Nasal Polyps>>Definition>>Classification>>Ethmoidal polyp>>Antrocoanal polyp>>Prevention>>Complication>>Differential diagnosis
Nasal Polyps
ETHMOIDAL POLYPI
Definition
There is edematous hypertrophy of submucosa with loose fibrous stroma.
ETIOLOGY
Polyps are RED FLAGS indicating the presence of chronic inflammatory: chronic sinusitis (longstanding bacterial infection of facial sinuses) is one explanation; as is allergy (eg allergy to pollen, dust mites, mould spore, cat danden e.t.c.).
Other possible causes are
1. Gravity
2. Forceful nose
3. Nasal defects e.g. D.N.S.
4. Heredity
5. Age
6 . Sex
7. Narrow nose
PATHOGENESIS.
Nasal mucosa becomes edematous due to collection of extracellular fluid causing polypoidal change. Polypi which are sessile in the beginning become pedunculated due to gravity and excessive sneezing which is associated with allergy.
PATHOLOGY
Due to metaplasia, the normal ciliated lining is converted into squamous type over the polyp side (which is exposed to atmospheric air). There is also infiltration with eosinophil and round cells.
SITE OF ORIGIN
Multiple nasal polypi arises from the lateral wall of nose usually from middle meatus.
Common sites are
· Uncinate process
· Bulla ethmoidalis
· Ostia of sinuses
· Medial surface and
· Edge of middle turbinate
NOTE
Allergic nasal polypi almost never arises from the septum or floor of nose.
SYMPTOMS
Nasal obstruction
2. Nasal discharge
3. Impaired sense of smell
4. Feeling of fullness in the face
5. Headache
6. Facial pain
SIGNS
On anterior Rhinoscopy
1. Polypi appears as smooth glistening grape like masses often pale in color.
2. They may be sessile or pedunculated.
3. Insensitive to probing.
4. Don’t touch on bleeding.
5. Nasal cavity may show purulent discharge due to associated sinusitis.
On Posterior Rhinoscopy.
Only to see the polyp are visible in posterior nares or not.
DIFFERENTIAL DIAGNOSIS OF MUCOSAL POLYP.
Antrocoanal polyp
2. Neoplastic lesions of nose.
3. Nasal obstruction
4. Maggots
5. D.N.S.
6. Rhinoliths
7. Hypertrophy of turbinates
8. Cystic middle turbinate.
STAGING OF MUCOSAL POLYP
The advantages of nasal endoscopy and imaging of sinuses make it possible to create a new classification based on morphologic data.
There is 4 stage grading system for nasal polyps of ethmoid based on endoscopic aspect supplemented by C.T scan and acoustic rhinometry.
STAGE 0 = Equivalent to normal mucosa .
STAGE 1 = Mucosal swelling in middle meatus
STAGE 2 = Polyps not extending the middle meatus.
STAGE 3 = Polyps may involve the middle turbinate.
STAGE 4 = All nasal structures may be involved.
INVESTIGATIONS
1 . Blood C.P (TLC, DLC ,ESR ,Hb % and platelets.)
2. Blood sugar (to exclude the diabetes)
3. Blood urea (to access the renal function)
4. Urine D.R
5. X-Ray of sinuses
6. Anterior rhinoscopy
7. Posterior rhinoscopy
8. C.T. Scan
9. M.R.I
10. Acoustic rhinometry
11. Nasal endoscopy
TREATMENT OF MUCOSAL POLYPS
CONSERVATIVE
1. Use of antihistamines and control of allergy if polyps are small and without symptoms.
2. Medical treatment with topical nasal steroids (beclomethasone dipropionate aqueous nasal spray; 200 micro gram twice a day) for 1-3 months initially is useful successful for small polyps.
A short course of oral corticosteroids (e.g. prednisolone; 6 day course using 21 5 milligram tablets) may be benefit.
Contraindications to use of steroids are
Hypertension
· Peptic ulcer
· Diabetes
· Pregnancy and
· Tuberculosis.
SURGICAL TREATMENT
When medical management is unsuccessful , polyps should be removed surgically.
When frequent recurrence is likely or surgery itself is associated with increased risk a more complete procedure (etmoidectomy) may be advisable.
In recurrent polyposis, it may be necessary to remove polyps from Ethmoid, sphenoid and maxillary sinuses to provide long lasting relief.
This may be done by intranasaly, endoscopically, via an anterior transantral route through the gingivolabial sulcus (Caldwell Luc) or through an external skin incision depending on the extent of disease.
COMPLICATIONS OF SURGERY.
· Adhesions
· Anosmia
· Damage to orbital contents
· Meningitis
· Asthma