Nasal Polyps
Nasal polyps can be described under following headings
A. Definition
B. Incidence
C. Classification
D. Ethmoidal Polyp
Definition – Etiology – Pathogenesis -Pathology – Site of origin – Symptoms – Signs – Differential Diagnosis – Staging of mucosal polyp – Investigations – Treatment – Complications of surgery
E. Antrocoanal Polyp – Definition -Etiology-Pathology -Symptoms -Signs -Differential diagnosis -Treatment
F. Prevention of Recurrence of Nasal Polyps
G. Complications of Nasal Polyps
H. Important Points to Remember in a Case of Nasal Polyps
A: Definition
Nasal polyps are non-neoplastic masses of edematous nasal or sinus mucosa
B: Incidence
Incidence in general population is unknown possibly between 1 % -2 % . There is higher incidence in asthmatics (20 -30 %) and even higher (49 %) in those asthmatics hypersensitive to aspirin. It is most common in middle aged men.
C: Classification
Nasal polyps are classified into 2 main categories.
- Ethmoidal polyps, or mucosal polyps.
- Antrocoanal polyps.
D: 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, mold spore, cat dander etc).
Other possible causes are:
- Gravity
- Forceful nose
- Nasal defects eg D.N.S.
- Heredity
- Age
- Sex
- 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
- Nasal discharge
- Impaired sense of smell
- Feeling of fullness in the face
- Headache
- Facial pain
Signs
On anterior Rhinoscopy
- Polypi appear as smooth glistening grape like masses often pale in color.
- They may be sessile or pedunculated.
- Insensitive to probing.
- Don’t touch on bleeding.
- 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
- Neoplastic lesions of nose.
- Nasal obstruction
- Maggots
- D.N.S.
- Rhinoliths
- Hypertrophy of turbinates
- 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 nasalstructures may be involved.
Investigations
- Blood C.P. (TLC, DLC, ESR, Hb % and platelets.)
- Blood sugar (to exclude the diabetes )
- Blood urea (to access the renal function )
- Urine D. R.
- X-Ray of sinuses
- Anterior rhinoscopy
- Posterior rhinoscopy
- C.T. Scan
- M.R.I.
- Acoustic rhinometry
- Nasal endoscopy
Treatment of Mucosal Polyps
Conservative
- Use of antihistamines and control of allergy if polyps are small and without symptoms.
- 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 (eg prednisolone; 6 day course using 215 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
E: Antrocoanal Polyps
Definition
This polyp arises from the mucosa of maxillary antrum near its accessory ostium, comes out and grows in choana and nasal cavity . Thus it has 3 parts
Antral, Choanal, Nasal
Etiology
Nasal allergy coupled with sinus infection is important cause. These polyps are seen in children and young adults .usually they are single and unilateral.
Pathology – Two views about it
- It is mucous cyst.
- It is due to catarrhal protrusion of mucosa through accessory ostium.
Symptoms
- Unilateral nasal obstruction.
- Voice may become thick and dull due to hyponasality.
- Mucoid nasal discharge.
- Difficulty in chewing and swallowing.
- Nasal deformity (late cases).
Signs
On Anterior Rhinoscopy
- When small, may be missed.
- When large, smooth grayish mass covered with nasal discharge may be seen.
- It is soft and can be moved up and down with a probe.
On Posterior Rhinoscopy
- May reveal globular mass filling the choana.
- A large polyp may hang down behind the soft palate and present in the oropharynx.
Differential Diagnosis
- A blob of mucous often looks like a polyp but it would disappear on blowing the nose.
- Hypertrophied Middle Turbinate – is differentiated with its pink appearance and hard feel of bone on probe testing.
- Angiofibroma – has history of profuse recurrent epistaxsis. It is firm in consistency and easily bleeds on probe testing.
- Other neoplasm may be differentiated by their fleshy pink appearance, friable nature and their tendency to bleed.
Treatment
- An antrocoanal polyp is easily removed by either through the nasal or oral route.
- Recurrence is uncommon after complete removal.
- If recurrence occur then Caldwell – Luc operation may be required to remove the polyp from the site of its origin.
F: Prevention of Recurrence of Nasal Polyps
Identify the underlying causeof polyps and treat it accordingly.
G: Complications of Nasal Polyps
- Nasal obstruction
- Insomnia
- Sinusitis
- Respiratory tract infections
- Broadening of nose and increased intercanthal distance
- Headache
- Facial pain
H: Important Points to Remember in a Case of Nasal Polyps
- If a polypus is red and fleshy, friable and has granular surface, especially in older patients, think of malignancy.
- Simple nasal polyp may masquerade a malignancy underneath, hence all polypi should be subjected to histology.
- A simple polyp in a child may be glioma, an encephalocele or a meningoenccephalocele. It should always be aspirated and fluid examined for CSF.
- Multiple nasal polypi in children may be associated with mucovisidosis.
- Epistaxis and orbital symptoms associated with a polyp should always arouse the suspicion of malignancy.
References:
-
- Diseases of Ear, Nose and Throat, by P.L. Dhingra. (second edition)
- Current Medical Diagnosis and Treatment, 2000.
- Textbook of Ear, Nose and Throat, by Abdul Ghani.
- Web sites
