This document describes the case of a 49-year-old male patient presenting with nasal polyps. It details his medical history, examination findings, investigations, diagnosis of allergic nasal polyps, and treatment involving polypectomy surgery. Nasal polyps are non-cancerous growths that can develop in the nose or sinuses. They are often caused by an allergic reaction and can lead to symptoms like nasal obstruction, discharge, and loss of smell. The patient's polyps were surgically removed and he was discharged with medication and follow-up appointments.

1. 03/13/13 1

2. ALLERGIC NASAL POLYPI
Dr. Muhammad Farooq Khan
Medical Officer
Department of Oto-Rhino-Laryngology
Capital Hospital, Islamabad
03/13/13 2

3. ALLERGIC NASAL POLYPI
CASE HISTORY
Patient: Mohammad Javed
Age: 49 years male
Occupation: Frash, CDA
Presenting Complaints:
Nasal irritation}
Runny nose}
Sneezing}- 10 years
Nasal blockade}- 6 years
Bronchial asthma}- 2 years
03/13/13 3

4. CASE HISTORY
GPE
Middle aged smoker of average height, Hypertensive,
Pulse- 92bpm, regular
B.P. 160/.100mm Hg
Temp. 98.6F
SYSTEMIC EXAMINATION
CNS-}
CVS- } NAD
GIT- }
Resp. System-
Scattered conducted sounds, with coarse crepts,
inspiratory rhonchi bilateraly.
03/13/13 4

5. CASE HISTORY
E.N.T EXAMINATION
EARS: Both ears normal
Ear Drums- intact bil.
Hearing normal
.
THROAT: Oro-pharyngeal mucosa consistant
with picture of Ch. Pharyngitis.
03/13/13 5 Contd.

6. CASE HISTORY
NOSE:
 Broadening of nose and Flaring of alar nasai,
No tenderness over the maxillary and ethmoid areas.
 Pale allergic nasal mucosa,with bunch of pale yellow grape
like polypoidal swellings seen bilaterally,confirmed to be
arising from middle meatus, turbinate and ethmoids, on
probe testing.
 Olfaction was found impaired.
 No polypi were seen in naso-pharynx on post. Rhinoscopy.
03/13/13 6

7. CASE HISTORY
PAST HISTORY
 H/O allergic rhinitis for last 10 years.
 H/O mucus polyps for 6 years.
 1st polypectomy done 5 years back,
 Recurrence of nasal polyposis 2 years back,
 Development of Bronchial Asthma 2 years back.
 Hypertension (untreated) 1 year.
03/13/13 7

8. CASE HISTORY
LABORATORY FINDINGS
 Blood CP:
Hb% 15.5g/dl
TLC 10500/cmm
DLC 68%N, 24%L, 2%M, 6%E
ESR 03mm/1st hr
 Blood Glucose: 88mg/dl
 B.T/ C.T: WNL
X-RAY CHEST(PA view)- WNL
03/13/13 8

9. CASE HISTORY
X-Ray PNS (O.M.view)-
Hazy maxillary & ethmoidal
sinuses, with soft tissue
shadows in nasal cavities
but no bony erosions.
03/13/13 9

10. MANAGEMENT
MEDICAL
 Control of Hypertension and Asthma
 Fitness for G/A
SURGICAL
 Polypectomy on 26th Oct. 2002 under General anaesthesia
through peroral endotracheal intubation with a pharyngeal
pack.
 Nasal pack removed after 48 hrs and patient discharged on 29 th
Oct. 2002 on following treatment:
o Nasal decongestants (local)
o Antibotic cover
o Antihistamine
o Oral Steroids
o Antihypertensives and bronchodilator as advised
by medical department.
03/13/13 10

11. CASE HISTORY
FOLLOW UP
 Weekly for 2 weeks:
1st Follow up- Air way clear, smell and breathing
improved.
 Fortnightly for 2 months:
 Last visit on 27th, Nov. 2002, Patient happy and
without recurrence.
03/13/13 11

12. ALLERGIC NASAL POLYPI
POLYP
A pedunculated portion of edematous mucosa
of the nose or Para-nasal sinuses.
Also termed as
Mucous Polyp/ Ethmoidal Polyps
03/13/13 12

13. ALLERGIC NASAL POLYPI
CLASSIFICATION
 Simple
 Allergic
 Vasomotor
 Inflamatory
 Mixed infective- allergic
 Neoplastic
 Benign – Angiofibroma, Pappiloma
 Malignant – Sarcoma, Melanoma
03/13/13 13

14. ALLERGIC NASAL POLYPI
AGE INCIDENCE
Ethmoidal- At any age.
Antrochoanal- Usually Children & young adults.
03/13/13 14

