NASAL POLYP - ETHMOIDAL and ANTROCHOANAL

1. NASAL POLYP
By : Nats

2. ETHMOIDAL POLYP
• Oedematous, hypertrophied nasal/ sinus mucosa which is
• Grape like mass
• Bluish
• Soft
• Smooth
• Mobile
• Sessile or pedunculated
• Insensitive to touch
• Doesn’t bleed on touch
• More males
• Occurs after age 2

3. Aetiology :
1. Allergy :
• 90% cases has Eosinophilia
• Increased IgA and IgE in Ethmoidal polyp ( Increased IgA in Antrochoanal polyp)
{Immunoglobulins-
Decreased than normal means chances of getting infection
Increased - can be seen in allergy or over reactive immune system}
• Polyp is associated with asthma
• Increases Histamine levels
2. Infections:
• Sinusitis – causes inflammatory changes – mucosal changes – mucosa becomes polypoidal
3. Vasomotor imbalance

4. 4. Bernoulli’s phenomenon
• When air passes through a narrow passage, its pressure drops
• This pressure drop will cause a negative impact and sucks mucosa of ethmoid into nasal cavity leading to
oedematous mucosa
5. Polysaccharide and polypeptide theory
• Its accumulation leads to water absorption leading to polyp formation
6. SAMPTER’S TRIAD
Polyp + Asthma + Aspirin Hypersensitivity
7. Cystic fibrosis

5. Histopathology and Histopathogenesis
• Ciliated columnar epithelium
• Neutrophil type and Eosinophil type
• Mucosal reactions – mucosal oedema
• Decreased blood supply to ethmoids
• Complex anatomy of ethmoids
Clinical features:
1. B/l Nasal obstruction
2. Hyposmia/ Anosmia
3. Nasal Discharge
4. Hypo nasal speech
5. Sneezing
6. Post nasal drip – can change from whitish to yellowish or greenish and is known as ALLERGIC
PUS

6. 7. Snoring, mouth breathing
8. FROG NOSE appearance ( widening of intercanthal distance – in late stages)
9.Anterior Rhinoscopy : Bilateral grape like mass, multiple, soft , smooth, bluish, shiny,
pedunculated, insensitive to touch and bleed
( INFECTED POLYP – Vascular appearance)
10. Cold spatula test – decreased fogging
POLYP GRADING:
Grade 1 – smaller than middle turbinate
Grade 2 – Larger than middle turbinate but smaller than inferior turbinate
Grade 3 – Larger than inferior turbinate

7. INVESTIGATIONS:
1. Absolute Eosinophil Count
2. ESR
3. Nasal swab
4. Allergy test
5. Biopsy – if needed
6. X-ray PNS
7. CECT PNS – IMAGING OF CHOICE
MANAGEMENT:
1. Topical steroid sprays :
• Fluticasone/ Mometasone – 2 puff B.D
2. Oral Steroids:
• Prednisolone 1mg/kg for 2 weeks
3. Alkaline nasal douching

8. • Normal saline with sodium bicarbonate
4. Antibiotics :
• Clarithomycin for 6 weeks or 3 months
5.Antihistamines
6. Leukotriene antagonists
• Montelukast - 10mg adults ; 5mg children
• To prevent recurrence :
• Furosemide topical application post surgery
• Immunotherapy
• Aspirin deactivation
• Triamcinolone – intralesional injection ; for those pts who cant tolerate oral/ topical steroids

9. Surgical Management:
• Done when medical management fails
• Nasal obstruction
• Steroid intolerance
• Persistent infection
• FESS – functional Endoscopic Sinus Surgery
• Ethmoidectomy – Intra nasal or external approach
Prognosis:
Poor
Recurrence
• Due to allergy
• Improper medical treatment
• Incomplete removal

10. ETHMOIDAL POLYP ANTROCHOANAL POLYP
Seen in ethmoids Seen in maxilla
Allergy related Anatomical variation
Bilateral Unilateral
Multiple polyps Single polyp
Grows backwards Grows backwards and forwards
IgA and IgE present IgA present
Avascular Vascular
Recurrence + Recurrence not common
Adults Children
Grape like appearance Dumb Bell shaped

11. Why ethmoidal polyps are directed posteriorly into nasopharynx ?
• Cilia beats in posterior direction
• Gravity
• Accessory ostium is directed posteriorly
• Air flow is to posterior direction
• Swallowing causes negative pressure and thus pulls polyp posteriorly

12. ANTROCHOANAL POLYP
• AC polyp arises from the mucosa of maxillary sinus and comes out accessory ostium into
middle meatus
• Unilateral
• Children
• Aka KILLIAN’S POLYP
Aetiology
Anatomical variation in Osteomeatal complex
Classification
Stage 1 – Polyp seen within antrum
Stage 2 – Polyp comes into middle meatus
Stage 3 – Polyp extends posteriorly into Nasopharynx

13. Parts:
• Antral
• Nasal
• Choanal
Sites of origin:
• Lateral wall of antrum
• Inferior wall
Clinical features:
• Nasal obstruction on expiration – Ball Valve effect
• Rhinorrhoea
• Epistaxis
• Post nasal drip
• Ear block and decreased hearing – due to ET block

14. • Anterior rhinoscopy : Large, single, soft, smooth, greyish, pedunculated, mobile mass ,
insensitive to touch and does not bleed on touch and extends to nasopharynx and orpharynx
Investigations:
• CT PNS – Investigation of choice
• X-ray PNS
• X-ray nasopharynx ( lateral view ) - polyp appears as a soft tissue mass above the soft palate
and extending into nasopharynx with an air column above it – CRESCENT or DODD’s sign
• DNE

15. Treatment:
• No role of medical management
• FESS
• Endoscopic polypectomy with Middle meatal antrostomy and by joining both accessory and
natural ostium
Prognosis:
• Good