Tumours of nasal cavity Benign MalignantSquamous papilloma CarciomaInverted papilloma -Squamous cell CaSchwannoma - AdenocarcinomaMeningioma Malignant melanomaHaemangioma Olfactory neuroblastomaChondroma HaemangiopericytomaAngiofibroma LymphomaEncephalocele Solitary plasmacytomaGlioma Various types of sarcomaDermoid
BENIGN1. Squamous papilloma : Verrucous lesions similar to skin warts arise from the nasal vestibule or lower part of nasal septum. Single or multiple, pedunculated or sessile. Treatment : local excision with cauterisation of the base. Cryosrugery Laser.
2) Inverted papilloma (transitional cell papilloma or Ringertz tumour) Microscopically neoplastic epithelium is seen to grow towards underlying stroma rather than on the surface. 40-70 years male preponderance (5:1). Arises from the lateral wall of nose Always unilateral, red or grey masses Translucent and oedematous marked tendency to recur after surgical removal. Associated with squamous cell carcinoma in 10- 15% of patients. Treatment : Wide surgical excision by lateral rhinotomy or medial maxillectomy and en bloc ethmoidectomy.
3) Pleomorphic adenoma : Arises from the nasal septum. Treatment : Wide surgical excision.4) Schwannoma and meningioma : Treatment : Surgical excision by lateral rhinotomy. Both the above mentioned are rare tumours
5) Haemangioma :a) Capillary haemangioma (bleeding polypus of the septum : Soft, dark red, pedunculated or sessile tumour arising from anterior part of nasal septum. Present with recurrent epistaxis and nasal obstruction. Treatment : Local excision with a cuff of surrounding mucoperichondrium.b) Cavernous haemangioma : Arises from the turbinates on the lateral wall of nose. Treated by surgical excision with preliminary cryotherapy.
Capillary haemangioma (bleedingpolypus of the septum
6)Chondroma : Arise from the ethmoid, nasal cavity or nasal septum. Treatment is surgical excision.7)Intranasal Meningoencephlocele : Herniation of brain tissues and meninges through foramen caecum or cribriform plate. Smooth polyp in the upper part of nose between the septum and middle turbinate. Seen in Infants and young children. Mass increases in size on crying or straining. CT scan is essential to demonstrate a defect in the base of skull. Treatment is frontal craniotomy, severing the stalk form the brain, and repair of dural and bony defect. Intranasal mass is removed as secondary procedure after cranial defect has sealed.
8) Gliomas : Seen in infants and children.9) Nasal dermoid : Widening of upper part of nasal septum with splaying of nasal bones and hypertelorism.
MALIGNANT1) Carcinoma of nasal cavity : Primary carcinoma per se is rare. May be an extension of maxillary or ethmoid carcinoma. Squamous cell variety, adenoid cystic carcinoma or an adenocarcinoma. a. Squamous cell carcinoma : From the vestibule, anterior part of nasal septum or the lateral wall of nasal cavity. In men past 50 years of age. i. Vestibular : It arises from the lateral wall of nasal vestibule. ii. Septal : Arises from mucocutaneous junction. “Nose-picker’s cancer”. iii. Lateral wall : Site most commonly involved. Easily extends into ethmoid or maxillary sinuses. Presents as a polypoid mass in the lateral wall of nose. Treatment : Combination of radiotherapya nd surgery. b. Adenocarcinoma and adenoid cystic carcinoma. Arises from the glands of mucous membrane. Involve upper part of the lateral wall of nasal cavity.
2) Malignant melanoma : Seen in persons about 50 years of age. Both sexes equally affected. Grossly, it presents as a slaty-grey or bluish black polypoid mass. Within the nasal cavity, most frequent site is anterior part of nasal septum followed by middle and inferior turbinate. Tumour spreads by lymphatics and blood stream. Treatment : Wide surgical excision.3) Olfactory neuroblastoma : Tumour of olfactory placode. Either sex at any age group. Cherry red, polypoidal mass in the upper third of the nasal cavity. Lymph node or systemic metastases can occur. Treatment : Surgical excision followed by radiation.
4) Haemangiopericytoma : Tumour of vascular origin. Arises from the pericyte. Age group of 60-70 presents with epistaxis. Treatment : Wide surgical excision.5) Lymphoma : Rarely a non-Hodgkin lymphoma presents on the septum.6) Plasmacytoma : Males over 40 years. Treatment : Radiotherapy followed three months later by surgery if total regression does not occur.7) Sarcomas
iv. Cystic fibrosis : Due to abnormal mucus.v. Allergic fungal sinusitis.vi. Kartagener’s syndrome : Bronchiectasis sinusitis, situs inversus and ciliary dyskinesis.vii. Young’s syndrome : Sinopulmonary disease and azoospermia.viii. Churg-Strauss syndrome : Asthma, fever, eosinophilia, vasculitis and granuloma.ix. Nasal mastocytosis : Chronic rhinitis in which nasal mucosa is infiltrated with mast cells.
