Definition
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Nasal polyps are soft ,jelly-like ,abnormal growths
emanating from around the openings of the paranasal
sinuses or the surface of the nasal mucosa
Polyps are teardrop-shaped. resemble a peeled,
seedless grape.
Unlike polyps in the colon or bladder, polyps in the
nose are not tumors and do not suggest an increased
risk of cancer. They are merely a reflection of
inflammation, although there may be a family history
of the problem.
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Historical background
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First recognised in India
1000 BC
Hippocrates devised instruments for removal
460370 BC
The word polyp comes from the Greek ; poly-pous ;
meaning many footed
was considered neoplastic condition till 1954
Billroth described histological characteristics
1955
Zuckerkandl considered these inflammatory 1956
Multifactorial aetiology
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A continuous inflam. process within the nose and sinuses thought to be the main source of nasal polyps. could be related to allergies;
things in the atmosphere (pollution, dust etc.) or by a sinus infection.
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Overproduction of fluid in the cells membrane(vasomotor
instability) causes polyps to become swollen and engorged with fluid These bags of fluid can enlarge and pop out through the sinus openings into
the nasal cavity.
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Engorged nasal membranes - Irritants such as alcohol and tobacco
may expose membranes to infection.
Aetiology contd
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Bernouillis phenomenon
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Allergy
90% have eosinophilia
association with asthma
allergic sign,symptoms
Conditions associated
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Asthma
20-40% have coexisting
Aspirin hypersensitivity
8%
Cystic fibrosis
children,unilateral
Other respiratory diseases
Incidence
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Betweeen one in 1000 of population would
have nasal polyps once or more in their life.
10 % suffers from seasonal allergic rhinitis
5 % suffer from perennial rhinitis
Male predominence 3:1
Disease of adults 30-60 yrs
pathogenesis
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Chronic inflammation causes the blood
vessels in the lining of nose and sinuses to
become more permeable, allowing water to
accumulate in the cells. Over time, as gravity
pulls on these waterlogged tissues, they may
develop into polyps
Ethmoidal sinuses complex anatomy
Poorly developed ethmoidal blood supply
Pathogenesis
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Several studies have consistently demonstrated
the active role of eosinophils in the
development of nasal polyp
An involvement of IgG, IgA and IgE has been
suggested since these immunoglobulin
receptors can be found on the surface of
eosinophil
Few studies demonstrate local production of
IgE within nasal polyp tissue .
Pathology
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Macro
translucent,multiple,insensitive
Micro
ciliated columner,goblet cells,
extracellular interstitial fluid
clinical presentation
A stuffy, runny nose and diminished sense of smell are the hallmarks of nasal
polyps
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Nasal obstruction,snoring
Dull headaches
Rhinolalia clausa
Persistent stuffiness ,sneezing,postnasal drip
Re-occurring sinus infections
Abundant nasal drainage
Thick, discolored nasal drainage
Reduced sense of smell and taste
Occasional pain in the face ,epistaxis
Diagnosis
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A physical examination will identify most polyps.
Small polyps located higher up or further back may
be hidden from view, but Otorhinolaryngologist is
equipped to diagnose nasal polyps.
In order to perform the exam, medicine must be
applied to decongest the membranes. Cotton balls
soaked with one of these agents and left in the nostrils
for a few minutes provide adequate shrinkage.
Examination
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Pedunculated,multiple,insensitive to touch
Change position
Probe can be passed all around
Red color/purulent discharge bacterial
infection
Green brown sludge coexisting fungal
infection
Effect of vasoconstriction
Anterior rhinoscopy
Screening and diagnosis
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To help diagnose , ask history, examine nasal
passages&investigate. CT scan may help determine the size
and exact location of the polyps, e.g. polyps in sinuses.
Child diagnosed with multiple nasal polyps , test for cystic
fibrosis, an inherited condition affecting the exocrine glands
The standard diagnostic test for it is a noninvasive sweat test,
which measures the amount of sodium and chloride in child's
perspiration.
Children who have both nasal polyps and hay fever may have
allergy skin tests, which can provide important information
about allergic sensitivities. Allergy skin tests aren't
uncomfortable for most children and can usually be completed
in 30 minutes or less.
Examination
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There may be a single nasal polyp or several,
clustered together like grapes on a stem. The
polyps are generally soft and pearl colored,
Very small single or multiple polyps may not
cause any problems, but larger ones are likely
to obstruct the airways in the nose, making it
difficult to breathe. This may lead to mouth
breathing, especially in children.
