Nasal polyposis

NASAL POLYPOSIS

1. NASAL POLYPOSIS

2. Inflammatory condition characterised by oedematous mucosa of nose and sinuses Non neoplastic Sinuses – ethmoid (mc), maxillary (2 nd ) TYPES Ethmoidal Antrochoanal True choanal , sphenochoanal – rare Polyp – many feet, these soft jelly like masses are shaped like a polyp Defination

3. Arise from ethmoid air cells – so multiple Present as multiple grape like masses Etiology Middle age Men Allergy – 30% of patients have allergic cause, so bilateral Infection – rhinosinusitis Fungal infection Allergic fungal sinusitis Hereditary – cystic fibrosis, ciliary dyskinesia ETHMOIDAL POLYP

4. Vasomotor rhinitis Ethmoidal labyrinth complex anatomy Bernoulli’s phenomenon – when air passes through narrow cavities – negative pressure – increased formation of tissue fluids – edematous mucosa Asthma NARES Endocrine Young’s syndrome – sinus, pulmonary, azoospermia Samter’s triad – polyp, asthma, aspirin allergy

5. Kartagener’s syndrome – sinusitis, bronchiectasis , sinus inversus , ciliary dyskinesia Polysaccharide theory – leads to vasomotor imbalance Churg strauss syndrome – asthma, fever, eosinophilia , vasculitis and granuloma Children – rule out cystic fibrosis and mucoviscidosis Adults – allergy, infection Pathologenesis – inflammation by bacteria, virus, allergens Site – OMC (origin)

6. Histopathology – Lined by respiratory epithelium Long standing cases/ exposure to enviroment – squamous metaplasia C/F Symptoms – LONG HISTORY OF DISEASE Nasal obstruction – B/L Allergic symptoms – sneezing, itching Nasal discharge – mucoid , purulent if infected Post nasal discharge, hawking Hyposmia , Anosmia Broadening of nose – long standing cases

7. Headache Rhinolalia clausa Snoring Sleep apnoea Recurrence – common Signs Multiple bilateral polyp like growth – mobile, pale, soft, insensitive to touch, non friable, non bleeding, probed all around, arise from middle meatus Involve anterior part of nasal cavity, grow anteriorly Sessile or pedunculated , non tender

8. If infected – pink and vascular If protruding – pink Frog face deformity – long standing cases – broadening of nose and increased inter canthal distance Look like a bunch of grapes PROBE TEST, COLD SPATULA TEST D/D Congenital – meningocele , glioma , meningoencephalocele – for age < 5 years Polyps – AC polyp, sphenochoanal polyp Polypoidal / hypertrophied middle/ inferior turbinate

9. Granulomatous diseases – rhinosporidiosis , rhinoscleroma , tuberculosis Neoplasms – inverted papilloma , angiofibroma (bleed) Malignancy – bleed on probing Adenoids – crescent sign absent Turbinate hypertrophy – hard on probing Diagnosis DNE Biopsy – to rule out neoplasm, malignancy Allergy tests

10. Radiology X Ray PNS – sinusitis X Ray Nasopharynx – adenoids CT OMC – bone erosion, malignancy, surgery planning Nasal swab – fungal culture CBC, AEC Urine C/E Nasal smear - eosinophilia

11. TREATMENT Medical Antibiotics Antihistaminics , antileukotriens Steroid nasal spray – for preventing recurrence post op, minimal polyposis , those with asthma, cant tolerate antihistaminics Alkaline nasal douching Oral steroids – rarely Decongestants – local/oral – no role as polyps are avascular , don’t shrink

12. Surgical Intranasal polypectomy by snare FESS Intranasal ethmoidectomy – blind procedure, more complications Extranasal ethmoidectomy – scar Transantral ethmoidectomy / Caldwel luc surgery – for recurrence Microdebrider – more precise, less bleed LASER

13. Originates – Maxillary sinus – floor and medial wall Enters middle meatus mainly through accessory ostia / rarely through natural ostia into ethmoidal infundibulum Grows posteriorly into choana then nasopharynx sometimes oropharynx 3 parts – thin stalk in maxillary sinus Flat from side to side – nasal Round and globular – choanal / nasopharynx / oropharynx Antrochoanal Polyp/ Killian’s Polyp

14. ETIOLOGY Children and adolescents – as children are prone to infection M=F Sinusitis – Infection of maxillary sinus (so single and unilateral) Maldevelopment of maxillary sinus Faulty development of accessory/ natural ostia Rarely allergy, mostly not a cause Pathology – dumb bell shaped

15. C/F – SHORT HISTORY DURATION Symptoms U/L Nasal obstruction, if choana / nasopharynx involved can be B/L Nasal discharge Post nasal discharge Headache Anosmia / hyposmia – rare, not common Allergic symptoms – rare, less frequent Ear symptoms – due to Eustachian tube obstruction

16. Signs Dumb bell shaped Grows posteriorly May not be seen on anterior rhinoscopy Arises from lateral wall – so probe cant be passed laterally Posterior rhinoscopy – large pale white smooth translucent mass covered with nasal discharge Can extend to oropharynx Pink and congested – if infected D/D Bleb of mucus – disappears on blowing nose angiofibroma

17. Glioma , encephalocele , meningoencephalocele Rhinosporidiosis Hypertrophied turbinates Sphenochoanal polyp Craniopharyngioma Adenoids Thornwaldt’s cyst Diagnosis DNE CT SCAN OMC, PNS

18. X Ray PNS – opacity of maxillary sinus (U/L) Convexity of mass in sinus – polyp X Ray Neck lateral view – crescent sign positive – column of air (translucent area) behind the polyp (opacity) TREATMENT Antibiotics for infection Surgical – FESS with middle meatal antrostomy by joining natural and accessory ostia Caldwel luc surgery ( Transantral ethmoidectomy ) After age of 18 years – after eruption of upper 2 nd molar For recurrence

