NASAL

POLYPI

Filza Saeed
Nimra Ishfaq
Maida Faheem

Sac-like
Non tender
Movable
Non Cancerous(nonneoplastic)
growths of mucous membranes
in nasal cavity or paranasal
sinuses
More frequent in males

Classification
2 types:

Antrochoanal Polyp
Occurs in children
Unilateral ( may become bilateral)
Single
Ethmoidal Polyp
Occurs in adults
Multiple
Bilateral

Aetiolgy

Antrochoanal
Nasal Allergies
Sinus Infections
Exposure to some forms of
Chromium
Ethmoidal
Chronic Rhinosinusitis
(Allergic/Non-Allergic)
Asthma

Non-Allergic Adult Asthma

Aspirin Induced Asthma
Allergic Fungal Sinusitis
Cystic Fibrosis
Kartegeners Syndrome
Youngs Syndrome
Churg-Strauss Syndrome
Nasal Mastocytosis

Pathogenesis
Nasal
mucosa of
middle
meatus

Oedematous
causing
polypoidal
change

Excessive
sneezing

First
sessile
then
pedunculat
ed

Pathology

Mucosa
Ciliated Columnar Epithelium
Atmospheric Irritation
Metaplasia
Transitional/Squamous type

Sub-Mucosa

Large intercellular spaces filled

with
Serous fluid

Seromucous glands
Inflammatory cells (Neutrophils and
Eosinophils)

Site of Origin

Antrochoanal
Maxillary sinuses near its ostium

Ethmoidal
Ethmoidal sinuses and lateral wall
of nose in the middle meatus
( Uncinate process, bulla ethmoidalis,
ostia of sinuses, medial surface and
edge of middle turbinate)

Growth
Antrochoanal
Seen in the nasal cavity, antrum of
maxillary sinuses, grows backward
into the choana and may hang down
behind the soft palate and into the
oropharynx.

Ethmoidal
Grows anteriorly and is present in
the nares.

DIAGNOSIS
OF NASAL
POLYPS

C L I N I C A L F E AT U R E S

P H Y S I C A L E X A M I N AT I O N

DIAGNOSTIC TESTS

DIFFERENTIAL DIAGNOSIS

CLINICAL FEATURES

ADDITIONAL FEATURES

PHYICAL EXAMINATION
The initial steps leading to diagnosis involve asking about
symptoms and examining the patient's nose. Often polyps
are visible with the aid of a lighted instruments and
anterior rhinoscopy
ANTERIOR RHINOSCOPY
Examination of the nasal cavities enabling to note nasal
secretions, swelling of the mucosal surfaces, properties of
the mucosal surface, ulcerations or presence of foreign
bodies etc. The speculum is introduced into the nasal
vestibule with its blades together and is then opened out

DIAGNOSTIC TESTS
Nasal endoscopy - a narrow tube with a
small camera (or magnifying lens) is
inserted into the patient's nose.
CT scan - this enables the doctor to
locate nasal polyps and other
abnormalities linked to chronic
inflammation. The doctor will also be
able to identify any other obstructions.
Skin prick allergy test - if the doctor
thinks that allergies may be
contributing to polyp development, he

NASAL ENDOSCOPY
Thenasal endoscopeis a
medical device consisting of a
thin, rigid tube with fiberoptic
cables for bringing in light.
Theendoscopeis then
connected to a light source and
a video camera to project
magnified images on a screen.
Theseendoscopicimages can
be captured and recorded for
documentation for each patient.
Anterior rhinoscopy allows a
limited key-hole view of the
front part of the nose, nasal
endoscopy,with its superior light
and magnification, provides a
superior detailed look at the
deeper internal nasal anatomy,
central airway and posterior
aspects of the nose and sinuses

CT SCAN
A computed tomography (CT) scan may be
used to determine the location and size of the
polyps. CT scanning also will tell if the polyps
are coming from the nose or from the sinuses.
Nasal polyps almost always occur on both
sides.

