NASAL POLYPI

NASAL POLYPI

• non-neoplastic masses of oedematous nasal or sinus mucosa

POLYPI

BILATERAL ETHMOIDAL

ANTROCHOANAL

• Multiple BILATERAL

• arise from the lateral wall of nose, usually from the middle meatus.

• Common sites • uncinate process,

• bulla ethmoidalis

• ostia of sinuses,

• medial surface and edge of middle turbinate.

• Allergic nasal polypi almost never arise from the septum or the floor of nose.

BILATERAL ETHMOIDAL POLYP

ETIOLOGY

• inflammatory conditions of nasal mucosa (rhinosinusitis),

• disorders of ciliary motility or

• abnormal composition of nasal mucus (cystic fibrosis)

KARTAGENER’S SYNDROME

ETIOLOGY

• CHRONIC RHINOSINUSUTITS esp N.A.R.E.S

• ASTHMA (atopic/nonatopic)

• ASPIRIN INTOLERANCE

• CYSTIC FIBROSIS.

• ALLERGIC FUNGAL SINUSITIS.

• KARTAGENER'S SYNDROME.

• YOUNG'S SYNDROME.

• CHURG-STRAUSS SYNDROME

• NASAL MASTOCYTOSIS.

Asthma Aspirin intolerance SAMTERS TRIADPolyp

PATHOGENESIS

Nasal mucosa(oedematous due to collection of ECF)

↓

polypoidal change.

sessile in the beginning pedunculated due to gravity & excessive sneezing.

Pathology

nasal polypi (ciliated columnar epithelium)

↓

metaplastic change on exposure to atmospheric irritation

↓

transitional and squamous type.

↓

Submucosa shows large intercellular spaces filled with serous fluid +infiltration with eosinophils and round cells.

Symptoms

• 1. mostly seen in adults.

• 2. Nasal stuffiness leading to total nasal obstruction may be the presenting symptom.

• 3. anosmia (Partial or total)

• 4. Headache due to associated sinusitis.

• 5. Sneezing and watery nasal discharge due to associated allergy.

• 6. Mass protruding from the nostril.

Signs

• On anterior rhinoscopy,

• multiple and bilateral

• smooth, glistening, grape-like masses often pale in colour.

• sessile or pedunculated,

• insensitive to probing and do not bleed on touch.

• Long-standing cases present with broadening of nose and increased intercanthal distance.

• A polyp may protrude from the nostril and appear pink and vascular simulating neoplasm

• purulent discharge due to associated sinusitis.

DIAGNOSIS

• CLINICAL EXAMINATION

• CT PARANASAL SINUSES } BONE EROSION &EXPANSIONNEOPLASIA

TREATMENT

• ANTIHISTAMINICS & CONTROL OF ALLERGY• Revert to normal with edematous mucosa

• SHORT COURSE OF STEROIDS }• Prevent recurrence after sx

• With intolerance to antihistamines/asthma

• c/I : dm,htn,peptic ulcer,pergnancy

Surgical

• Polypectomy: • 1 or 2 & pedunculated polyp }using snare ….• multiple & sessile } with special forceps

• Intranasal ethmoidectomy: • multiple & sessile polyps• by uncapping of air cells by intranasal route

• Extranasal ethmoidectomy: • recur after intranasal procedure due to lack of surgical landmarks ….• through medial wall of orbit

• Transantral ethmoidectomy : • Infn and polypoidal change also involves maxillary antrum• Cald well luc approach maxillary antrum through medial wall of

antrumethmoidal air cells

Endoscopic sinus surgery

• Functional endoscopic sinus surgery (FESS)

• Using endoscopes of 0’ , 30’ & 70’ angulation

• Polypi can be removed more accurately when ethmoid cells are removed, and drainage and ventilation provided to the other involved sinuses such as maxillary,sphenoidal or frontal

Antrochoanal type

Antrochoanal

• Single & unilateral

• Children & young adults

Antrochoanal polyp

It arises from mucous membrane of the floorand medial wall of maxillary sinus close tothe accessory ostium, comes out of it andstarts growing towards the choana and nasalcavity.That

is the reason it has 3 parts, i.e. antral, choanal & nasal

Parts of antrochoanal type

• Antral thin stalk

• Choanalround & globular

• Nasal flat from side to side

etiology

• Exact ?

• Nasal allergy with sinus infn?

SYMPTOMS

• U/L NASAL OBSTN polyp grows in to nasopharynxobstructopposite choanaB/L NASAL OBSTN

• THICK & DULL VOICE(HYPONASALITY)

• NASAL DISCHARGE (MUCOID)

SIGNS

• missed on anterior rhinoscopy (antrochoanal polyp grows posteriorly) When large, a smooth greyish mass covered with nasal discharge may be seen.

• It is soft and can be moved up and down with a probe.

• A large polyp may protrude from the nostril and show a pink congested look on its exposed part .

• Posterior rhinoscopy may reveal a globular mass filling the choana or the nasopharynx. A large polyp may hang down behind the soft palate and present in the oropharynx

DDs

• ANGIOFIBROMA } firm & bleeds on touch….H/O recurrent epistaxis

• BLEB OF MUCUS } disappear on blowing nose

• HYPERTROPHY OF CONCHAE (MIDDLE) } PINK & hard feel of bone

• OTHER NEOPLASMS } pink ,friable,bleeds on touch

Treatment

• avulsion either through the nasal or oral route.

• Caldwell-Luc operation } RECURRENCE +maxillary sinusitis.

• endoscopic sinus surgery

• 1. red and fleshy, friable and has granular surface, especially in older patientsmalignancy.

• Epistaxis and orbital symptoms associated with a polyp } malignancy.

• 2. histology } Simple nasal polyp with a malignancy underneath.

• 3. A simple polyp } glioma, an encephalocele or a meningoencephalocele. It should always be aspirated and fluid

• examined for CSF. Careless removal of such polyp would result in CSF rhinorrhoea and meningitis.

• 4. Multiple nasal polypi in children } mucoviscidosis.

Causes of unilateral nasal obstruction

Causes of bilateral nasal obstruction