15. ALLERGIC NASAL POLYPI
ANATOMY
 Polyp usually arise from lateral wall of the middle meatus,
middle turbinate or ethmoid, and hang down into the nasal
cavity.
 Polyp consists of a pedicle, a body and a fundus.
 Usually round, smooth, soft, translucent, yellow or pale
glistening structure attached to nasal mucosa with narrow
stalk.
 Occasionally cubical, or pavement in places.
03/13/13 15

16. ALLERGIC NASAL POLYPI
SITES OF ORIGIN
Multiple Ethmoidal polypi Antrochoanal polyp
filling the nasopharynx
03/13/13 16

17. ALLERGIC NASAL POLYPI
HISTOLOGY
 Microscopically covered with ciliated columnar
epithelium with large amount of fluid i.e.
transudate, in the substance of Polypus.
 Very few glands and blood vessels.
 Round cell infiltration and Eosinophils.
 No nerves.
03/13/13 17

18. ALLERGIC NASAL POLYPI
PATHOPHYSIOLOG
Y
Hypersensitivity reaction; Type-I IgE mediated.
 Release of Histamine from mast cells and basophils
in the submucosa of nasal cavity.
 Vasodilation, smooth muscle contraction and
increased capillary permeability.
 Odema,
 Polyp formation.
03/13/13 18

19. ALLERGIC NASAL POLYPI
ETIOLOGY
Five theories:

Bernouli Phenomenon- (Gravitational Pull)

Polysacharide Changes- (Alteration in the ground
substance has been postulated but analysis shows no
collagen changes).

Vasomotor Imbalance- (Sympathetic- Parasympathetic
imbalance with parasympathetic dominance).
 Infection- Rhinitis & Sinusitis play a role.
 Purulent
 Hyperplastic
 Allergic- See next slide
03/13/13 19 Contd.

20. ALLERGIC NASAL POLYPI
ETIOLOGY
 Allergy: Allergy is implicated because of histologic
picture of eosinophilia and association with asthma.
 Nasal Allergy- an expression of pathologic
hypersensitivity, mediated by antibody upon exposure
to an antigen.
 Two types of Antibodies:
 Humoral- associated with immediate reaction,
e.g, Hay Fever, Urticaria,
 Somatic antibodies- associated with delayed
reaction, e.g, Tuberculosis, Allergic reaction to
infection.
03/13/13 20

21. ALLERGIC NASAL POLYPI
SYMPTOMS
 Nasal Obstruction
 Thin profuse Nasal discharge
 Anosmia
 Headache/ loss of concentration
 Epiphora
 Conductive deafness
 Rhinolalia clausa - Dull, toneless speech due
to nasal blockage
03/13/13 21

22. SIGNS:NASAL POLYPI
ALLERGIC
INTRANASAL SIGNS
Anterior Rhinoscopy:
 multiple grape like swellings(Polyps)
hanging from the roof.
 Smooth and shinny, covered with thin
discharge, non tender, can be moved with
blunt nasal probe.
Posterior Rhinoscopy:
 Engorged posterior tips of the inferior
turbinates and septal turbinates.
03/13/13 22 Contd.

23. ALLERGIC NASAL POLYPI
SIGNS
 Frog-nose, due to broadening of nasal bridge,
 Typical faces of chronic mouth breather,
 Allergic shiners caused by dark circles under the
eyes due to venous stasis by engorged nasal
membranes.
 Rabbit nose due to wrinkling of the end of the nose.
 Allergic Salute- due to repeated wiping of runny
nose.
03/13/13 23

24. ALLERGIC NASAL POLYPI
COMPLICATIONS
 Nasal blockade
 Repeated infections
 Infective rhinnitis
 Infective sinusitis– Bacterial/ Fungal
 Epistaxis
 Anosmia
 Hyper telorism
 Eustachian tube dysfunction- with middle ear
effusion.
 Facial deformity– Frog nose (adults)
Rabbit nose (children)
 Asthma.
03/13/13 24

25. ALLERGIC NASAL POLYPI
LABORATORY FINDINGS
 Periphiral Eosinophilia:3- 10 % eosinophils in the
nasal secretion is diagnostic of allergic rhinitis.
 Nasal secretion cytology reveals presence of
eosinophils.
 Elevated IgE serum levels seen in 50% patients.
 Allergic Skin testing, by methods like Prick test,
Scratch test and Intradermal test.
03/13/13 25

26. ALLERGIC NASAL POLYPI
DIFFERENTIAL DIAGNOSIS
03/13/13 26(Contd.)

27. ALLERGIC NASAL POLYPI
D/D
Ethmoidal Polyp Antrochoanal Polyp
03/13/13 27(Contd.)

28. ALLERGIC NASAL POLYPI
D/D
Inverted Papilloma
Fleshy cauliflower like
mass with single
attachment in the nose
commonly arising
from the septum.
03/13/13 28(Contd.)