Pathogenesis : Nasal mucosa, particularly in the region of middle meatus and turbinate becomes oedematous due to collection of extracellular fluid causing polypoidal change. Polypi, sessile in the beginning become pedunculated due to gravity and the excessive sneezing. Pathology : Surface of nasal polypi is covered by ciliated columnar epihtelium. Later it undergoes a metaplastic change to transitional and squamous type on exposure to atmospheric irritation. Submucosa: large intercellular spaces filled with serous fluid. Infiltration with esoinophils and round cells.Site of origin : Lateral wall of nose, usually from the middle meatus.
HIGH PSEUDOSTRATIFIED CILIARY EPITHELIUM WITHMANY GOBLET CELLS
MIGRATION OF EOSINOPHILS (ARROWS) THROUGH THE EPITHELIUMOF A NASAL POLYP. THE EOSINOPHILS ARE CONCENTRATEDMAINLY BENEATH THE BASAL MEMBRANE
Symptoms : Signs : Mostly seen in adults Anterior rhinoscopy – Nasal suffiness, total polypi appear as smooth, nasal obstruction. glistering, grape-like masses often pale in Loss of sense of smell colour. Headache, sinusitis. Sessile or pedunculated Sneezing and watery Insensitive to probing, do nasal discharge due to not bleed on touch. associated allergy. Multiple and bilateral. Mass protruding from the Broadening of nose and nostril. increased intercanthal distance. Nasal cavity may show purulent discharge due to associated sinusitis.
Diagnosis : Clinical examination CT scan of paranasal sinuses to exclude the bony erosion and expansion suggestive of neoplasia. Histological examination of the tissue.
TreatmentConservative :1. Antihistaminics and control of allergy.2. A short course of steroids may also be used to prevent recurrence after surgery.Surgical :1. Polypectomy using a Snare, Multiple and sessile polypi require special forceps.2. Intranasal ethmoidectomy – when polypi are multiple and sessile. Uncapping of the ethmoidal air cells by intranasal route.3. Extranasal ethmoidectomy – when polypi recur after intranasal procedures. Approach is through the medial wall of the orbit by an external incision, medial to medial canthus.4. Transantral ethmoidectomy – This is indicated when infection and polypoidal changes are also seen in the maxillary antrum.5. Endoscopic sinus surgery – FESS done with variuos endoscopes of 0°, 30° and 70° angulation.
Antrochoanal polyp ( Killian’sPolyp) This polyp arises form the mucosa of maxillary antrum near its accessory ostium, comes out of it and grows in the choana and nasal cavity. Three parts. i) Antral: Which is a thin stalk. ii) Choanal : Which is round and globular iii) Nasal : Which is flat from side to side.
Aetiology : Unknown Nasal allergy coupled with sinus infection. Seen in children and young adults. Usually they are single and unilateral.Symptoms : Unilateral nasal obstruction. Obstruction, bilateral when polyp grows into the nasopharynx. Voice thick and dull due to hyponasality. Nasal discharge, mostly mucoid.
Signs : Anterior rhinoscopy: A smooth greyish mass covered with nasal discharge. Soft and can be moved up and down. A large polyp may protrude from the nostril and show a pink congested look on its exposed part. Posterior rhinoscopy: globular mass filling choana or the nasopharynx. May hang down behind the soft palate and present in the oropharynx.
X-rays of paranasal sinuses. Opacity of the involved antrum. X-ray, (lateral view) soft tissue nasopharynx a globular swelling in the postnasal space.Treatment : Removed by avulsion either through the nasal or oral route. In cases which do recur, Caldwell-Luc operation may be required to remove the polyp completely from the site of its origin and to deal with co-existing maxillary sinusitis. Endoscopic sinus surgery.
Differential diagnosis :1. A blob of mucus2. Hypertrophied middle turbinate is differentiated by its pink appearance and hard feel of bone on probe testing.3. Angiofibroma has history of profuse recurrent epistaxis. Firm in consistency easily bleeds on probing.4. Other neoplasms may be differentiated by their fleshy pink appearance, friable nature and their tendency to bleed.
Differences between antrochoanal and ethmoidal polypi Antrochoanal polypi Ethmoidal polypiAge Common in children Common in adultsAetiology Infection Allergy or multifactorialNumber Solitary MultipleLaterality Unilateral BilateralOrigin Max.sinus near the ostium Ethmoidal sinuses, uncinate process, middle turbiante and middle meatus.Growth Grows backwards to the Mostly grow anteriorly and choana may present at the naresSize & shape Trilobed Usually small and grape like masses.
Antrochoanal EthmoidalPolyp Polyp Trilobed in shape Usually small and grape- like masses Recurrence is uncommon Recurrence is common if removed completely Treatment: Polypectomy; Treatment: Polypectomy, endoscopic removal or Endoscopic surgery or Caldwell-Luc Operation Ethmoidectomy