nasal polyps

Inflammation of the mucosa of sinuses associated with inflammation of the nasal mucosa is called rhinosinusitis (RS).
CLASSIFICATION:
• Acute RS: Symptoms lasting for less than 4 weeks with complete resolution.
• Subacute RS: Duration 4-12 weeks.
• Chronic RS: Duration ~ 12 weeks.
• Recurrent RS: Four or more episodes of RS per year; each lasting for 7-10 days or more with complete resolution in between the episodes.
• Nasal obstruction.
• Nasal discharge/congestion, anterior, or posterior in the form of postnasal drip.
• Facial pain or pressure.
• Alteration in the sense of smell, hyposmia or anosmia.
• Other symptoms include cough, fever, halitosis, fatigue, dental pain, pharyngitis, headache or ear fullness.

1. RHINOSINUSITIS/ ALLERGIC FUNGAL SINUSITIS/ NASAL POLYPS DR AWAIS IRSHAD

2. RHINOSINUSITIS: Inflammation of the mucosa of sinuses associated with inflammation of the nasal mucosa is called rhinosinusitis (RS). CLASSIFICATION: • Acute RS: Symptoms lasting for less than 4 weeks with complete resolution. • Subacute RS: Duration 4-12 weeks. • Chronic RS: Duration ~ 12 weeks. • Recurrent RS: Four or more episodes of RS per year; each lasting for 7-10 days or more with complete resolution in between the episodes.

3. Symptoms • Nasal obstruction. • Nasal discharge/congestion, anterior, or posterior in the form of postnasal drip. • Facial pain or pressure. • Alteration in the sense of smell, hyposmia or anosmia. • Other symptoms include cough, fever, halitosis, fatigue, dental pain, pharyngitis, headache or ear fullness.

4. ACUTE VIRAL RHINOSINUSITIS It is caused by respiratory viruses, usually the common cold viruses such as rhinoviruses, influenza and parainfluenza. They spread by aerosolized droplets through coughing and sneezing. Clinical features: nasal congestion (blockage), rhinorrhea, sneezing and low-grade fever. Unless complicated by bacterial infection, the patient improves within a week or 10 days. It is a self-limiting disease. Treatment is symptomatic with use of topical nasal decongestants and antihistamines. Analgesics are useful to relieve headache, fever and myalgia. Aspirin should be avoided, as it causes increased shedding of the virus. Plenty of fluid intake should be encouraged. Nasal saline sprays are useful. Antibiotics are not needed.

5. Pathophysiology

6. ACUTE BACTERIAL RHINOSINUSITIS This usually follows viral upper respiratory infection. The virus damages the cilia and epithelium, and causes oedema of the mucosa membrane and obstruction of sinus ostia with stasis of sinus secretion and subsequent bacterial infection. The most common bacteria responsible for RS are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Staphylococcus aureus. Clinical features include nasal obstruction and purulent rhinorrhoea . Facial pain/pressure are the cardinal symptoms. Hyposmia/anosmia, cough, fever, headache, fullness of ear, dental pain or halitosis. Treatment strategies 1. Analgesics 2. Antibiotics 3. Saline irrigations

7. Pathophysiology

8. FUNGAL INFECTIONS OF SINUSES COMMEN SPECIE INVOLVE : Aspergillus, Alternaria, Mucor or Rhizopus. TYPES: Fungal ball. It is due to implantation of fungus, which on CT shows a hyperdense area with no evidence of bone erosion or expansion. Maxillary sinus is the most commonly involved followed by sphenoid, ethmoid and the frontal in that order. 2. Allergic fungal sinusitis . It contains eosinophils, Charcot Leyden crystals and fungal hyphae. No invasion of the sinus mucosa with fungus. CT scan shows mucosal thickening with hyperdense areas. There may be expansion of the sinus or bone erosion due to pressure, but no fungal invasion.

9. 3. Chronic invasive sinusitis. fungus invades into the sinus mucosa. There is bone erosion by fungus. Patient presents with chronic rhinosinusitis. CT scan shows thickened mucosa with opacification of sinus and bone erosion. Patient may have intracranial or intraorbital invasion. 4. Fulminant fungal sinusitis. mostly seen in immunocompromised or diabetic individuals. Mucor causes rhinocerebral disease. Due to invasion of the blood vessels, mucor fungus causes ischemic necrosis presenting as a black eschar, involving inferior turbinate, palate or the sinus. It spreads to the face, eye, skull base and the brain Aspergillus tissue invasion. Such patients present with acute sinusitis and develop sepsis and other sinus complications. Unlike Mucor infection, there is no black eschar.

10. Nasal polyp Nasal polypi are non-neoplastic masses of edematous nasal or sinus mucosa. They are divided into two main varieties:  1. Bilateral ethmoidal .   2. Antrochoanal polyp

11. ETIOLOGY They may arise in inflammatory conditions of nasal mucosa (rhinosinusitis), disorders of ciliary motility or abnormal composition of nasal mucus (cystic fibrosis). Various diseases associated with the formation of nasal polypi 1. Chronic rhinosinusitis. 2. Asthma 3. Aspirin intolerance. 4. Cystic fibrosis. 5. Allergic fungal sinusitis. 6. Kartagener syndrome. 7. Young syndrome. 8. Churg–Strauss syndrome.

