B). Mature adipose tissue makes up the core (Figure 2C). Hairy polyps differ from mature teratomas (dermoids) histopathologically because they lack endodermal elements. Both hairy polyps and mature teratomas contain ectodermal and mesodermal contents. Hairy polyps may contain mesodermal elements, such as cartilage, bone, or muscle, but they lack endodermal elements and are not true teratomas. A hairy polyp is classified as a type of choristoma, which is a nonneoplastic mass composed of mature heterotopic tissue.3,4 Reported cases of hairy polyps have occurred mainly in the nasopharynx and oropharynx, including the soft palate, hard palate, tonsils, eustachian tube, middle ear cavity, and tongue.5,6 To our knowledge, there is only one other case report of a hairy polyp in the nasal cavity.1

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Article Information

Corresponding Author: Peter S. Karempelis, MD, Department of Otolaryngology–Head and Neck Surgery, University of Minnesota, Phillips Wangensteen Bldg, 516 Delaware St, SE, Ste 8A, Minneapolis, MN 55455 (karem003@umn.edu).

Published Online: December 6, 2018. doi:10.1001/jamaoto.2018.3123

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s mother for granting permission to publish this information.

References
1.
White  LJ, Shehata  BM, Rajan  R.  Hairy polyp of the anterior nasal cavity.  Otolaryngol Head Neck Surg. 2013;149(6):961-962. doi:10.1177/0194599813506527PubMedGoogle ScholarCrossref
2.
Jarvis  SJ, Bull  PD.  Hairy polyps of the nasopharynx.  J Laryngol Otol. 2002;116(6):467-469. doi:10.1258/0022215021911095PubMedGoogle ScholarCrossref
3.
Heffner  DK, Thompson  LD, Schall  DG, Anderson  V.  Pharyngeal dermoids (“hairy polyps”) as accessory auricles.  Ann Otol Rhinol Laryngol. 1996;105(10):819-824. doi:10.1177/000348949610501010PubMedGoogle ScholarCrossref
4.
Dutta  M, Roy  S, Ghatak  S.  Naso-oropharyngeal choristoma (hairy polyps): an overview and current update on presentation, management, origin and related controversies.  Eur Arch Otorhinolaryngol. 2015;272(5):1047-1059. doi:10.1007/s00405-014-3050-2PubMedGoogle ScholarCrossref
5.
Wu  J, Schulte  J, Yang  C, Baroody  F, Ginat  DT.  Hairy polyp of the nasopharynx arising from the eustachian tube.  Head Neck Pathol. 2016;10(2):213-216. doi:10.1007/s12105-015-0632-2PubMedGoogle ScholarCrossref
6.
Cone  BM, Taweevisit  M, Shenoda  S, Sobol  S, Schemankewitz  E, Shehata  BM.  Pharyngeal hairy polyps: five new cases and review of the literature.  Fetal Pediatr Pathol. 2012;31(3):184-189. doi:10.3109/15513815.2011.648722PubMedGoogle ScholarCrossref
7.
Lowe  LH, Booth  TN, Joglar  JM, Rollins  NK.  Midface anomalies in children.  Radiographics. 2000;20(4):907-922. doi:10.1148/radiographics.20.4.g00jl07907PubMedGoogle ScholarCrossref
8.
Huisman  TA, Schneider  JF, Kellenberger  CJ, Martin-Fiori  E, Willi  UV, Holzmann  D.  Developmental nasal midline masses in children: neuroradiological evaluation.  Eur Radiol. 2004;14(2):243-249. doi:10.1007/s00330-003-2008-3PubMedGoogle ScholarCrossref
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