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Nasal Polyps: etiology,pathogenesis,clinical features,management
- 1. NASAL POLYPI
- 2. Definitio n drtbalu's otolaryngology online 2 • The term polyp derived from Latin word “Polypous” Manyfooted • Defined as simple oedematous hypertrophic nasal mucosa • Can be unilateral / bilateral
- 3. Histor y “Nasal polypi are sacs of phlegm that cause nasal obstruction” Hippocrates drtbalu's otolaryngology online 3
- 4. 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 drtbalu's otolaryngology online 4
- 6. 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 drtbalu's otolaryngology online 6
- 8. 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 drtbalu's otolaryngology online 8
- 9. Manageme nt drtbalu's otolaryngology online 9 • 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
- 10. • Simple nasal polyp 1 • Fungal polyp 2 • Malignant polyp 3 drtbalu's otolaryngology online 10 Classificatio n
- 11. Simple nasal polypi • Also known as inflammatory polyp • Ethmoidal polyp • Antrochoanal polyp drtbalu's otolaryngology online 11
- 12. AC polyp / Ethmoidal polypi drtbalu's otolaryngology online 12 Ethmoidalpolypi Antrochoanalpolyp Seen inadults Seen in children andadolescents Allergy is the commoncause Infection is the commoncause Multiple (bunch ofgrapes) Unilateral Arises from ethmoidallabyrinth Arises from maxillaryantrum Seen easily on anteriorrhinoscopy Seen commonly in post nasalexam X rayPNS may show hazy ethmoids and normal maxillarysinuses X rayPNS showshazy maxillary antrum Mostlybilateral Usuallyunilateral Recurrence iscommon Recurrence isuncommon Polypectomy Caldwel luc surgery in recurrentcases
- 13. Fungal polyp• 5 Different types • Acute fulminant • Chronic invasive • Granulomatou s invasive • Fungal ball • AFRS drtbalu's otolaryngology online 13
- 15. Acute fulminant invasive sinusitis drtbalu's otolaryngology online 15 Common in: • Diabetics • HIV + • On immunosuppression • Malignancy causing immunosuppression • Mucor mycosis is the common pathogen • Angio invasion common
- 16. Chronic invasive fungal sinusitis drtbalu's otolaryngology online 16 • Non granulomatous chronic invasive fungal sinusitis • Common in diabetics • Low grade inflammation & tissue necrosis are its features • Vascular invasion not common • Orbital extension common
- 17. Granulomatous invasive fungal sinusitis drtbalu's otolaryngology online 17 • 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
- 18. Fungal ball Features • Immunocompetent • Fungal ball is tightly packed hyphae of aspergillus (common) • Antifungal trt is not necessary drtbalu's otolaryngology online 18
- 19. AFR S Bent’scriteria • 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 drtbalu's otolaryngology online 19
- 20. Malignant polypi drtbalu's otolaryngology online 20 • 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
- 22. Theories of nasal polyposis drtbalu's otolaryngology online 22 • 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
- 23. 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 drtbalu's otolaryngology online 23
- 24. Necrotizing ethmoiditis – Woakes theory drtbalu's otolaryngology online 24 • Ethmoiditis cause osteitis of ethmoid bone • Necrotic bone initiates mucosal reaction causing oedema • Bone necrosis has not been demonstrated in the polypoidal tissue studied
- 25. Glandular cyst theory drtbalu's otolaryngology online 25 • 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
- 26. 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 drtbalu's otolaryngology online 26
- 27. Blockage theory of Jenkins drtbalu's otolaryngology online 27 • Nasal mucosal inflammation • Accumulation of intracellular fluid • This causes polyp to develop
- 28. Periphlebitis / Perilymphangitis theory of Eggston & Wolff drtbalu's otolaryngology online 28 • 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
- 29. Glandular hyperplasia theory of Krajina drtbalu's otolaryngology online 29 • Ch inflammation of nasal mucosa causes hyperplasia of nasal mucosal glands • This causes bulging of overlying mucosa • Associated vascular congestion aggravates the condition
- 30. 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 nasaldrtbalu's otolaryngology online 30
- 32. A/C polyp theories of etiopathogenesis drtbalu's otolaryngology online 32 • Proetz theory • Bernoulli’s phenomenon • Mucopolysaccharide changes • Infections • Mill’s theory • Ewing’s theory • Vasomotor imbalance
- 33. Proetz theory drtbalu's otolaryngology online 33 • 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
- 34. Bernoulli’s phenomenon drtbalu's otolaryngology online 34 Pressure drop occurs next to the constriction. This causes a suction effect pulling the sinus mucosa into the nasal cavity.
- 35. Mucopolysaccharide theory drtbalu's otolaryngology online 35 • 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
- 36. Mill’s theory drtbalu's otolaryngology online 36 Antrochoanal polyp could be maxillary mucoceles. This could be caused due to obstruction to mucinous glands.
- 37. Ewing’s theory drtbalu's otolaryngology online 37 • 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
- 38. Vasomotor imbalance theory drtbalu's otolaryngology online 38 This theory suggests that vasomotor imbalance can cause antrochoanal polyp.
- 39. Infection / inflammation drtbalu's otolaryngology online 39 • 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
- 40. Reasons for posterior migration of AC polyp drtbalu's otolaryngology online 40 • 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
- 42. Clinical features drtbalu's otolaryngology online 42 • Nasal obstruction – Unilateral / bilateral • Anosmia • Loss of taste • Rhinorrhoea – watery / mucoid / mucopurulent • Head ache • Broadening of nose (Frog face)
- 43. Examinatio n • Smooth glossy multiple mass seen in anterior rhinoscopy • Insensitive on probing. Probe can be passed around the polyp • Soft and mobile drtbalu's otolaryngology online 43
- 44. Posterior rhinoscop y• Polyp can be seen at the level of choana • Antrochoanal polyp can be seen exiting out of accessory ostium drtbalu's otolaryngology online 44
- 45. Differential diagnosis drtbalu's otolaryngology online 45 • Meningocele • Angiofibroma • Sq cell carcinoma • Enlarged turbinates • Inverted papilloma
- 47. Medical Management drtbalu's otolaryngology online 47 • Antihistamines ? • Nasal decongestant • Steroids • Antibiotics ?
- 48. Surger y drtbalu's otolaryngology online 48 • Polypectomy • Endoscopic polypectomy • Caldwel Luc procedure • External ethmoidectomy