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  1. 1. NASAL POLYPI Dr T Balasubramanian
  2. 2. Definition • The term polyp derived from Latin word “Polypous” Many footed • Defined as simple oedematous hypertrophic nasal mucosa • Can be unilateral / bilateral drtbalu's otolaryngology online 2
  3. 3. History “Nasal polypi are sacs of phlegm that cause nasal obstruction” Hippocrates drtbalu's otolaryngology online 3
  4. 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
  5. 5. Etiopathogenesis drtbalu's otolaryngology online 5
  6. 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
  7. 7. History of nasal instruments drtbalu's otolaryngology online 7
  8. 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. 9. Management • 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 drtbalu's otolaryngology online 9
  10. 10. • Simple nasal polyp1 • Fungal polyp2 • Malignant polyp3 Classification drtbalu's otolaryngology online 10
  11. 11. Simple nasal polypi • Also known as inflammatory polyp • Ethmoidal polyp • Antrochoanal polyp drtbalu's otolaryngology online 11
  12. 12. AC polyp / Ethmoidal polypi Ethmoidal polypi Antrochoanal polyp Seen in adults Seen in children and adolescents Allergy is the common cause Infection is the common cause Multiple (bunch of grapes) Unilateral Arises from ethmoidal labyrinth Arises from maxillary antrum Seen easily on anterior rhinoscopy Seen commonly in post nasal exam X ray PNS may show hazy ethmoids and normal maxillary sinuses X ray PNS shows hazy maxillary antrum Mostly bilateral Usually unilateral Recurrence is common Recurrence is uncommon Polypectomy Caldwel luc surgery in recurrent cases drtbalu's otolaryngology online 12
  13. 13. Fungal polyp • 5 Different types • Acute fulminant • Chronic invasive • Granulomatous invasive • Fungal ball • AFRS drtbalu's otolaryngology online 13
  14. 14. drtbalu's otolaryngology online 14
  15. 15. Acute fulminant invasive sinusitis Common in: • Diabetics • HIV + • On immunosuppression • Malignancy causing immunosuppression • Mucor mycosis is the common pathogen • Angio invasion common drtbalu's otolaryngology online 15
  16. 16. Chronic invasive fungal sinusitis • Non granulomatous chronic invasive fungal sinusitis • Common in diabetics • Low grade inflammation & tissue necrosis are its features • Vascular invasion not common • Orbital extension common drtbalu's otolaryngology online 16
  17. 17. Granulomatous invasive fungal sinusitis • 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 drtbalu's otolaryngology online 17
  18. 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. 19. AFRS Bent’s criteria • 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. 20. Malignant polypi • 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 drtbalu's otolaryngology online 20
  21. 21. THEORIES drtbalu's otolaryngology online 21
  22. 22. Theories of nasal polyposis • 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 drtbalu's otolaryngology online 22
  23. 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. 24. Necrotizing ethmoiditis – Woakes theory • Ethmoiditis cause osteitis of ethmoid bone • Necrotic bone initiates mucosal reaction causing oedema • Bone necrosis has not been demonstrated in the polypoidal tissue studied drtbalu's otolaryngology online 24
  25. 25. Glandular cyst theory • 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 drtbalu's otolaryngology online 25
  26. 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. 27. Blockage theory of Jenkins • Nasal mucosal inflammation • Accumulation of intracellular fluid • This causes polyp to develop drtbalu's otolaryngology online 27
  28. 28. Periphlebitis / Perilymphangitis theory of Eggston & Wolff • 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 drtbalu's otolaryngology online 28
  29. 29. Glandular hyperplasia theory of Krajina • Ch inflammation of nasal mucosa causes hyperplasia of nasal mucosal glands • This causes bulging of overlying mucosa • Associated vascular congestion aggravates the condition drtbalu's otolaryngology online 29
  30. 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 nasal polyp drtbalu's otolaryngology online 30
  31. 31. drtbalu's otolaryngology online 31
  32. 32. A/C polyp theories of etiopathogenesis • Proetz theory • Bernoulli’s phenomenon • Mucopolysaccharide changes • Infections • Mill’s theory • Ewing’s theory • Vasomotor imbalance drtbalu's otolaryngology online 32
  33. 33. Proetz theory • 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 drtbalu's otolaryngology online 33
  34. 34. Bernoulli’s phenomenon Pressure drop occurs next to the constriction. This causes a suction effect pulling the sinus mucosa into the nasal cavity. drtbalu's otolaryngology online 34
  35. 35. Mucopolysaccharide theory • 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 drtbalu's otolaryngology online 35
  36. 36. Mill’s theory Antrochoanal polyp could be maxillary mucoceles. This could be caused due to obstruction to mucinous glands. drtbalu's otolaryngology online 36
  37. 37. Ewing’s theory • 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 drtbalu's otolaryngology online 37
  38. 38. Vasomotor imbalance theory This theory suggests that vasomotor imbalance can cause antrochoanal polyp. drtbalu's otolaryngology online 38
  39. 39. Infection / inflammation • 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 drtbalu's otolaryngology online 39
  40. 40. Reasons for posterior migration of AC polyp • 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 drtbalu's otolaryngology online 40
  41. 41. drtbalu's otolaryngology online 41
  42. 42. Clinical features • Nasal obstruction – Unilateral / bilateral • Anosmia • Loss of taste • Rhinorrhoea – watery / mucoid / mucopurulent • Head ache • Broadening of nose (Frog face) drtbalu's otolaryngology online 42
  43. 43. Examination • 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. 44. Posterior rhinoscopy • 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. 45. Differential diagnosis • Meningocele • Angiofibroma • Sq cell carcinoma • Enlarged turbinates • Inverted papilloma drtbalu's otolaryngology online 45
  46. 46. Radiology drtbalu's otolaryngology online 46
  47. 47. Medical Management • Antihistamines ? • Nasal decongestant • Steroids • Antibiotics ? drtbalu's otolaryngology online 47
  48. 48. Surgery • Polypectomy • Endoscopic polypectomy • Caldwel Luc procedure • External ethmoidectomy drtbalu's otolaryngology online 48
  49. 49. drtbalu's otolaryngology online 49