N ASAL POLYPI Dr T Balasubramanian. Definition The term polyp derived from Latin word “Polypous”...

NASAL POLYPI

Dr T Balasubramanian

drtbalu's otolaryngology online 2

Definition

• The term polyp derived from Latin word “Polypous” Many footed

• Defined as simple oedematous hypertrophic nasal mucosa

• Can be unilateral / bilateral

History

“Nasal polypi are sacs of phlegm that cause nasal obstruction” Hippocrates

1. First described 4000 years ago2. Egyptians were pioneers in the treatment of

nasal polyposis. They used intranasal route to complete mummification process

3. Celsus during the 1st century AD documented that nasal polypi increased during moist weather

4. Boerhaave during 17th century considered polpi to be elongation of nasal mucosa

Lets not forget our past

Etiopathogenesis

1. Virchow – Nasal polypi were primary tumors like myxomas2. Eggston & Wolff – Nasal polypi were caused by passive oedema of nasal

mucosa3. Billroth – Microscopically nasal polypi resembled nasal mucosa.

Suggested that hypertrophied nasal mucosa could be the cause4. Kern & Shenck – allergy was common among patients with nasal polypi5. Burn’s theory – Acid mucopolysaccharide theory6. Lurie – Association between nasal polyposis and cystic fibrosis7. Samter’s triad – Aspirin sensitivity, nasal polypi and bronchial asthma

History of nasal instruments

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

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

• Simple nasal polyp1

• Fungal polyp2

• Malignant polyp3

Classification

Simple nasal polypi

• Also known as inflammatory polyp

• Ethmoidal polyp• Antrochoanal polyp

AC polyp / Ethmoidal polypiEthmoidal polypi Antrochoanal polyp

Seen in adults Seen in children and adolescents

Allergy is the common cause Infection is the common cause

Multiple (bunch of grapes) Unilateral

Arises from ethmoidal labyrinth Arises from maxillary antrum

Seen easily on anterior rhinoscopy Seen commonly in post nasal exam

X ray PNS may show hazy ethmoids and normal maxillary sinuses

X ray PNS shows hazy maxillary antrum

Mostly bilateral Usually unilateral

Recurrence is common Recurrence is uncommon

Polypectomy Caldwel luc surgery in recurrent cases

Fungal polyp

• 5 Different types• Acute fulminant• Chronic invasive• Granulomatous

invasive• Fungal ball• AFRS

Acute fulminant invasive sinusitis

Common in:• Diabetics• HIV +• On immunosuppression• Malignancy causing immunosuppression• Mucor mycosis is the common pathogen• Angio invasion common

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

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

Fungal ball

Features• Immunocompetent• Fungal ball is tightly packed

hyphae of aspergillus (common)

• Antifungal trt is not necessary

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

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

THEORIES

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

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

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

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

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

Blockage theory of Jenkins

• Nasal mucosal inflammation• Accumulation of intracellular fluid• This causes polyp to develop

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

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

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

AC POLYP THEORIES

A/C polyp theories of etiopathogenesis

• Proetz theory• Bernoulli’s phenomenon• Mucopolysaccharide changes• Infections• Mill’s theory• Ewing’s theory• Vasomotor imbalance

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

Bernoulli’s phenomenon

Pressure drop occurs next to the constriction. This causes a suction effect pulling the sinus mucosa into the nasal cavity.

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

Mill’s theory

Antrochoanal polyp could be maxillary mucoceles. This could be caused due to obstruction to mucinous glands.

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

Vasomotor imbalance theory

This theory suggests that vasomotor imbalance can cause antrochoanal polyp.

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

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

Clinical Features

Clinical features

• Nasal obstruction – Unilateral / bilateral• Anosmia• Loss of taste• Rhinorrhoea – watery / mucoid /

mucopurulent• Head ache• Broadening of nose (Frog face)

Examination

• Smooth glossy multiple mass seen in anterior rhinoscopy

• Insensitive on probing. Probe can be passed around the polyp

• Soft and mobile

Posterior rhinoscopy

• Polyp can be seen at the level of choana

• Antrochoanal polyp can be seen exiting out of accessory ostium

Differential diagnosis

• Meningocele• Angiofibroma• Sq cell carcinoma• Enlarged turbinates• Inverted papilloma

Radiology

Medical Management

• Antihistamines ?• Nasal decongestant• Steroids• Antibiotics ?

Surgery

• Polypectomy• Endoscopic polypectomy• Caldwel Luc procedure• External ethmoidectomy

Thank you

N ASAL POLYPI Dr T Balasubramanian. Definition The term polyp derived from Latin word “Polypous”...

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