N ASAL POLYPI Dr T Balasubramanian

Definition The term polyp derived from Latin word “Polypous” Many footed Defined as simple oedematous hypertrophic nasal mucosa Can be unilateral / bilateral drtbalu's otolaryngology online2

History “Nasal polypi are sacs of phlegm that cause nasal obstruction” Hippocrates drtbalu's otolaryngology online3

1.First described 4000 years ago 2.Egyptians were pioneers in the treatment of nasal polyposis. They used intranasal route to complete mummification process 3.Celsus during the 1 st century AD documented that nasal polypi increased during moist weather 4.Boerhaave during 17 th century considered polpi to be elongation of nasal mucosa Lets not forget our past drtbalu's otolaryngology online4

Etiopathogenesis drtbalu's otolaryngology online5

1.Virchow – Nasal polypi were primary tumors like myxomas 2.Eggston & Wolff – Nasal polypi were caused by passive oedema of nasal mucosa 3.Billroth – Microscopically nasal polypi resembled nasal mucosa. Suggested that hypertrophied nasal mucosa could be the cause 4.Kern & Shenck – allergy was common among patients with nasal polypi 5.Burn’s theory – Acid mucopolysaccharide theory 6.Lurie – Association between nasal polyposis and cystic fibrosis 7.Samter’s triad – Aspirin sensitivity, nasal polypi and bronchial asthma drtbalu's otolaryngology online6

History of nasal instruments drtbalu's otolaryngology online7

Hippocrates designed the first nasal speculum which was tubular in nature It was Hildanous whose designed the nasal speculum which is still used with minor modifications Morrel Mekenzie used mirror to reflect sunlight into the nasal cavity so that its contents can be seen clearly Kierstein designed the modern headlight drtbalu's otolaryngology online8

Management Hippocrates used various packs and tampoons dipped in pepper to manage these patients Celsus used caustic agents like oil of turpentine to treat nasal polypi Daniel Bowet was the first to use antihistamines to treat nasal polypi drtbalu's otolaryngology online9

Simple nasal polypSimple nasal polyp 1 Fungal polypFungal polyp 2 Malignant polypMalignant polyp 3 Classification drtbalu's otolaryngology online10

Simple nasal polypi Also known as inflammatory polyp Ethmoidal polyp Antrochoanal polyp drtbalu's otolaryngology online11

AC polyp / Ethmoidal polypi Ethmoidal polypiAntrochoanal polyp Seen in adultsSeen in children and adolescents Allergy is the common causeInfection is the common cause Multiple (bunch of grapes)Unilateral Arises from ethmoidal labyrinthArises from maxillary antrum Seen easily on anterior rhinoscopySeen commonly in post nasal exam X ray PNS may show hazy ethmoids and normal maxillary sinuses X ray PNS shows hazy maxillary antrum Mostly bilateralUsually unilateral Recurrence is commonRecurrence is uncommon PolypectomyCaldwel luc surgery in recurrent cases drtbalu's otolaryngology online12

Fungal polyp 5 Different types Acute fulminant Chronic invasive Granulomatous invasive Fungal ball AFRS drtbalu's otolaryngology online13

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Acute fulminant invasive sinusitis Common in: Diabetics HIV + On immunosuppression Malignancy causing immunosuppression Mucor mycosis is the common pathogen Angio invasion common drtbalu's otolaryngology online15

Chronic invasive fungal sinusitis Non granulomatous chronic invasive fungal sinusitis Common in diabetics Low grade inflammation & tissue necrosis are its features Vascular invasion not common Orbital extension common drtbalu's otolaryngology online16

Granulomatous invasive fungal sinusitis Also known as indolent fungal sinusitis Pts have intact CMI Immune system limits invasion to just mucosa Granulomatous reaction can be seen around fungal elements Debridement alone would do drtbalu's otolaryngology online17

Fungal ball Features Immunocompetent Fungal ball is tightly packed hyphae of aspergillus (common) Antifungal trt is not necessary drtbalu's otolaryngology online18

AFRS Bent’s criteria Type I hypersensitivity (demonstrable) Nasal polyposis Heterodense mass lesion seen in CT scans Presence of eosinophilic mucin mixed with non invasive fungus + Fungal stain / culture drtbalu's otolaryngology online19

Malignant polypi Also known as sentinel polyp Caused due to mucosal oedema resulting from the malignant tumor All nasal polypoidal mass removed from elderly patients should be subjected to HPE drtbalu's otolaryngology online20

T HEORIES drtbalu's otolaryngology online21

Theories of nasal polyposis Adenoma fibroma theory of Billroth Necrotizing ethmoiditis theory of Woakes Glandular cyst theory Mucosal exudate theory of Hayek Blockade theory of Jenkins Periphlebitis / perilymphangitis theory of Eggston & Wolff Glandular hyperplasia theory of Krajina Epithelial rupture theory drtbalu's otolaryngology online22

