DefinitionDefinition

Nasal polyps are soft ,jelly-like ,abnormal growths Nasal polyps are soft ,jelly-like ,abnormal growths emanating from around the openings of the paranasal emanating from around the openings of the paranasal sinuses or the surface of the nasal mucosasinuses or the surface of the nasal mucosa

Polyps are teardrop-shaped. resemble a peeled, Polyps are teardrop-shaped. resemble a peeled, seedless grape. seedless grape.

Unlike polyps in the colon or bladder, polyps in the Unlike polyps in the colon or bladder, polyps in the nose are not tumors and do not suggest an increased nose are not tumors and do not suggest an increased risk of cancer. They are merely a reflection of risk of cancer. They are merely a reflection of inflammation, although there may be a family history inflammation, although there may be a family history of the problem.of the problem.

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Historical backgroundHistorical background

First recognised in India 1000 BCFirst recognised in India 1000 BC Hippocrates devised instruments for removal 460- Hippocrates devised instruments for removal 460-

370 BC 370 BC The word polyp comes from the Greek ; poly-pous ; The word polyp comes from the Greek ; poly-pous ;

meaning many footedmeaning many footed was considered neoplastic condition till 1954was considered neoplastic condition till 1954 Billroth described histological characteristics Billroth described histological characteristics

19551955 Zuckerkandl considered these inflammatory 1956Zuckerkandl considered these inflammatory 1956

Multifactorial aetiologyMultifactorial aetiology

A continuous inflam. process within the nose and sinusesA continuous inflam. process within the nose and sinuses - - thought to be the main source of nasal polyps. could be related to allergies; 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.things in the atmosphere (pollution, dust etc.) or by a sinus infection.

Overproduction of fluid in the cells membrane(vasomotor Overproduction of fluid in the cells membrane(vasomotor instabilityinstability)) causes polyps to become swollen and engorged with fluid causes polyps to become swollen and engorged with fluid - - These bags of fluid can enlarge and pop out through the sinus openings These bags of fluid can enlarge and pop out through the sinus openings into the nasal cavity. into the nasal cavity.

Engorged nasal membranesEngorged nasal membranes - - Irritants such as alcohol and tobacco Irritants such as alcohol and tobacco may expose membranes to infection. may expose membranes to infection.

AetiologyAetiology contdcontd

Bernouillis phenomenonBernouillis phenomenon

Allergy Allergy

90% have eosinophilia90% have eosinophilia

association with asthmaassociation with asthma

allergic sign,symptomsallergic sign,symptoms

Conditions associatedConditions associated

AsthmaAsthma 20-40% have coexisting20-40% have coexisting

Aspirin hypersensitivity Aspirin hypersensitivity 8 %8 %

Cystic fibrosisCystic fibrosis children,unilateralchildren,unilateral

Other respiratory diseasesOther respiratory diseases

IncidenceIncidence

Betweeen one in 1000 of population would Betweeen one in 1000 of population would have nasal polyps once or more in their life.have nasal polyps once or more in their life.

10 % suffers from seasonal allergic rhinitis10 % suffers from seasonal allergic rhinitis 5 % suffer from perennial rhinitis5 % suffer from perennial rhinitis Male predominence 3:1Male predominence 3:1 Disease of adults 30-60 yrsDisease of adults 30-60 yrs

pathogenesispathogenesis

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

Ethmoidal sinuses complex anatomyEthmoidal sinuses complex anatomy Poorly developed ethmoidal blood supplyPoorly developed ethmoidal blood supply

PathogenesisPathogenesis

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 .

PathologyPathology

MacroMacro

translucent,multiple,insensitivetranslucent,multiple,insensitive

MicroMicro

ciliated columner,goblet cells,ciliated columner,goblet cells,

extracellular interstitial fluidextracellular interstitial fluid

clinical presentationclinical presentation A stuffy, runny nose and diminished sense of smell are the hallmarks of nasal A stuffy, runny nose and diminished sense of smell are the hallmarks of nasal

polypspolyps

Nasal obstruction,snoringNasal obstruction,snoring Dull headaches Dull headaches Rhinolalia clausaRhinolalia clausa Persistent stuffiness ,sneezing,postnasal dripPersistent stuffiness ,sneezing,postnasal drip Re-occurring sinus infections Re-occurring sinus infections Abundant nasal drainage Abundant nasal drainage

Thick, discolored nasal drainage Thick, discolored nasal drainage Reduced sense of smell and taste Reduced sense of smell and taste Occasional pain in the face ,epistaxisOccasional pain in the face ,epistaxis

DiagnosisDiagnosis

A A physical examinationphysical examination will identify most polyps. will identify most polyps. Small polyps located higher up or further back may Small polyps located higher up or further back may be hidden from view, but Otorhinolaryngologist is be hidden from view, but Otorhinolaryngologist is equipped to diagnose nasal polyps.equipped to diagnose nasal polyps.

