NASAL POLYP

NASAL 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 online 2

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

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 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 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

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 polypi
Ethmoidal 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

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

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

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
• 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

NASAL POLYP

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NASAL POLYP