Adenoma fibroma theory of Billroth Large number of tubular glands seen in polypoidal tissue Increase in the number of these glands causing adenomatous change could be the cause for nasal polyposis drtbalu's otolaryngology online23

Necrotizing ethmoiditis – Woakes theory Ethmoiditis cause osteitis of ethmoid bone Necrotic bone initiates mucosal reaction causing oedema Bone necrosis has not been demonstrated in the polypoidal tissue studied drtbalu's otolaryngology online24

Glandular cyst theory Presence of cystic glands in the nasal polypoidal tissue studied forms the basis Submucosal oedema causes obstruction of tubular glands Taylor in his study has proved that glandular oedema is caused after the formation of nasal polypi drtbalu's otolaryngology online25

Mucosal exudate theory of Hayek Nasal polyp is formed due to accumulation of exudate localized deep in the mucosa This accumulation leads to mucosal bulge leading to polyp formation These glands are found in the distal part of the polyp drtbalu's otolaryngology online26

Blockage theory of Jenkins Nasal mucosal inflammation Accumulation of intracellular fluid This causes polyp to develop drtbalu's otolaryngology online27

Periphlebitis / Perilymphangitis theory of Eggston & Wolff Recurrent inflammation of nasal mucosa blocks intracellular fluid transport mechanism Oedema of lamina propria These changes are diffuse and cannot account for localized nasal polyp drtbalu's otolaryngology online28

Glandular hyperplasia theory of Krajina Ch inflammation of nasal mucosa causes hyperplasia of nasal mucosal glands This causes bulging of overlying mucosa Associated vascular congestion aggravates the condition drtbalu's otolaryngology online29

Epithelial rupture theory Current Epithelial rupture due to tissue oedema Prolapse of lamina propria through the defect If the prolapse is large it continues to grow forming nasal polyp drtbalu's otolaryngology online30

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A/C polyp theories of etiopathogenesis Proetz theory Bernoulli’s phenomenon Mucopolysaccharide changes Infections Mill’s theory Ewing’s theory Vasomotor imbalance drtbalu's otolaryngology online32

Proetz theory Faulty development of maxillary sinus ostium This is usually large in these pts Hypertrophied mucosa from antral cavity sprouts through this enlarged ostium The growth of polyp is due to impediment to the venous return from the polyp drtbalu's otolaryngology online33

Bernoulli’s phenomenon Pressure drop occurs next to the constriction. This causes a suction effect pulling the sinus mucosa into the nasal cavity. drtbalu's otolaryngology online34

Mucopolysaccharide theory Proposed by Jakson Changes in the mucopolysaccharide present in the ground substance causes nasal polyposis These changes causes excessive water retention causing swelling of nasal mucosa which appears polypoidal drtbalu's otolaryngology online35

Mill’s theory Antrochoanal polyp could be maxillary mucoceles. This could be caused due to obstruction to mucinous glands. drtbalu's otolaryngology online36

Ewing’s theory This occurs due to mucosal fold being left close to the maxillary sinus ostium during development This fold can be aspirated into the sinus cavity due to the effects of inspired air drtbalu's otolaryngology online37

Vasomotor imbalance theory This theory suggests that vasomotor imbalance can cause antrochoanal polyp. drtbalu's otolaryngology online38

Infection / inflammation Acinous mucous glands inside the antrum gets blocked This forms a cystic lesion within the sinus cavity This cyst gradually enlarges to completely fill the antrum It exits via the accessory ostium to reach the nasal cavity drtbalu's otolaryngology online39

Reasons for posterior migration of AC polyp The accessory ostium is present posteriorly Inspiratory air current is more powerful than expiratory current there by pushing the polyp posteriorly The natural slope of nasal cavity is directed posteriorly Cilia beats towards the choana drtbalu's otolaryngology online40

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Clinical features Nasal obstruction – Unilateral / bilateral Anosmia Loss of taste Rhinorrhoea – watery / mucoid / mucopurulent Head ache Broadening of nose (Frog face) drtbalu's otolaryngology online42

Examination Smooth glossy multiple mass seen in anterior rhinoscopy Insensitive on probing. Probe can be passed around the polyp Soft and mobile drtbalu's otolaryngology online43

Posterior rhinoscopy Polyp can be seen at the level of choana Antrochoanal polyp can be seen exiting out of accessory ostium drtbalu's otolaryngology online44

Differential diagnosis Meningocele Angiofibroma Sq cell carcinoma Enlarged turbinates Inverted papilloma drtbalu's otolaryngology online45

Radiology drtbalu's otolaryngology online46

Medical Management Antihistamines ? Nasal decongestant Steroids Antibiotics ? drtbalu's otolaryngology online47

Surgery Polypectomy Endoscopic polypectomy Caldwel Luc procedure External ethmoidectomy drtbalu's otolaryngology online48

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