college presentation about nasal polp for reviews email at drsana.ak@gmail.com

2. Welcome
To The
Presentation
Of group “A”

3. “Table of Contents”
1st part
“Anatomy of nasal
cavity in relationship
with polp”
2nd part
Main topic :nasal polpi
3rd part
Case study

4. PART-1
“ANATOMY OF NASAL CAVITY IN
RELATION TO POLYP”

5. MEDIAL WALL OF NASAL SEPTUM
Skeleton of nasal septum is partly bone and partly cartilage.
The bony part is formed by perpendicular plate of the ethmoid bone ,the vomer and small
vertical ridges from the superior surfaces of the palatine bone and maxilla
Anterior septum is formed by septal vomerine and alar cartilage

6. LATERAL WALL OF NASAL SEPTUM
The lateral wall of the nasal cavity consist of prominent elevation
Superior concha
Middle concha
Inferior concha
Conchas narrow the nasal passage create large surface area foricng inhaled air to pass around and over them which helps in warming n moisting of air
Chonca are projections of bones from lateral wall of the nasal cavity covered by mucous membrane

8. The spaces around concha are called meatuses
The inferior meatus
lies below and lateral to inferior concha
Middle meatus
lies below and lateral to middle concha
Superior meatus
lies below n lateral to superior concha
Space above sup erior concha is Sphenoethmoidal recess

9. Superior
ethmoid bone that forms (upper and middle concha)
Lower half
by vertical process of palatine bone and the body of maxillary bone
Inerior concha is a separate bone
Anteriorly the lateral wall is formed by nasal bone and lateral nasal and alar cartilages

11. The openings or ostia through which the sinuses communicate with nasal cavity are coved with overl ining concha but after removal of concha can be seen
Frontal sinus
drains into infundibulum , a furnel like turnel that opens into the upper end of hiatus semilunaris .

12. Ethmoidal sinus:
Can be divided into 3 parts
Anterior part drain ant to hiatus semilunaris
Middle air cells drain into one or more openings in bubble like structure ethmoidal bulla
Posterior air cells drain by one or more opening into the superior meatus

13. Sphenoidal sinus:
One or more openings may be presnt drains into sphenoethmoidal sinus

14. Maxillary sinus
drains into middle meatus by an opening in the inferior part of hiatus semilunaris

15. Nasolacrimal duct
Opening at inferior meatus
Carries tears from eyes

18. MUCOUS MEMBRANE
•Cilia and mucus along the inside wall of the nasal cavity trap remove dust and pathogens from the air
as it flows through the nasal cavity.
• The cilia move the mucus down the nasal cavity to the pharynx, where it can be swallowed.
•The nasal mucous membrane lines the nasal cavities, and is adherent to
the periosteum or perichondrium.
The epithelium is divided into :
• Respiratory epithelium:
(consisting of mucous secreting goblet cells and ciliated cells)
• Olfactory epithelium:
(bipolar nerve cells the olfactory cells)

20. Nasal cavities
The nasal cavities consist of two extensive chambers and their
associated nasal sinuses.
 The two main chambers are separated by midline wall the nasal
septum.
The cavities are lined by mucus membrane,contains sebaceous glands
hair follicles called VIBRISSAE

21. PART -2
NASAL POLYP

22. NASAL POLYP
According to wikipedia:
“Nasal polyps are polypoidal masses arising mainly from the mucous
membranes of the nose and paranasal sinuses. They are overgrowths of the
mucosa that frequently accompany allergic rhinitis. They are freely movable
and non tender.” OR
According to authentic medical dictionary
―A polyp is the medical term for any overgrowth of tissue from the surface of a
body organ. Polyps come in all shapes—round, droplet, and irregular being the
most common. Nasal polyps are teardrop-shaped while growing and resemble
peeled grapes when they have reached their full size.
The condition of nasal polyps is sometimes called nasal polyposis.‖
OR
Text book describes it as:
―Nasal polypi are non –neoplastic masses of oedematous nasal or sinous mucosa.‖

24. Classification of polyp according to location
1.Bilateral ethmoid polypi
2.antrochoanal polyp
1.Bilateral Ethmoidal polypi
• Bilateral,multiple in number,usually
small grape like mass
• Usually found in adults.
• Originate from ethmoidal
sinuses,uncinate process, middle
turbinate and middle meatus
• Mostly grow anteriorly may present at
nares
• Reoccurence common
ETIOLOGY:
• A)chronic rhinosinusitis
• B)Asthma (risk factor)
• C)Asprin intolerence
• D)cystic fibrosis
• E)Allergic fungal sinusitus

