Definition Nasal polyps are soft ,jelly-like ,abnormal growths emanating from around the openings of the paranasal sinuses or the surface of the nasal mucosa Polyps are teardrop-shaped. resemble a peeled, seedless grape. Unlike polyps in the colon or bladder, polyps in the nose are not tumors and do not suggest an increased risk of cancer. They are merely a reflection of inflammation, although there may be a family history of the problem. .

Historical background First recognised in India 1000 BC Hippocrates devised instruments for removal 460- 370 BC The word polyp comes from the Greek ; poly-pous ; meaning many footed was considered neoplastic condition till 1954 Billroth described histological characteristics 1955 Zuckerkandl considered these inflammatory 1956

Multifactorial aetiology A continuous inflam. process within the nose and sinuses - thought to be the main source of nasal polyps. could be related to allergies; things in the atmosphere (pollution, dust etc.) or by a sinus infection. Overproduction of fluid in the cells membrane(vasomotor instability) causes polyps to become swollen and engorged with fluid - These bags of fluid can enlarge and pop out through the sinus openings into the nasal cavity. Engorged nasal membranes - Irritants such as alcohol and tobacco may expose membranes to infection.

Aetiology contd Bernouillis phenomenon Allergy 90% have eosinophilia association with asthma allergic sign,symptoms

Conditions associated Asthma 20-40% have coexisting Aspirin hypersensitivity 8 % Cystic fibrosis children,unilateral Other respiratory diseases

Incidence Betweeen one in 1000 of population would have nasal polyps once or more in their life. 10 % suffers from seasonal allergic rhinitis 5 % suffer from perennial rhinitis Male predominence 3:1 Disease of adults 30-60 yrs

pathogenesis Ethmoidal sinuses complex anatomy Chronic inflammation causes the blood vessels in the lining of nose and sinuses to become more permeable, allowing water to accumulate in the cells. Over time, as gravity pulls on these waterlogged tissues, they may develop into polyps Ethmoidal sinuses complex anatomy Poorly developed ethmoidal blood supply

Pathogenesis Several studies have consistently demonstrated the active role of eosinophils in the development of nasal polyp An involvement of IgG, IgA and IgE has been suggested since these immunoglobulin receptors can be found on the surface of eosinophil Few studies demonstrate local production of IgE within nasal polyp tissue .

Pathology Macro translucent,multiple,insensitive Micro ciliated columner,goblet cells, extracellular interstitial fluid

clinical presentation A stuffy, runny nose and diminished sense of smell are the hallmarks of nasal polyps Nasal obstruction,snoring Dull headaches Rhinolalia clausa Persistent stuffiness ,sneezing,postnasal drip Re-occurring sinus infections Abundant nasal drainage Thick, discolored nasal drainage Reduced sense of smell and taste Occasional pain in the face ,epistaxis

Diagnosis A physical examination will identify most polyps. Small polyps located higher up or further back may be hidden from view, but Otorhinolaryngologist is equipped to diagnose nasal polyps. In order to perform the exam, medicine must be applied to decongest the membranes. Cotton balls soaked with one of these agents and left in the nostrils for a few minutes provide adequate shrinkage.

Examination Pedunculated,multiple,insensitive to touch Change position Probe can be passed all around Red color/purulent discharge bacterial infection Green brown sludge coexisting fungal infection Effect of vasoconstriction

Anterior rhinoscopy

Screening and diagnosis To help diagnose , ask history, examine nasal passages&investigate. CT scan may help determine the size and exact location of the polyps, e.g. polyps in sinuses. Child diagnosed with multiple nasal polyps , test for cystic fibrosis, an inherited condition affecting the exocrine glands The standard diagnostic test for it is a noninvasive sweat test, which measures the amount of sodium and chloride in child's perspiration. Children who have both nasal polyps and hay fever may have allergy skin tests, which can provide important information about allergic sensitivities. Allergy skin tests aren't uncomfortable for most children and can usually be completed in 30 minutes or less.

