A class on nasal polyps

1. Nasal Polyps
Dr. Krishna Koirala

2. Definition
• Nasal Polyp
– Hypertrophied, edematous, pedunculated mucosa
prolapsing out of the nose or paranasal sinus
• Simple nasal polyps
– Antrochoanal Polyp
– Ethmoidal polyps

3. • Properties of Nasal Polyps
– Pale /gray in color
– Glistening
– Smooth surface
– Pedunculated
– Insensitive to touch
– Mobile
– Does not bleed on probing

4. Antro - choanal Polyp
( Killian’s Polyp)

5. Etiology and origin
• Etiology:
– Infection
– Proetz Theory (anomaly of maxillary sinus ostium)
– Bernoulli’s phenomenon ( pressure drop next to
constriction)
• Origin:
– Arises from maxillary sinus mucosa and exits via
its natural or accessory ostium and extends to
choana

6. Why does AC polyp prefer to extend
towards the choana?
1. Maxillary ostium is directed posteriorly
2. Cilia beat posteriorly
3. Air current flows posteriorly in a greater force
4. Nasal floor slopes posteriorly
5. Posterior nasal cavity is larger
6. Negative oropharyngeal pressure while swallowing

7. Parts of Killian’s Antrochoanal polyp
• Antral: globular
• Choanal: globular
• Nasal: flattened
transversely
• Neck : present at
maxillary ostium

8. Clinical presentation
• Common in children and adolescent age
• Unilateral nasal obstruction
• Unilateral nasal discharge
• Occasionally nasal mass

9. Mass hanging in OropharynxUnilateral nasal mass

10. Posterior rhinoscopy

11. Examination of nasal mass
• Inspection : side, size, number, color, surface,
pedunculated or sessile, origin, attachment
• Probing : consistency, sensitivity to touch, bleeding on
touch, can be passed all around
• Shrinkage with decongestant drops

12. Probe test
Antrochoanal polyp Hypertrophied turbinate
Insensitive to pain Sensitive
Probe can be passed all
around
Cannot be passed
Mobile Not mobile

13. Differential Diagnosis
• Hypertrophied inferior turbinate
• Blob of mucous
• Inverted papilloma
• Rhinosporidiosis / rhinoscleroma
• Angiofibroma
• Meningocoele
• Malignancy

14. Investigations
• Diagnostic Nasal Endoscopy
• X-ray PNS (Waters view)
• X-ray nasopharynx lateral view: presence of air b/w
skull base & polyp
• CT scan PNS (coronal cuts)

15. Diagnostic Nasal Endoscopy

16. X-ray Paranasal Sinuses

17. C.T. scan Paranasal Sinus

18. Treatment
• Antibiotics (pre & post operatively)
• Avulsion polypectomy with middle meatal
antrostomy
• F.E.S.S.
• Caldwell – Luc operation (for recurrence)

19. Middle meatal antrostomy

20. Caldwell – Luc Operation

21. How to prevent recurrence ?
• Complete removal of all parts ( Nasal , Antral ,
Choanal)
• Wide middle meatal antrostomy (widening of
maxillary sinus ostium)
• Post-operative antibiotics

22. Ethmoid Polyps

23. Clinical Presentation
Adult patient
• Bilateral nasal obstruction
• Bilateral watery nasal discharge
• Excessive, paroxysmal sneezing
• H/o previous nasal surgery

24. B/L nasal polyps

25. Anterior Rhinoscopy

26. Broadening of nasal bridge

27. Etiology of ethmoid polyp
1. Allergy
2. Allergy + Infection
3. Vasomotor imbalance
4. Bernoulli phenomenon
5. Poly-saccharide changes

28. Associated diseases
1. Aspirin intolerance + Bronchial asthma + Ethmoid
polyps  Samter’s triad
2. Cystic fibrosis
3. Allergic fungal sinusitis
4. Kartagener’s syndrome (ciliary dyskinesia + situs
invertus)
5. Young’s syndrome (hyperviscous mucous +
azoospermia)

29. Investigations
• Diagnostic Nasal Endoscopy (D.N.E.)
• X-ray PNS (Rhese lateral oblique view)
• C.T. scan P.N.S. (coronal cuts)
• Tests for allergy

30. Diagnostic Nasal Endoscopy

31. CT Scan Paranasal Sinus

32. Non-surgical Treatment
Given for very small polyps
• Avoid allergens
• Oral antihistamines (1-3 months)
• Corticosteroid nasal sprays (3-6 months)
• Oral prednisolone (1 mg/kg/day for 2 weeks )

33. Pre - steroid vs. Post- steroid

34. Surgical Treatment
1. Intra-nasal avulsion polypectomy
2. Extra-nasal external ethmoidectomy
3. Trans-antral ethmoidectomy
4. Functional Endoscopic Sinus Surgery
 Conventional
 Micro - debrider
 Laser

35. F.E.S.S.

36. F.E.S.S. instruments

37. F.E.S.S. with navigation

38. Micro-debrider

39. How to prevent recurrence?
1. Complete removal of all polyps
2. Avoid allergens
3. Post-operative course of:
− Oral antihistamines (1-3 months)
− Corticosteroid nasal sprays (3-6 months)

40. Bilateral FESS cavities

41. Post FESS CT scan

42. Antrochoanal polyp Ethmoid polyps
Seen in adolescents & children Adult
Etiology is infection Allergic
Single Multiple
Unilateral Bilateral
Shape is tri-lobed (dumb-bell) Grape like
Grows backward Forward
Treatment is surgical Medical + Surgical
Recurrence is uncommon Common