19. Functional Endoscopic Sinus Surgery Principle – To improve mucociliary clearance of sinuses by removing the obstruction of drainage of ostia with maximum preservation of sinus mucosa, when medical treatment fails INDICATIONS Recurrent and chronic sinusitis not responding to medical therapy Diffuse Nasal polyposis Allergic fungal sinusitis Complications of sinusitis CSF Rhinnorhoea Endoscopic DCR Endoscopic Septoplasty Endoscopic FB removal FESS

20. Mucocele of frontoethmoid or sphenoid sinus Inverted Papilloma , Juvenile Nasopharyngeal Angiofibroma Concha Bullosa resection Optic Nerve decompression Orbital decompression Choanal atresia Epistaxis C/I Lack of experience and proper instruments Intracranial complications Intraorbital complications Aggressive fungal infection – Mucormycosis Osteomyelitis Stenosis of sinus openings

21. Anaesthesia LA with sedation – adults, safer as when manipulation of orbital periosteum or dura – pain, but limited work possible GA – paediatric , anxious, long cases Preparation Topic anaesthesia and decongestant Local infiltration with 2% lignocaine with 1:100000 adrenaline into inferior turbinate, middle turbinate, uncinate process, bulla, septum Position – supine, head resting on ring and rotated towards surgeon, table raised at head end

22. TECHNIQUES Messerklinger / Stammberger technique More conservative as middle turbinate not resected Anterior to posterior Removal of uncinate process and exposure of ethmoidal infundibulum - Uncinectomy Identification and widening of maxillary sinus ostium and joining it with accessory ostia – Middle Meatal Antrostomy Removal of ethmoidal bulla – Bullectomy / Ant Ethmoidectomy Exploration and clearance of frontal sinus ostia – Frontal sinusotomy Penetration of basal lamella

23. Clearance of Posterior ethmoids – Posterior Ethmoidectomy Opening of anteriorwall of spenoid and clearance – Sphenoid Sinusotomy If middle turbinate enlarged as in Concha bullosa – partial or total turbinectomy Packing – Middle meatus packed to prevent adhesions Wigand technique Partial or complete resection of middle turbinate always done Posterior to anterior For recurrence or extensive disease When surgical landmarks not identified Middle turbinate resection – post ethmoid – sphenoid – anterior ethmoid

24. Post Operative Care Watch for swelling, visual status, mental status Look for surgical emphysema Antibiotics – Amoxyclav , Cephalosporin – intra op and post op for 10 days Steroids – post op for 6 weeks Leukotriene inhibitors – allergy Analgesics Antifungal agents Alkakine nasal douching for 1 week Avoid sternous activity, blowing of nose, medications which risk bleeding After 1 week post op – endoscopic toilet and crust/blood removal

25. Complications Minor Post op bleeding – post septal artery, internal maxillary artery Post op infection Stenosis of ostia Hyposmia Synechiae Headache Periorbital / subcutaneous emphysema NLD/Sac injury Toothache Exacebation of asthma

26. Major CSF Leak – due to skull base trauma (#), treatment involves using graft from temporalis fascia, fat, muscle, bone, cartilage Meningitis Intracranial bleed Orbital haematoma – due to injury to thmoidal artery – lead to blindness – treat by bleeding control, immediate pack removal and steroids Injury to optic nerve – blindness Diplopia , decreased visual acuity Injury to lamina papyracea Injury to ICA

27. Advantages of FESS Minimally invasive – no bone removal, preservation of nasal and sinus mucosa Better visualisation Better illumination Less trauma Photography/recording No skin incision Preservation of function of mucociliary clearance

28. Radical antrostomy /Canine fossa antrostomy / Anterior antrostomy Principle – 2 antrostomies are created for drainage and irrigation of maxillary sinus – inferior meatal (intra nasal) – permanent and canine fossa (sub labial approach) Indications Management of complex midfacial and orbital floor # Medial maxillectomy initial step FB maxilla – cant be removed by FESS Management of Ca Palate Chronic Maxillary Sinusitis – with irreversible changes to sinus mucosa Complicated acute maxillary sinusitis Caldwell Luc Surgery

29. Recurrent AC Polyp Atrophic Rhinitis – for implantation of stenson’s duct into maxillary sinus Approach to pterygopalatine fossa for ligation of maxillary artery Dental cyst C/I Age < 18 years Acute infections Diabetes, HTN, Bleeding disorder Preparation GA with endotracheal intubation Supine

30. Incision – sub labial incision between canine and 2 nd molar (upper) Canine fossa antrostomy done Removal of disease Intranasal antrostomy below inferior turbinate for drainage Packing through nasal antrostomy Closure of sublabial incision Post operative Antibiotics Ice pack Removal of pack after 2 days (48 hours) Saline irrigation

31. Complications Inferior meatal opening – useless Bleeding Anaesthesia of cheek – injury to infra orbital nerve Anaesthesia of teeth Injury to orbit Injury to NLD – Dacrocystitis Oroantral / sublabial fistula Orbital infection

32. Intra Nasal Through middle meatus Blind procedure – bleed, injury to optic nerve and orbit, CSF leak Extra nasal/ External/ Howarth’s Through medial canthus incision – curved incision medial to medial canthus Indication – pyocele , orbital complications, repeated recurrence, CSF repair Complications – External scar Ethmoidectomy

33. Transantral Horgan’s operation When both maxillary and ethmoid sinus affected Do Caldwell luc followed by ethmoidal surgery