Examination There may be a single nasal polyp or several, clustered together like grapes on a stem. The polyps are generally soft and pearl colored, Very small single or multiple polyps may not cause any problems, but larger ones are likely to obstruct the airways in the nose, making it difficult to breathe. This may lead to mouth breathing, especially in children.

Complications A single, small nasal polyp rarely causes complications, but a large polyp or many smaller polyps (polyposis) may lead to the following: Acute or chronic sinus infections. Obstructive sleep apnea — a potentially serious condition in which one stops and starts breathing a number of times during sleep. Altered facial structure leading to diplopia or unusually wide-set eyes.

Treatment corticosteroid nasal spray These medications relieve inflammation, increase nasal airflow and may help shrink polyps. Side effects of steroid nasal sprays are far less serious than are those of oral steroids and may include nosebleeds, headache or sore throat. Oral corticosteroids. either alone or in combination with a nasal spray. Because oral steroids can cause serious side effects,

Control of allergies & infections Antihistamines In case of hay fever or other allergies, antihistamines may help relieve congestion, although they won't eliminate polyps. Antibiotics for an acute sinus infection. Antifungal medications. Researchers have discovered that some cases may be caused by an unusual immune system response to environmental fungus. these are being tested as a treatment for sinusitis-related polyps.

Surgery Small or isolated polyps can often be completely removed using a small mechanical suction device or a microdebrider — an instrument that cuts and extracts soft tissue. The procedure, called a polypectomy can be performed on an outpatient basis. Following polypectomy, patient should be treated for any underlying inflammation, usually with corticosteroid nasal sprays and sometimes with antibiotics or oral steroids. Even so, polyps frequently return, and may need additional operations. When medications aren't effective, consider removing polyps surgically. This is often the only option for people with cystic fibrosis who usually don't respond to steroids.

ethmoidectomy Intra nasal Trans antral external

External ethmoidectomy

surgery The most effective surgery is functional endoscopic sinus surgery (FESS), which involves fibre optic scopes and power tools. A combination of polypectomy, endoscopic ethmoidectomies and antrostomies seems to give the best results, far superior to previous techniques. It's essential to be aware that polyps can recur, despite successful surgical removal. For this reason, most surgeons start patients on nasal steroid sprays shortly after surgery to help control recurrence.

Endoscopic sinus surgery This procedure not only removes polyps, but also opens the part of the sinus cavity where polyps usually form. If sinuses are blocked or inflamed, surgeon may open even more of sinus cavity. Surgeon uses a thin, rigid tube and a camera called a video endoscope. Because endoscopic surgery requires small incisions, patient generally heal more quickly and with less discomfort than with other types of surgery. Still, full recovery may take several weeks, and polyps often return. This surgery has serious potential risks, including leakage of cerebrospinal fluid, injury to the optic nerve or eye muscles, and hemorrhage.

F E S S

Endoscopic view

Prevention In many cases, polyps can't be prevented, however, managing asthma, hay fever or chronic sinus infections may reduce the chances that polyps will develop or recur. medications and avoiding as much as possible — indoor and outdoor allergens and pollutants. Irrigating your sinuses with salt water may help relieve mild nasal congestion and eliminate mucus.. preservative-free saline sprays.

Prognosis Polyps reappear as long as the allergic irritation continues Even with good surgical intervention, the recurrence rate is high, estimated at 30-40%.

Antrochoanal polyp Arise from maxillary antrum and prolapse through the ostium of the sinus in the middle meatus The choanal part hang into nasopharynx and may be seen in the oropharynx Polyp tends to be dumb-bell Unilateral nasal obstruction mostly in expiration and serous otitis media if they occlude the eustachian tube Radioopaque max.sinus on xrays

Killians polyp Antrochoanal polyps, are solitary polyps and were first described by Killian in 1906 hence also known as killians polyp.  Although their etiology remains unknown, allergy has been implicated.

Antrochoanal polyp

Treatment Surgical removal is indicated. Recurrence is frequent and may necessitate a Caldwell-lucs operation F E S S

Other nasal polyps Benign bleeding polyp of septum meningioma,gliomas Malignant carcinoma,lymphoma,sarcoma red,fleshy,friable,bleed to touch