Endobronchial Inflammatory Polyp Associated with a Foreign Body

Endobronchial Inflammatory Polyp Associated with a Foreign Body

seleeted reoorts Endobronchial Inflammatory Polyp Associated with a Foreign Body* Successful Treatment with Corticosteroids David E. Bennan , M.D.;t E...

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seleeted reoorts Endobronchial Inflammatory Polyp Associated with a Foreign Body* Successful Treatment with Corticosteroids David E. Bennan , M.D.;t E. S. Wright, M.D ., F.C.C.P.;:I: and H. W Edstrom, M.D ., F.C.C .P.§

We describe a case ofendobronchial polyp associated with a foreign body. To our knowledge, this is the first report of such an occurrence. The polyp was successfully treated with steroids. This is only the third report of steroid treatment of endobronchial polyps.


nd obro nch ial polyps are exceedingly rare. Most of the experience in the literature is based upon isolated case reports. ,.. The largest series reported in the literature is seven bronchial polyps. 5 CASE REPORT A 17-year-old female patient was transferred to this hospital for

treatment of a presumed unresponding asthma. She gave a threemonth history of central nocturnal pain in the chest. In the seven days prior to admission, she developed a sore throat, cough, and pleuritic chest pain. Past history revealed a ten-year history of cough, hemoptysis, dyspnea, and greenish sputum, and the patient was thought to have bronchial asthma by her doctor. When admitted for appendectomy three years earlier, a preoperative chest x-ray film showed left lower lobe atelectasis which was not present after surgery and was not investigated. The patient smoked two packages of cigarettes per day. Her only medication was a birth-eontrol pill. Findings from physical examination and the chest x-ray film on admission were consistent with left lower lobe collapse with a mediastinal shift to the left (Fig I). Flexible fiberoptic bronchoscopic examination revealed a fleshy friable mass filling the left main-stem bronchus . Tomographic studies and a computerized tomographic scan confirmed this mass and suggested a further density distally (Fig 2). A combined flexibleand rigid bronchoscopic procedure was then performed . Ablue plastic plug from the bottom ofa Bicpen was identified in the bronchial lumen distal to the bronchial growth and removed. The growth was then biopsied . The pathology report described corrugated ciliated pseudoepithelium occasionally dipping into the stroma to form mucous glands. Focalsquamous metaplasia was present. The stroma demonstrated neovascularization and an eosinophilic and chronic inflammatory cell infiltrate. The pathologist stated that no neoplasia was seen and that it was not a foreign-body granuloma, but it very closely resembled a nasal polyp (Fig 3). Bronchoscopic resection was subsequently attempted but was aborted early in the procedure when brisk bleeding developed . Only *From Memorial University of Newfoundland, St. John's, Newfoundland, Canada. tGeneral Surgery Resident. :j:Professor and Chairman of Surgery. § Professor of Medicine. Reprint requests: Dr. Edstrom, Memorial University of Newfoundland, St . John's, Newfoundland, Canada AlB 3V6

FIGURE 1. Left lower lobar collapse. a very small amount ofthe polyp wasactually removed. After surgery the patient was placed on therapy with prednisone (20 mg/day)and Beclovent (two puffs four times daily). After six months of this medical management , a repeat bronchoscopic procedure was performed. The polyp was found to have almost totally disappeared. DISCUSSION

Classification of endobronchial polyps is confusing. Some authors stress that papillomas and polyps are distant entities. 6.7 Zimmerman et al" define a papilloma as a "complexly arranged, cauliflower-like outgrowth from an epithelial surface composed of vessel-bearing connective tissue core covered by a uni- or multilayered epithelium." This is to be distinguished from a polyp which they state is a "m or-

FIGURE 2. Computerized tomographic scan, showing endobronch ial polyp in left mainstem bronchus . CHEST I 86 I 3 I SEPTEMBER, 1984


FIGURE 3. Low-power micrograph of 5x4X3-mm polyp. Note similarity to nasal polyp (H and E, original magnificationX20).

