NASAL POLYP

EXAMINATION(SIGNS) AND SYMPTOMS

Nasal polyps are non-neoplastic masses of oedematous
nasal/paranasalsinus mucosa.
Two types
-Antrochoanal polyp
-Bilateral ethmoidal polyp
Antrochoanal polyp(Killian”s polyp)
• It is a solitary sinonasal polyp that arises from the mucosa of
maxillary antrum near the ostium.
• It passes to the nasopharynx through the sinus ostium and
posterior nasal cavity.
• It grows backwards to the choana; hangs down behind the
soft palate.
Features
• Three parts(trilobed)
-Antral
-Choanal
-Nasal
Aetiology
• Nasal allergy and sinusitis
• Common in children and young adults
• Mostly solitary
• Usually unilateral
Symptoms
• Unilateral nasal obstruction
• Bilateral nasal obstruction occurs when polyp grows into the
nasopharynx and obstructs the opposite choana.
• Hyponasal voice
• Nasal discharge(mucoid)
Signs
• Can be missed on anterior rhinoscopy(grows posteriorly)
• Smooth,greyish mass covered with nasal discharge
• Soft and can be moved up and down with a probe
• Large polyp -> protrudes from the nostrils -> pink and congested on
its exposed parts
• Posterior rhinoscopy reveals a globular mass filling the choana or the
nasopharynx
• Large polyp can hang down behind the soft palate and present in the
oropharynx
• Examination of nose with the endoscope may reveal a choanal or
antrochoanal polyp hidden posteriorly in the nasal cavity
 PATHOPHYSIOLOGY of a POLYP
• MECHANISM : BERNOULLIS PHENOMENON.
• IN PREDISPOSED CONDITIONS LIKE ALLERGY , SINUSITIS , INFECTION,
• AIR ATTAINS A HIGH VELOCITY AFTER PASSING THOUGH A NARROW PATH
(INTERNAL NASAL VALVE) WHICH LEADS TO A NEGATIVE PRESSURE IN ITS
VICINTY.
• THIS NEGATIVE PRESSURE SUCKS THE MUCOSA OF THE SINUSES INTO NASAL
CAVITY LEADING TO POLYP FORMATION.
• ETHMOIDAL POLYPS FOLLOW OEDEMATOUS CHANGE DUE TO ECF
ACCUMULATION CAUSING POLYPOIDAL CHANGE.
• SESSILE TO PEDUNCULATED D/T GRAVITY AND EXCESSIVE SNEEZE(ALLERGIC
AETIOLOGY).
PATHOPHYSIOLOGY OF ETHMOIDAL
POLYP
FEATURES
• Ethmoidal polyps are usually multiple ,bilateral ,painless mass.
• Grape-like masses arising from the ethmoidal air cells mucosa. i.e
(bulla ethmoidalis , ager nasi , haller cells , onodi cells).
• Aetiology is usually allergic in nature.
AETIOLOGY
(B/L NASAL POLYPOSIS-ADULTS)
• CHRONIC RHINOSINUSISTIS :
• ALLERGIC RHINITIS CHRONICALLY LEADS TO ETHMOIDAL POLYPOSIS.
• AND CALLED CHRONIC RHINOSINUSITIS WITH NASAL POLYPOSIS.
• IGE INCREASED WITH FAMILY HISTORY OF ALLERGY.
• MANAGEMENT : MEDICAL-DECONGESTANT (<7 DAYS), ANTI
ALLERGICS, STEROID NASAL SPRAY.
• AURGICAL INTERVENTION : FESS(REVIVES FUNCTION).
• RECURRENCE IS HIGH.
 ASPIRIN HYPERSENSITIVITY
• ASPIRIN – BLOCKS COX ENZYME – REDUCES PG – MAST CELL NOT
STABILIZED - HISTAMINE - VASCULAR PERMEABILITY – OEDEMA IN
MIDDLE MEATUS – POLYP FORMATION.
• LOX PATHWAY HYPERACTIVE - LEUKOTRIENES –
BRONCHOCONSTRICTION – MUCUS SECRETION – ASTHMA.
• SAMTER’S TRIAD : ASPIRIN HYPERSENSISITIVITY+NASAL
POLYP+ASTHMA.
• 36% PEOPLE SHOW NASAL POLYPS WITH ASPIRIN INTOLERNACE
CHURG STRAUSS SYNDROME
• A.K.A EOSINOPHILIC GRANULOMATOSIS WITH POLYANGITIS.
• ANCA MEDIATED SMALL VESSEL VASCULITIS.
• UPPER AIRWAY – CHRONIC SINUSISTIS
• LOWER AIRWAY – ASTHMA
• IgE , EOSINOPHILS IN BLOOD SMEAR >10%.
• DIAGNOSIS BY BIOPSY.
• VASCULITIS , GRANULOMA , FEVER ASSOCIATED.
YOUNG’S SYNDROME
• PALE GRAPE LIKE POLYPS PRESENT.
• TRIAD : CHRONIC SINUSISTIS , BRONCHIECTASIS ,
AZOOSPERMIA(INFERTILITY).
• CILIARY DYSFUNCTION.
B/L NASAL POLYPOSIS - CHILDREN
• CYSTIC FIBROSIS : MUCOVISCIDOSIS
• B/L ETHMOIDAL POLYPS IN YOUNG(5-20 YEARS) THE PATIENT SHOULD
BE INVESTIGATED FOR CYSTIC FIBROSIS.
• DEFECT IN CHLORIDE ION TRANSPORT(CFTR) LEADING TO THICK AND
INSPISSATED SECRETION OF EXOCRINE GLANDS.
• RECURRENT PULMOPNARY INFECTION, BRONCHIECTASIS,
PANCREATITIS.
• SWEAT CHLORIDE RAISED >70mEq/L.
PRIMARY CILIARY DYSKINESIA
• A.K.A KARTAGENER SYNDROME
• AUTOSOMAL RECESSIVE INHERITANCE
• TRIAD : CHRONIC SINUSISTIS, BRONCHIECTASIS,
DEXTROCARDIA(SITUS INVERSUS)
ALLERGIC FUNGAL SINUSITIS

DOUBLE DENSITY SIGN

(HETEROGENOUS
APPEARANCE)

NASAL MASTOCYTOSIS
 SITE OF ORIGIN
• Multiple nasal polyps always arise from the lateral wall of nose,
Usually from the middle meatus

Common sites:
-Uncinate process
-Bulla ethmiodalis
-Ostia of sinuses
-Medial surface &edge of middle turbinate
SYMPTOMS:
• Multiple polypi can occur at any age but mostly seen in adults
• Nasal stuffiness leading to total nasal obstruction may be the
presenting symptom.
• Partial or total loss of sense of smell(ANOSMIA).
• Headache due to associated sinusitis (PAIN WITH EYE MOVEMENT).
• Sneezing &watery nasal discharge due to associated allergy.
• Mass protruding from the nostril.
SIGNS:
On ANTERIOR RHINOSCOPY:Polyps appear as;
-Smooth,glistening
-grape-like masses
-Often pale in color
-may be sessile or pedunculated
-insensitive to probing
-do not bleed on touch
-often multiple &bilateral
-Long standing cases present with BROADENING OF NOSE
-Increased intercanthal distance.
-May protrude from the nostril and appear pink &vascular, simulating
neoplasm.
-Purulent discharge due to sinusitis.
-ON PROBING NO PAIN , NO BLEEDING CAN MOVE AROUND THE POLYP.
-UNLIKE TURBINATE HYPERTROPHY.
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