Nasal Polyposis DEPARTMENT OF ENT K.S.Hegde Medical Academy Deralakatte, Mangalore
Def: INTRODUCTION Chronic inflammatory disease of the mucous membrane in the nose & PNS, presenting as pedunculated smooth gelatinous semi translucent round or pear shaped masses prolapsing into the nose
INCIDENCE 1-4% Common in adults Non atopic asthmatics 13% TYPES: Ethmoidal Choanal Diffuse Polypoidal Rhino Sino Pathy (DPRSP)
SITE OF ORIGIN ETHMOIDAL 80% from anterior ethmoids Other sites: UncinatePr. Middle Turbinate Frontal Recess CHOANAL: Originates from Antrum ( Posterolateral wall) Inferior margin of maxillary ostium Septum Rarely: Sphenoethmoidal recess & Sphenoid sinus
Diffise Polypoidal Rhino Sino Pathy DPRSP Distinct Endoscopic Appearance Individual polyps not distinguishable Diffuse engorged Polypoidal Mucous membrane of Middle Meatus Becomes confluent with free margin of MT
DPRSP CT homogenous opacity of all sinuses Commonly seen in Aspirin Sensitivity Asthmatics Cystic Fibrosis Recurrence common after surgical removal Resistant to medical conservative treatment
DPRSP
AETIOPATHOGENESIS Unknown MULTIFACTORIAL
Aetiopathogenesis Allergy Alteration of aerodynamics Aspirin sensitivity Bernoulli phenomenon Chronic infection Deletion of Gene (Cystic fibrosis- CFTR ) Fungus
Aetiopathogenesis Contd.. Nasal Polyposis is a chronic inflammatory condition Exposure of nasal mucosa to allergen/ infective agent Release of cytokines GM-csf, IL- 5 & Stem cell factor. Trigger the release of progenitor cells from Bonemarrow. Migration into the airway mucosa. Differentiation to Inflammatory cells (eosinophils.)
PREVALENCE OF NASAL POLYPS IN VARIOUS DISORDERS AFS 66-100% Aspirin intolerence 36-72% Asthma 7-13% Cystic Fibrosis 10% (children) Rhinosinusitis 2% Young s Syndrome 5% Primary Ciliary dyskinesia 5%
HISTOPATHOLOGY Extravasation of plasma through widened endothelial junctions in blood vessels Edematous fluid with sparse fibrous cells Few mucous glands with no inervation Squamous metaplasia of surface epithelium Lowered goblet cells Increased eosinophils
CLINICAL FEATURES Nasal blockage Hyposmia / anosmia Features of sinusitis Nasal allergy Post nasal drip Headache / Facial pain Facial Deformity
DIAGNOSIS History Clinical examination Nasal endoscopy
Reasons why AC Polyp Grows Posteriorly Direction of Accessory Ostium Direction of mucociliary clearance Shape of nasal cavity & choana Air currents / sniffing
ASPIRIN TRIAD aka SAMTER TRIAD 1. ASPIRIN HYPERSENSITIVITY 2. ASTHMA 3. NASAL POLYPOSIS ARACHIDONIC ACID CYCLO-OXYGENASE Tx A2 LIPO-OXYGENASE Lk, SRS-A( Bronchospasm)
DIAGNOSIS Radiography -CT
DIAGNOSIS Bacteriology / Fungal stain & culture Allergy testing Aspirin sensitivity Sweat chloride test. Pulmonary function tests
DIFFERENTIAL DIAGNOSIS Hypertrophied Inferior TURBINATE Rhinosporidiosis Angioma Inverted Papilloma Glioma Encephalocoele Malignancy / Polyp JNA
ETHMOIDAL vs ANTRO-CHOANAL Age No. Situation Origin O/E Deformity Recurrence Elderly Multiple Bilateral Ethmoidal cells Ant. Rhinoscopy Broadening Common Children & Young Adults Single Unilateral Maxillary Antrum Post. Rhinoscopy NIL Uncommon
TREATMENT Medical Antibiotics Steroids Topical Systemic Antihistamines Immunotherapy
SURGICAL TREATMENT AIMS: Increase the ostial patency Increased drainage Reduced inflammatory exudate Improve the sense of smell Quality of life
Conventional Approaches Trans nasal polypectomy Trans nasal ethmoidectomy External Fronto- ehthmoidectomy ( Howarth Lynch op.) Trans antral ethmoidectomy (Jansen Horgan op.) Caldwell-Luc surgery
Types of polyps FESS Steps of surgery Nasal decongestion & packing Removal of nasal polyps ( conventional) Uncinectomy MMA Bullectomy Ground lamellectomy Posterior ethmoids and Mini caldwell Luc for AC polyps Fungal Sinusitis
COMPLICATIONS Lamina Papyracea Anterior ethmoidal artery bleed CSF leak Orbital complications
SUMMARY Not clear whether single unified disease Inflammation major factor Eosinophils play key role in perpetuating inflammation DPRSP Distinct entity with poor prognosis & high recurrence Nasal Polyp is a self perpetuating chronic inflammatory condition which does not seem to require the continued presence of a provoking stimulus
SUMMARY Topical Steroid nasal sprays help in reducing polyp size, improving nasal patency, relieving the symptoms of rhinitis and reducing relapse after surgery Surgery helps in clearance of inflammatory exudate,improving the sense of smell and Quality of life