12. Nasal mucosa, particularly in the region of middle meatus and turbinate, becomes oedematous due to collection of extracellular fluid causing polypoidal change. Polypi which are sessile in the beginning become pedunculated due to gravity and excessive sneezing . In early stages, surface of nasal polypi is covered by ciliated columnar epithelium like that of normal nasal mucosa but later it undergoes a metaplastic change to transitional and squamous type on exposure to atmospheric irritation. Submucosa shows large intercellular spaces filled with serous fluid. There is also infiltration with eosinophils and round cells. Pathogenesis

13. Symptoms

14. Signs On anterior rhinoscopy, or endoscopic examination, polypi appear as smooth, glistening, grape-like masses Pale in color Sessile or pedunculated insensitive to probing and do not bleed on touch. Often they are multiple and bilateral. Broadening of nose and increased intercanthal distance. Pink and vascular simulating neoplasm Purulent discharge due to associated sinusitis. Probing of a solitary ethmoidal polyp may be necessary to differentiate it from hypertrophy of the turbinate or cystic middle turbinate

15. EXAMINATION INVESTIGATION TREATMENT ( CONSERVATIVE AND SURGICAL ) Computed tomography (CT ) scan of paranasal sinuses is essential to exclude the bony erosion and expansion suggestive of neoplasia. Simple nasal polypi may sometimes be associated Histological examination: Management:

16. TREATMENT CONSERVATIVE  TREATMENT 1. Early polypoidal changes with oedematous mucosa may revert to normal with antihistaminics and control of allergy 2. A short course of steroids may prove useful in case of people who cannot tolerate antihistaminics and/or in those with asthma and polypoidal nasal mucosa. They may also be used to prevent recurrence after surgery

17.   1. Polypectomy.  One or two polyps which are pedunculated can be removed with snare. Multiple and sessile polypi require special forceps.  2. Intranasal ethmoidectomy. When polypi are multiple and sessile, they require uncapping of the ethmoidal air cells by intranasal route, a procedure called intranasal ethmoidectomy.  3. Extranasal ethmoidectomy. This is indicated when polypi recur after intranasal procedures and surgical landmarks are ill-defined due to previous surgery. Approach is through the medial wall of the orbit by an external incision, medial to medial canthus. 

18. 4. Transantral  ethmoidectomy  . antrum is opened by Caldwell–Luc approach and the ethmoid air cell approached through the medial wall of the antrum.  5. Endoscopic sinus surgery . It is done with various endoscopes of 0°, 30° and 70° angulation. Polypi can be removed more accurately when ethmoid cells are removed, and drainage and ventilation provided to the other involved sinuses such as maxillary, sphenoidal or frontal.

19. COMMON CAUSES OF UNILATERAL NASAL OBSTRUCTION: Vestibule Nasal cavity Nasopharynx Furuncle Vestibulitis Stenosis of nares Atresia Nonalveolar cyst Papilloma Squamous cell carcinoma • Foreign body • Deviated nasal septum (DNS) • Hypertrophic turbinate • Concha bullosa • Intraconal polyp • Synechia • Rhinolith • Bleeding polypus of septum • Benign and malignant tumors of nose and paranasal sinuses • Sinusitis, unilateral • Unilateral choanal atresia

20. COMMON CAUSES OF BILATERAL NASAL OBSTRUCTION: Vestibule Nasal cavity Nasopharynx • Bilateral vestibulitis • Collapsing nasal alae • Stenosis of nares • Congenital atresia of nares • Acute rhinitis (viral and bacterial) • Chronic rhinitis and sinusitis • Rhinitis medicamentosa • Allergic rhinitis • Hypertrophic turbinates • DNS • Nasal polypi • Atrophic rhinitis • Rhinitis sicca • Septal hematoma • Septal abscess • Bilateral choanal atresia • Adenoid hyperplasia • Large choanal polyp • Thorwald's cyst • Adhesions between soft palate and posterior pharyngeal wall • Large benign and malignant tumor

21. ANTROCHOANAL POLYP (SYN. KILLIAN’S POLYP) This polyp arises from the mucosa of maxillary antrum near its accessory ostium, comes out of it and grows in the choana and nasal cavity. it has three parts . 1. Antral, which is a thin stalk. 2. Choanal, which is round and globular.  3. Nasal, which is flat from side to side

22. SYMPTOMS Unilateral nasal obstruction is the presenting symptom Obstruction may become bilateral when polyp grows into the nasopharynx and starts obstructing the opposite choana Voice may become thick and dull due to hypernasality Nasal discharge, mostly mucoid, may be seen on one or both sides

23. Signs As the antrochoanal polyp grows posteriorly, it may be missed on anterior rhinoscopy. When large, a smooth greyish mass covered with nasal discharge may be seen. It is soft and can be moved up and down with a probe. A large polyp may protrude from the nostril and show a pink congested look on its exposed part. Posterior rhinoscopy may reveal a globular mass filling the choana or the nasopharynx. A large polyp may hang down behind the soft palate and present in the oropharynx. Examination of the nose with an endoscope may reveal a choanal or antrochoanal polyp hidden posteriorly in the nasal cavity.

24. TREATMENT An antrochoanal polyp is easily removed by avulsion either through the nasal or oral route. Recurrence is uncommon after complete removal. Caldwell– Luc operation may be required to remove the polyp completely from the site of its origin and to deal with coexistent maxillary sinusitis. These days, endoscopic sinus surgery has superceded other modes of polyp removal. Caldwell–Luc operation is avoided

25. DIFFERENTIAL DIAGNOSIS

26. A 20 year old female presented to ENT opd with the complaint of complete bilateral nasal obstruction, facial headache and nasal discharge. On examination there were glistening white grapelike mass occupying the whole nasal cavity on both sides.  What specific question you would ask in history to elicit the diagnosis? Give specific examination findings to rule out the other types of nasal masses. Give differentials and highlight important points in case of nasal masses. Give management plan of most probable diagnosis including relevant investigations & medical and surgical treatment Differentiate between Antrochoanal and ethmoidal polyps CBL 14