SKIN PRICK ALLERGY TEST

Checks for immediateallergicreactions to as many as 40
different substances at once. A microscopic amount of an
allergenis introduced to a patient's skin by various means
eg. By pricking with a needle.
SIGNIFICANCE
According to a comparative study carried out in Oct 2009
Cordoba,Spainof 190 patients with nasal polyposis and 190
healthy individuals.
Skin prick tests were positive in 63.2% of the patients and
31.1% of the controls.
Conclusion of the study: Patients with nasal
polyposis are sensitive to the most common
allergens in our environment and exhibit a clear-cut
correlation with other allergic factors, as confirmed
by personal and family histories, the presence of
chronic rhinitis, and the results of in vivo tests.

CYSTIC FIBROSIS
Autosomal recessive disorder caused by
the presence of mutations in both copies
of the gene for the (CFTR) protein.
Nasal polyps are a sinonasal
manifestation of cystic fibrosis (CF).
Up to 67% of all CF patients will manifest
polyps in their lifetime.
The polyps are usually a consequence of
chronic inflammation; however, their
specific etiology is unclear.

DIFFERENTIAL DIAGNOSIS
Intranasal examination reveals bilateral, mobile, grey,
smooth and semi translucent polypoid masses that
usually originate in the ethmoid sinuses or the middle
meatus.
Differential diagnosis is important to rule out congenital
anomalies, as well as benign or malignant tumors.
Look for distinguishing clinical features eg.
First of all, the majority of polyps arise in the ethmoids,
and are almost always bilateral. On the other hand,
tumors are unilateral. The only exception is polyps
(choanal polyps) that arise from the maxillary antra and
can be unilateral.

DIFFERENTIAL DIAGNOSIS
Inverted papilloma
Always unilateral red or gray masses from
lateral wall of nose
Haemangioma
Capillary( anterior nasal septum with
reccurent epistaxis)
Intranasal meningoencephelocele
Herniation of brain tissue (CT scan will
show a defect in base of brain, mass
increases when standing or crying)
Further examples include Gliomas, Nasal

Treatment
For
Ethmoidal
Polypi

There are two main approaches

that can be adopted for treatment:
1. Conservative treatment
2. Surgical treatment

CONSERVATIVE
TREATMENT
This an approach to treating pain utilizing
non-surgical treatment options
These may include:
1. Physical therapy
2. Medications
3. Injections

The conservative approach is adopted

during early stages of polypoidal
changes

It involves counteracting the underlying

oedematous cause.
This can be done by the use of
antihistamines to counteract the
inflammatory response associated with
histamines, as seen mostly in cases of
allergies.
Note: steroids may be used in case of
patients who cannot tolerate antihistamines.

In cases of inflammation due to infection,

it is also necessary to treat the underlying
cause.
This may involve the use of :
1.Antiobiotics
2.Antifungals

Surgical treatment
1.Polypectomy

This is carried out when

there are only one or two
polyps that are
pedunculated .
It involves the use of a snare
with the aid of an
endoscope.

2. Intranasal
ethmoidectomy
This is carried out when infection in the
ethmoid sinus has become severe enough to
cause multiple polypi that are also sessile. It
involves removal of infected tissue and bone
via an intranasal route.

3. Extranasal ethmoidectomy
This is carried when polypi recur after the
intranasal procedure, thus leading to
landmarks being ill defined.
An external incision is made medial to the
medial canthus and the the ethmoidal cells
are approached through the medial wall of
the orbit.

4.Transantral ethmoidectomy
This is carried out when infection is also
indicated in the maxillary sinus.
1. It first involves opening the maxillary
antrum by the Caldwell-luc approach :
An opening is made at the canine fossa
through the vestibule of the mouth.
2. Ethmoidal air cells are then approached
through the medial wall of the antrum.

5.Endoscopic sinus surgery

Functional Endoscopic Sinus Surgery is
done with endoscopes at various angles of
0, 30 and 70 degrees angulation.
Polypi can be removed more accurately
and drainage and ventilation is thus
provided to other involved sinuses.

Treatment for
Antrochoanal polyp
Functional Endoscopic Sinus Sugery is the
treatment of choice and involves easy
removal of the polyp by avulsion.
The Caldwell-luc approach is rarely taken
on these days and is only performed for
recurrent polyposis.