Complications
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A single, small nasal polyp rarely causes
complications, but a large polyp or many smaller
polyps (polyposis) may lead to the following:
Acute or chronic sinus infections.
Obstructive sleep apnea — a potentially serious
condition in which one stops and starts breathing a
number of times during sleep.
Altered facial structure leading to diplopia or
unusually wide-set eyes.
Treatment
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corticosteroid nasal spray
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These medications relieve inflammation, increase nasal airflow
and may help shrink polyps.
Side effects of steroid nasal sprays are far less serious than are
those of oral steroids and may include nosebleeds, headache or
sore throat.
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Oral corticosteroids. either alone or in combination with a
nasal spray. Because oral steroids can cause serious side
effects,
Control of allergies & infections
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Antihistamines
In case of hay fever or other allergies, antihistamines
may help relieve congestion, although they won't
eliminate polyps.
Antibiotics for an acute sinus infection.
Antifungal medications.
Researchers have discovered that some cases may be
caused by an unusual immune system response to
environmental fungus. these are being tested as a
treatment for sinusitis-related polyps.
Surgery
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Small or isolated polyps can often be completely removed
using a small mechanical suction device or a microdebrider —
an instrument that cuts and extracts soft tissue. The procedure,
called a polypectomy can be performed on an
outpatient basis. Following polypectomy, patient should be
treated for any underlying inflammation, usually with
corticosteroid nasal sprays and sometimes with antibiotics or
oral steroids. Even so, polyps frequently return, and may need
additional operations. When medications aren't effective,
consider removing polyps surgically. This is often the only
option for people with cystic fibrosis who usually don't
respond to steroids.
ethmoidectomy
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Intra nasal
Trans antral
external
External ethmoidectomy
surgery
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The most effective surgery is functional endoscopic
sinus surgery (FESS), which involves fibre optic
scopes and power tools. A combination of
polypectomy, endoscopic ethmoidectomies and
antrostomies seems to give the best results, far
superior to previous techniques.
It's essential to be aware that polyps can recur,
despite successful surgical removal. For this reason,
most surgeons start patients on nasal steroid sprays
shortly after surgery to help control recurrence.
Endoscopic sinus surgery
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This procedure not only removes polyps, but also
opens the part of the sinus cavity where polyps
usually form. If sinuses are blocked or inflamed,
surgeon may open even more of sinus cavity.
Surgeon uses a thin, rigid tube and a camera called a
video endoscope. Because endoscopic surgery
requires small incisions, patient generally heal more
quickly and with less discomfort than with other
types of surgery. Still, full recovery may take several
weeks, and polyps often return. This surgery has
serious potential risks, including leakage of
cerebrospinal fluid, injury to the optic nerve or eye
muscles, and hemorrhage.
FESS
Endoscopic view
Prevention
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In many cases, polyps can't be prevented, however,
managing asthma, hay fever or chronic sinus
infections may reduce the chances that polyps will
develop or recur. medications and avoiding as much
as possible — indoor and outdoor allergens and
pollutants.
Irrigating your sinuses with salt water may help
relieve mild nasal congestion and eliminate mucus..
preservative-free saline sprays.
Prognosis
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Polyps reappear as long as the allergic
irritation continues
Even with good surgical intervention, the
recurrence rate is high, estimated at 30-40%.
Antrochoanal polyp
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Arise from maxillary antrum and prolapse through
the ostium of the sinus in the middle meatus
The choanal part hang into nasopharynx and may be
seen in the oropharynx
Polyp tends to be dumb-bell
Unilateral nasal obstruction mostly in expiration and
serous otitis media if they occlude the eustachian tube
Radioopaque max.sinus on xrays
Killians polyp
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Antrochoanal polyps, are solitary polyps and
were first described by Killian in 1906 hence
also known as killians polyp.
Although their etiology remains unknown,
allergy has been implicated.
Antrochoanal polyp
Treatment
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Surgical removal is
indicated. Recurrence is
frequent and may
necessitate a Caldwelllucs operation
FESS
Other nasal polyps
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Benign
bleeding polyp of septum
meningioma,gliomas
Malignant
carcinoma,lymphoma,sarcoma
red,fleshy,friable,bleed to touch