25. F)Kartagener’s syndrome
G)young’s syndrome
H)Churg-Strauss syndrome
I)nasal mastocytosis
PATHOGENESIS:
Nasal mucosa ,perticularly in the region of
middle meatus and turbinate becomes
oedematus due to collection of ECF.
PATHOLOGY:
A) Early :surface of nasal polp I is covered
byciliated coloumnar epithelium (normal
nasal mucosa)
B) Late : it undergoes metaplastic change to
transitional and squamous type on exposure
to atmospheric irritation
Submucosa shows large intercellular spaces
filled with serous fluid.
Infiltration with eosinophills
SYMPTIOMS:
Nasal stiffness that leads to nasal obstruction
Partial or total loss of smell
Headache due to associated sinusitis

26. • Sneezing and watery nasal discharge
due to associated allergy
• Mass protruding from the nostrils.
SIGNS:
Anterior rhinoscopy :
 Polpi appears as smooth, glistering,
grape-like mass often pale in colour .
 May be sessile or penduculated.
 Insensitive to probing.
 Do not bleed on touch.
DIAGNOSIS:
1) Clinical examination
2) CT scan for correct analysis of extent
and also helps to plan surgery

27. TREATMENT
• CONGESTIVE TREATMENT
―That is designed to avoid radical medical therapeutic measures or operative procedures.‖
• Control of allergy
• Anti histaminics
Short course of steroids (for those who cant tolerate anti histaminics or asthma)
CONTRAINDICATION OF STEROIDS
1. Hypertension
2. peptic ulcer
3. Diabetes
4. Pregnancy
5. Tuberculosis

28. TREATMENT
• SURGERICAL TREATMENT
“Surgery is an ancient medical specialty that uses operative manual and instrumental techniques
on a patient to investigate and/or treat a pathological condition such as disease or injury, or to
help improve bodily function or appearance.‖
For removal of nasal polyps:
1.Polypectomy
2.Intranasal ethomoidectomy
3.Extranasal ethmoidectomy
4.Transnasal ethmoidectomy
5.Endoscopic sinus surgery

29. Polypectomy
• 1 or 2 polyps which
are pedunculated are
removed with snare.
• Multiple and sessile
polypi reqire special
forceps.

30. Intranasal ethmoidectomy
• Done for multiple and
sessile polypi
• Uncapping of
ethmoidal air cells by
intranasal route
required

31. External nasal ethmoidectomy
• Done if reoccurance of
polyps occur after
surgery
• Approach is through
the medial wall of the
orbitby an external
incision ,medial to
medial canthus

32. Transnasal ethmoidectomy
• Done if infection and
polypoidal changes are
also seen in maxillary
antrum
• Caldwell-luc approach
is used

33. Endoscopic sinus surgery
FESS(functional endoscopic sinus
surgery
• Presently used
• Polypi can be removed
more accurately when
ethmoidal cells are
removed, and drainage
and ventilation
provided to the othe
involved sinuses.
• Done with endoscope
of 0,30,70 degree

35. Classification of polyps according to site of
origion
• 1. Antrochoanal
– a. Single, Unilateral
– b. Can originate from maxillary
sinus near ostium
– It has 3 parts
Antral which is a thin stalk
Choanal which is round and globular
Nasal which is flat from side to side
– c. Usually found in children.
– Grows backward to choana may
hang down behind the soft palaet.
– Trilobed with antral, nasal and
choana & fill the nasopharynx
obstruction both sides
– Reoccurrence uncommon, if
removed completely

36. ETIOLOGY:
• Nasal Allergy
• Sinus infection
SYMPTOMS:
• Unilateral nasal obstruction
May be bilateral if polyp grows in
nasopharynx
• Voice may be thick and dull due to
hyponasality
• Nasal discharge
SIGNS:
Anterior rhinoscopy:
• As it grows posteriorly can be missed at
anterior rhinoscopy
• A smooth greyish mass can be seen,it is
soft and can be moved up and down
with a prob.
TREATMENT:
Polypectomy,endoscopic removalor
caldwell-luc operation