phological term usually reserved for the description of reactive lesions of the mucosa or skin." In the series reported by Caldarola et al," 80 percent of squamous papillomas occurred in the trachea, with an average size of 4.5 mm. This was in contrast to polyps, which had an average size oflO mm. In addition, after resection, 90 percent of the papillomas recurred, whereas none of the polyps did ; however, in practice, it is difficult to determine whether an isolated papilloma of large size is a polyp or a papilloma. Drennan and Douglas" have devised a practical and easy-to-use classification. They have classified bronchial papillomas into three categories . The first type is multiple papillomatosis, where multiple papillomas occur throughout the upper and middle respiratory tract of children and adolescents ." It rarely occurs in adults . The second group is the inflammatory polyp, which arises in the chronically inflamed bronchial mucosa. A stratified or pseudostratified epithelium with focal metaplasia and a chronic inflammatory cell infiltrate is seen . The fibroid stroma is edematous, and neovascularization occurs by small submucosal vessels and capillaries. Atypia is never seen ." Frequently, the inflammatory polyp occurs in asthmatic subjects or those with a long history of chronic respiratory infections.· Histologically, this polyp closely resembles the common nasal polyp,'? however, unlike nasal polyps, these polyps are usually single and are not as closely associated with asthma and its eosinophilic infiltrate . When type-2 bronchial polyps do occur in asthmatic subjects, an eosinophilic infiltrate is found.•.10 Arguelles and Blanco" reported the remarkable case of a ten-year-old asthmatic subject who expectorated 50 inflammatory polyps in one year. Our case report is a type-2 bronchial polyp. The third group is the solitary bronchial papilloma, which arises from normal bronchial epithelium. This group is the least common type . Jackson and Hatch" found only four such cases reported in the literature as ofl967. The major basis of distinguishing type-2 from type-S polyps is the amount of inflammatory infiltrate ; differentiation can be difficult.


On gross appearance the polyps are red and velvety and may be pedunculated or sessile, with a "nodular or mulberry like appearance:" They may resemble adenoma and therefore discourage biopsy for fear of bleeding. 12 They may act as check valves leading to distal airway obstruction (which may be massive, causing acute shortness of breath) with secondary atelectasis, infection, and hemoptysis.".s.s,12 The wheezing may be misinterpreted as asthma . A pneumonectomy has been carried out when the clinical picture was incorrectly interpreted as cancer." A lesser procedure may have been adequate. Although standard roentgenograms, tomograms, and computerized tomographic scans may all be of assistance, the diagnosis and frequently the cure can usually be made at bronchoscopy. It is not always possible to remove all of the polyp. There are only two reported cases in the literature where steroids caused a bronchial polyp to dtsappear,":" One occurred in a nonatopic asthmatic subject in whom only part of the polyp was removed surgically, and steroids brought about the final resolution. 10 Adams et al" reported the case of a 28-year-old man who developed multiple polyps throughout the tracheal and bronchial tree two months after a thermal inhalation injury. After six months of treatment with steroids, half of the polyps disappeared, and the others decreased in size. We believe that treatment of an inflammatory polyp with steroids is based upon sound basic principles and recommend their use as an alternative to the conventional surgical treatment in selected cases. ACKNOWLEDGMENT: We thank the radiologist, Dr. John D. Quigley, for his assistance. REFERENCES

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Salek J, Pazderka S, Zak F. Solitary bronchial polyps of inflammatory origin: a report oftwo cases treated by operation . J Thorac Surg 1958; 35:807-15 Saini VK, Wahi PL. Inflammatory polyp of the bronchus . Ann Thorac Surg 1968; 5:141-45 Tedeschi LG, Libertini R, Conte B. Endobronchial polyp. Chest 1973; 63:110-12 Ashley DJB, Danino EA, Davies HD. Bronchial polyps. Thorax 1963; 18:45-9 Caldarola VT, Harrison EG Jr, Clagett TO, Schmidit HW. Benign tumors and tumor-like conditions of the trachea and bronchi. Ann Otol Rhinol Laryngoll964; 73:1042-61 Zimmermann A, Lang HR, Muhlberger F, Bachmann M. Papilloma of the bronchus. Respiration 1980; 39:286-90 Miller DR. Benign tumors of lung and tracheobronchial tree . Ann Thorac Surg 1969; 8:542-60 Drennan JM, Douglas AC. Solitary papilloma of a bronchus. J Cltn Path 1965; 18:401-02 Arguelles M, Blanco I. Inflammatory bronchial polyps associated with asthma . Arch Intern Med 1983; 143:57Q.-71 Shale DJ, Lane DJ, Fisher CWS, Dunnill MS. Endobronchial polyp in an asthmat ic subject. Thorax 1983; 38:75-6 Jackson DA, Hatch HB. Solitary benign squamous papilloma of the bronchus : report of two cases. Am Rev Respir Dis 1968; 97:699-705 Sears HF, Michaelis LL, Minor GR, Sweet DE . Endobronchial polyp: a case presentation. J Thorac Cardiovasc Surg 1975; 70:371-75 Adams C, Moisan T, Chandrasekhar AJ, Warpeha R. Endobronchial polyposis secondary to thermal inhalation injury. Chest 1979; 75:643-45

Endobronchial Inflammatory Polyp (Berman , Wright, Edstrom)