Article Outline: A 6-month-old term infant was referred with a history of snuffly breathing and obstructive sleep-disturbed breathing unless she was postured upright. From birth she had had daily right-sided rhinorrhea, which was mostly grayish and of egg-white consistency. It had not responded to antibiotics or intranasal steroids. Feeding was slow but weight gain was normal. Perinatal history was unremarkable, with cigarette smoking 4 per week the only potential teratogen identified. Clinical examination showed a left unilateral middle ear effusion, a left preauricular sinus, a bifid tip of uvula, and ankyloglossia. Flexible transnasal endoscopy demonstrated a pale skin-covered finger-like projection, arising from the left lateral nasopharyngeal wall in close proximity to the Eustachian tube, crossing to the contralateral side. CT showed patent bony choanae bilaterally with a 9 × 7-mm soft tissue density superior to the soft palate. MRI (T2 weighting and T1 fat saturation, pre- and postcontrast) showed a 7-mm-diameter lesion projecting 12.5 mm into the pharynx. It was separate to the left internal carotid artery, with slight contrast enhancement. The absence of a wide range of signal intensities and the ordered structure suggested teratoma unlikely. There appeared to be a cord-like extension with concentric ring structure immediately adjacent to the Eustachian tube, to the skull base postero-inferior to the Eustachian tube. Under general anesthesia a combined transnasal and retropalatal endoscopic approach was commenced. The attachment of the lesion to the mucosa of the anterior aspect of the Eustachian tube was needle-point diathermy-divided under vision and then with steady traction using non-thru-cut forceps the lesion was avulsed from its origin in the postero-inferior aspect of the lower third of the Eustachian tube, and delivered transorally. After removal the size of the left Eustachian tube orifice was seen to be 4 to 5 times that of the right (Fig 1 - Dilated Eustachian tube orifice after removal of hairy polyp). The operative procedure was uncomplicated. The left unilateral mucoid effusion was aspirated. Histopathology demonstrated a 15 × 7 × 7-mm polypoid lesion covered by epidermis with associated adnexae (hair follicles, sebaceous glands, and eccrine glands) overlying a core of fibroadipose tissue with minor salivary glands and skeletal muscle. This was characterized as a “hairy polyp of the Eustachian tube.” At general anesthetic for division of the ankyloglossia 5 months postexcision there was no recurrence of either the lesion or the middle ear effusion, and the orifice of the Eustachian tube had shrunk so as to be only a little larger than the contralateral side. Discussion: “Hairy polyp of the nasopharynx” is a clinico-pathological descriptive term. The clinical description derives from macroscopically visible fine hairs arising from the pale external covering of skin (Fig 2 - Hairy polyp of the Eustachian tube). At flexible or rigid transnasal or retropalatal endoscopy they typically appear as a sausage-like lesion projecting medially across the nasopharynx. Up to 2004, 114 cases of hairy polyp of the nasopharynx had been described, most arising from the lateral pharyngeal wall. Origin specifically from the Eustachian tube was thought to be excessively rare but it is quite possible that increasing use of nasal endoscopes before and after removal will show that origin from within the lower end of the Eustachian tube is more common than previously thought. It is presumably this origin that resulted in dilation of the developing cartilaginous Eustachian tube; and removal of the hairy polyp allowed remodeling towards a normal size. They most commonly present early in the first year, with a female preponderance up to 6:1. Presentation with nasal signs and symptoms occurs when nasopharyngeal and nasal obstruction predominate, and occurs with otologic signs and symptoms when Eustachian tube obstruction coexists. When larger, the lesions may be visible below the soft palate or acting as a ball-valve may obstruct the larynx causing positional cyanosis; indeed, fatal obstruction has been reported. Several theories of embryologic origin exist. Hairy polyps arising from the Eustachian tube may originate in the fourth postconceptual week from entrapped cells between the first pouch endoderm and first cleft ectoderm. Because they resemble the pinna, they have been postulated to be accessory auricles arising “internally” from the first branchial anlarge. Less likely would seem to be persistence of the bucconasal or buccopharyngeal membranes, or uncontrolled development from entrapped pluripotential cells.
Otolaryngology: Head and Neck Surgery Vol. 139, Issue 1, p. 162-163