In order to perform the exam, medicine must be In order to perform the exam, medicine must be applied to decongest the membranes. Cotton balls applied to decongest the membranes. Cotton balls soaked with one of these agents and left in the nostrils soaked with one of these agents and left in the nostrils for a few minutes provide adequate shrinkage.for a few minutes provide adequate shrinkage.

ExaminationExamination

Pedunculated,multiple,insensitive to touchPedunculated,multiple,insensitive to touch Change positionChange position Probe can be passed all aroundProbe can be passed all around Red color/purulent discharge bacterial Red color/purulent discharge bacterial

infectioninfection Green brown sludge coexisting fungal Green brown sludge coexisting fungal

infectioninfection Effect of vasoconstrictionEffect of vasoconstriction

Anterior rhinoscopyAnterior rhinoscopy

Screening and diagnosisScreening and diagnosis

To help diagnose , ask history, examine nasal To help diagnose , ask history, examine nasal passages&investigate. CT scan may help determine the size passages&investigate. CT scan may help determine the size and exact location of the polyps, e.g. polyps in sinuses.and exact location of the polyps, e.g. polyps in sinuses.

Child diagnosed with multiple nasal polyps , test for cystic Child diagnosed with multiple nasal polyps , test for cystic fibrosis, an inherited condition affecting the exocrine glands fibrosis, an inherited condition affecting the exocrine glands The standard diagnostic test for it is a noninvasive sweat test, The standard diagnostic test for it is a noninvasive sweat test, which measures the amount of sodium and chloride in child's which measures the amount of sodium and chloride in child's perspiration.perspiration.

Children who have both nasal polyps and hay fever may have Children who have both nasal polyps and hay fever may have allergy skin tests, which can provide important information allergy skin tests, which can provide important information about allergic sensitivities. Allergy skin tests aren't about allergic sensitivities. Allergy skin tests aren't uncomfortable for most children and can usually be completed uncomfortable for most children and can usually be completed in 30 minutes or less.in 30 minutes or less.

ExaminationExamination

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

ComplicationsComplications

A single, small nasal polyp rarely causes A single, small nasal polyp rarely causes complications, but a large polyp or many smaller complications, but a large polyp or many smaller polyps (polyposis) may lead to the following:polyps (polyposis) may lead to the following:

Acute or chronic sinus infections. Acute or chronic sinus infections. Obstructive sleep apnea — a potentially serious Obstructive sleep apnea — a potentially serious

condition in which one stops and starts breathing a condition in which one stops and starts breathing a number of times during sleep. number of times during sleep.

Altered facial structure leading to diplopia or Altered facial structure leading to diplopia or unusually wide-set eyes. unusually wide-set eyes.

TreatmentTreatment

corticosteroid nasal spraycorticosteroid nasal spray These medications relieve inflammation, increase nasal airflow These medications relieve inflammation, increase nasal airflow

and may help shrink polyps.and may help shrink polyps. Side effects of steroid nasal sprays are far less serious than are Side effects of steroid nasal sprays are far less serious than are

those of oral steroids and may include nosebleeds, headache or those of oral steroids and may include nosebleeds, headache or sore throat.sore throat.

Oral corticosteroidsOral corticosteroids.. either alone or in combination with a either alone or in combination with a nasal spray. Because oral steroids can cause serious side nasal spray. Because oral steroids can cause serious side effects, effects,

Control of allergies & infectionsControl of allergies & infections

Antihistamines Antihistamines In case of hay fever or other allergies, antihistamines In case of hay fever or other allergies, antihistamines

may help relieve congestion, although they won't may help relieve congestion, although they won't eliminate polyps. eliminate polyps.

Antibiotics for an acute sinus infection. Antibiotics for an acute sinus infection. Antifungal medications. Antifungal medications. Researchers have discovered that some cases may be Researchers have discovered that some cases may be

caused by an unusual immune system response to caused by an unusual immune system response to environmental fungus. these are being tested as a environmental fungus. these are being tested as a treatment for sinusitis-related polyps. treatment for sinusitis-related polyps.