37. PART-3
CASE STUDY

38. CASE NUMBER 1:
A 36 years old patient presented with complaints of nasal obstruction
which was mainly on the left side for last 1 year .It was often associated
with left sided facial pain, left side watering of eye,frontal headache and
thick, clear nasal discharge. reliving factor include medication and his
symptoms were relived upto short extent of time. Anterior rhinoscopy
showed soft, smooth and pale mass in left nasal cavity
• IMPORTANT POINTS IN HISTORY
TAKING:
• Nasal obstruction
• (onset, duration, progression, unilateral
or bilateral, continuous or intermittent,
aggravating and relieving factors)
• Nasal discharge(colour ,frequency,
consistency)
• Allergy or asthma, excessive sneezing,
watery rhinorrhea, dyspnoea
• Watering from eyes
• Nasal surgery

39. EXTERNAL EXAMINATION:
external examination of nose, face and eyes (watery eyes positive)
CLINICAL EXAMINATION:
•ANTERIOR RHINOSCOPY : presence of mass in left nasal cavity filling it completely
•PROBE TEST : mass was soft, mobile, polypoidal, insensitive to touch, but did not bleed
•NASAL PATENCY TEST: absent on left side
•POSTERIOR RHINOSCOPY : mass was not visible
INVESTIGATIONS:
1)X-rays PNS(water’s view) will show opacification in left maxillary sinus and with soft tissue
in left nasal cavity.
2) CT Scan show soft tissues arising from left maxillary sinus involving nasal cavity and nasopharynx
3)For general anaesthesia e.g blood CP, prothrombin time, activated partial thromboplastin time and
Urine D/R :all were in normal limits
DIAGNOSIS:
Antrochoanal polp involvinf left maxillary sinus nasal cavity
and nasopharynx
TREATMENT :
Convensional intranasal polypectomy
OR
Functional endoscopic sinus surgery

43. CASE -2
A 28 years old female patient came with complaints of bilateral nasal obstruction ,excessive sneezing
And watery rhinorrhoea for past 8 to 10 years now nasal obstruction has increased markedly to
become almost continuous and she can not breath through her nose. On clinical examination the
nose was pale, multiple and bilateral polypi were present in nasal cavities.
•IMPORTANT POINTS IN
HISTORY TAKING:
•Nasal obstruction
(onset, duration, progression, u
nilateral or
bilateral, continuous or
intermittent, aggravating and
relieving factors)
•Nasal discharge(colour
,frequency, consistency)
•Allergy or asthma, excessive
sneezing, watery
rhinorrhea, dyspnoea
•Watering from eyes
•Nasal surgery

44. EXTERNAL EXAMINATION:
external examination of nose, face and eyes (no positive findings)
CLINICAL EXAMINATION:
•ANTERIOR RHINOSCOPY: It revealed multiple, pale, smooth and shiny grape like polypi
completely filling both nasal cavities
•PROBE TEST : mass was soft, mobile, polypoidal, insensitive to touch, but did not bleed
•NASAL PATENCY TEST: absent on both side
•POSTERIOR RHINOSCOPY : nasopharynx was clear
INVESTIGATIONS:
1) CT Scan shows presence of polypi in both nasal cavities with involvement of both ethmoidal air
cells and maxillary sinuses
2)For general anaesthesia e.g blood CP, prothrombin time, activated partial thromboplastin time
and
Urine D/R :all were in normal limits
3)Peripheral eosinophil count and total serumIge level both were increased
DIAGNOSIS:
Bilateral ethmoidal nasal polypi
TREATMENT :
Convensional intranasal polypectomy
OR
Functional endoscopic sinus surgery
Histopathological examination of polyp

45. Bilateral ethmoidal

46. Point to remember:
1- if polypus is red flshy, friable and has granular surface, especially in older patients think about
MALIGNENCY
2-All polyps should be subjected to histology
3-A simple polp in achild may be a glioma , an encephalocele or a meningoencephalocele.
It should always be aspirated and fluid examination for CSF should be done.careless removal of such
Polyp would cause CSF rhinorrhoea and meningitis .
4-Multiple nasal polyps in children may be associated with mucoviscidosis
5-Epistaxis and orbital syndrome associated with polyp should
always arouse the suspicion of malignancy
malignancy

47. DIFFERENTIAL DIAGNOSIS:
1- A blob of mucus often looks like polypi but it would disappear on blowing the nose
2-Hypertrophied turbinate is differentiated by its pink appearance and hard fell on probe testing
3-Absence or presence of bleeding history e.g angiofibroma has history of profuse recurrent
epistaxis.
4- Other neoplasm can be differentiated by their fleshy pink appearance, friable nature and their
tendency to bleed
Neoplasm Hypertrophied turbinate
epistaxis