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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
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History
“Nasal polypi are sacs of phlegm that cause nasal obstruction” Hippocrates
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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
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Etiopathogenesis
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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
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History of nasal instruments
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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
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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
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• Simple nasal polyp1
• Fungal polyp2
• Malignant polyp3
Classification
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Simple nasal polypi
• Also known as inflammatory polyp
• Ethmoidal polyp• Antrochoanal polyp
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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
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Fungal polyp
• 5 Different types• Acute fulminant• Chronic invasive• Granulomatous
invasive• Fungal ball• AFRS
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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
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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
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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
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Fungal ball
Features• Immunocompetent• Fungal ball is tightly packed
hyphae of aspergillus (common)
• Antifungal trt is not necessary
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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
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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
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THEORIES
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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
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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
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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
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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
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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
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Blockage theory of Jenkins
• Nasal mucosal inflammation• Accumulation of intracellular fluid• This causes polyp to develop
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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
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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
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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
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AC POLYP THEORIES
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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
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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
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Bernoulli’s phenomenon
Pressure drop occurs next to the constriction. This causes a suction effect pulling the sinus mucosa into the nasal cavity.
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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
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Mill’s theory
Antrochoanal polyp could be maxillary mucoceles. This could be caused due to obstruction to mucinous glands.
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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
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Vasomotor imbalance theory
This theory suggests that vasomotor imbalance can cause antrochoanal polyp.
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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
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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
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Clinical Features
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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)
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Examination
• Smooth glossy multiple mass seen in anterior rhinoscopy
• Insensitive on probing. Probe can be passed around the polyp
• Soft and mobile
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Posterior rhinoscopy
• Polyp can be seen at the level of choana
• Antrochoanal polyp can be seen exiting out of accessory ostium
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Differential diagnosis
• Meningocele• Angiofibroma• Sq cell carcinoma• Enlarged turbinates• Inverted papilloma
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Radiology
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Medical Management
• Antihistamines ?• Nasal decongestant• Steroids• Antibiotics ?
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Surgery
• Polypectomy• Endoscopic polypectomy• Caldwel Luc procedure• External ethmoidectomy
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Thank you