SurgerySurgery

Small or isolated polyps can often be completely removed Small or isolated polyps can often be completely removed using a small mechanical suction device or a microdebrider — using a small mechanical suction device or a microdebrider — an instrument that cuts and extracts soft tissue. The procedure, an instrument that cuts and extracts soft tissue. The procedure,

called acalled a polypectomy polypectomy can be performed on an can be performed on an outpatient basis. Following polypectomy, patient should be outpatient basis. Following polypectomy, patient should be treated for any underlying inflammation, usually with treated for any underlying inflammation, usually with corticosteroid nasal sprays and sometimes with antibiotics or corticosteroid nasal sprays and sometimes with antibiotics or oral steroids. Even so, polyps frequently return, and may need oral steroids. Even so, polyps frequently return, and may need additional operations. When medications aren't effective, additional operations. When medications aren't effective, consider removing polyps surgically. This is often the only consider removing polyps surgically. This is often the only option for people with cystic fibrosis who usually don't option for people with cystic fibrosis who usually don't respond to steroids. respond to steroids.

ethmoidectomyethmoidectomy

Intra nasalIntra nasal Trans antralTrans antral externalexternal

External ethmoidectomyExternal ethmoidectomy

surgerysurgery

The most effective surgery is functional endoscopic The most effective surgery is functional endoscopic sinus surgery (FESS), which involves fibre optic sinus surgery (FESS), which involves fibre optic scopes and power tools. A combination of scopes and power tools. A combination of polypectomy, endoscopic ethmoidectomies and polypectomy, endoscopic ethmoidectomies and antrostomies seems to give the best results, far antrostomies seems to give the best results, far superior to previous techniques.superior to previous techniques.

It's essential to be aware that polyps can recur, It's essential to be aware that polyps can recur, despite successful surgical removal. For this reason, despite successful surgical removal. For this reason, most surgeons start patients on nasal steroid sprays most surgeons start patients on nasal steroid sprays shortly after surgery to help control recurrence. shortly after surgery to help control recurrence.

Endoscopic sinus surgeryEndoscopic sinus surgery

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

F E S SF E S S

Endoscopic viewEndoscopic view

PreventionPrevention

In many cases, polyps can't be prevented, however, In many cases, polyps can't be prevented, however, managing asthma, hay fever or chronic sinus managing asthma, hay fever or chronic sinus infections may reduce the chances that polyps will infections may reduce the chances that polyps will develop or recur. medications and avoiding as much develop or recur. medications and avoiding as much as possible — indoor and outdoor allergens and as possible — indoor and outdoor allergens and pollutants.pollutants.

Irrigating your sinuses with salt water may help Irrigating your sinuses with salt water may help relieve mild nasal congestion and eliminate mucus.. relieve mild nasal congestion and eliminate mucus.. preservative-free saline sprays.preservative-free saline sprays.

PrognosisPrognosis

Polyps reappear as long as the allergic Polyps reappear as long as the allergic irritation continues irritation continues

Even with good surgical intervention, the Even with good surgical intervention, the recurrence rate is high, estimated at 30-40%.recurrence rate is high, estimated at 30-40%.

Antrochoanal polypAntrochoanal polyp

Arise from maxillary antrum and prolapse through Arise from maxillary antrum and prolapse through the ostium of the sinus in the middle meatusthe ostium of the sinus in the middle meatus

The choanal part hang into nasopharynx and may be The choanal part hang into nasopharynx and may be seen in the oropharynxseen in the oropharynx

Polyp tends to be dumb-bellPolyp tends to be dumb-bell Unilateral nasal obstruction mostly in expiration and Unilateral nasal obstruction mostly in expiration and

serous otitis media if they occlude the eustachian tubeserous otitis media if they occlude the eustachian tube Radioopaque max.sinus on xraysRadioopaque max.sinus on xrays

Killians polypKillians polyp

Antrochoanal polyps, are solitary polyps and Antrochoanal polyps, are solitary polyps and were first described by Killian in 1906 hence were first described by Killian in 1906 hence also known as killians polyp.  also known as killians polyp. 

Although their etiology remains unknown, Although their etiology remains unknown, allergy has been implicated. allergy has been implicated.

Antrochoanal polypAntrochoanal polyp

TreatmentTreatment

Surgical removal is Surgical removal is indicated. Recurrence is indicated. Recurrence is frequent and may frequent and may necessitate a Caldwell-necessitate a Caldwell-lucs operationlucs operation

F E S SF E S S

Other nasal polypsOther nasal polyps

BenignBenign

bleeding polyp of septumbleeding polyp of septum

meningioma,gliomasmeningioma,gliomas

MalignantMalignant

carcinoma,lymphoma,sarcomacarcinoma,lymphoma,sarcoma

red,fleshy,friable,bleed to touchred,fleshy,friable,bleed to touch