29. ALLERGIC NASAL POLYPI
D/D
Sometimes need to be differentiated from
“Naso-Pharyngeal Fibroma”:
 Teen age males,
 H/O recurrent & severe epistaxis,
 Lobulated mass with irregular surface,
 Bleeds easily on touch.
03/13/13 29

30. ALLERGIC NASAL POLYPI
DIAGNOSIS
 Through clinical examination
 Radiography of the sinuses
 Biopsy
 C.T/ M.R.I Scan
03/13/13 30

31. TREATMENT:
ALLERGIC NASAL POLYPI
MANAGEMENT
 Conservative
 Surgical
03/13/13 31

32. ALLERGIC NASAL POLYPI
CONSERVATIVE MANAGEMENT
 Avoidance of allergens/Irritants.
 Environmental control.
 Immunotherapy
 Intermittent use of anti-histamines, locally or per oral.
 Local decongestants, as drops or sprays.
 Topical steroid therapy- to avoid recurrence.
 Anti-biotic therapy, where indicated.
03/13/13 32

33. TREATMENT:
ALLERGIC NASAL POLYPI
SURGICAL MANAGEMENT
 Removal of polypi under local or general
anesthesia with non-cutting nasal polypus
snare.
 Recurrent cases- Intranasal ethmoidectomy
 Removal of cause- Allergy sinusitis, DNS.
03/13/13 33

34. ETHMOIDAL POLYPI
SUMMARY
SURGICAL MANAGEMENT
SURGICAL COMPLICATIONS
Dr. Ghulam Saqulain
M.B.B.S., D.L.O., F.C.P.S.
E.N.T Surgeon, Capital Hospital
ISLAMABAD
03/13/13 34

35. ETHMOIDAL POLYPI
SUMMARY
 Bil. Nasal polyps usually originate from ethmoid
sinuses and are sometimes associated with nasal
allergy.
 These polypi are usually multiple and nasal airway
obstruction caused by them is occasionally the prime
symptom forcing the patient for an E.N.T
consultation.
 Broadening of the nose could be a prominent feature
in advanced cases. Hypertelorism and proptosis is
often seen associated with them if left untreated.
 Cases have been reported where nasal polypi have
invaded the anterior cranial fossa.
03/13/13 35

36. ETHMOIDAL POLYPI
SUMMARY
 Aggressive, invasive and recurrent polyp formation
could not possibly have only allergic basis. It may be
due to allergic and infective processes acting
together including fungal infection.
 Aspergillus is the most common organism
responsible for the sinusitis and recurrent polypi.
 Polyps with onset in childhood may be very
aggressive and lead to splay the bones producing
widened bridge. They are however nearly always
associated with cystic fibrosis.
03/13/13 36

37. ETHMOIDAL POLYPI
MEDICAL TREATMENT
 Case Awaiting Surgery. Incomplete and
aimed at relieving symptoms of polypi
 Post Surgical Definitive Medical Treatment.
TREAT THE CAUSE
03/13/13 37

38. ETHMOIDAL POLYPI
SURGICAL MANAGEMENT
 Asymptomatic Small Polypi
 No active surgical intervention required
 Local steriods have a role.
 Large symptomatic polypi
 Surgical options need to be considered.
03/13/13 38

39. ETHMOIDAL POLYPI
SURGICAL MANAGEMENT
AIMS
 Establish normal nasal airway patency
 Complete removal of polypoidal mucosa,
avoiding damage to neighbouring structures.
03/13/13 39

40. ETHMOIDAL POLYPI
SURGICAL OPTIONS
 Nasal polypectomy
 Nasal polypectomy + intranasal Ethmoidectomy
 Nasal polypectomy + External Ethmoidectomy
 Nasal polypectomy +CWL
 Nasal polypectomy + Transantral ethmoidectomy.
 Endoscopic Sinus Surgery.
03/13/13 40

41. ETHMOIDAL POLYPI
 NASAL POLYPECTOMY - Pernasal Removal
Repeat Nasal polypectomies:
Accepted until this necessitates an unreasonable
amount of hospitalization and mobidity
03/13/13 41

42. ETHMOIDAL POLYPI
ANAESTHESIA:
Local Anaesthesia
 Little bleeding
 Polypi shrink into the ethmoids –High recurrence
rate.
General Anaesthesia
 Cuffed peroral endotracheal tube
 Pharyngeal pack.
 Better Clearance of polypi
 Excellent access to the ethmoids.
 More bleeding.
03/13/13 42

43. ETHMOIDAL POLYPI
POLYPECTOMY
Position: Reversed Trendelenburg position
Procedure: Access is obtained using a Thudicum
or Killian nasal speculum and polypi removed
with:
Removal with a snare
03/13/13 43

44. ETHMOIDAL POLYPI
Removal with Henkel’s Forceps
Removal of remnants with
Citilli’s Forceps
03/13/13 44

45. ETHMOIDAL POLYPI
Ethmoidal Polypi
03/13/13 45

46. ETHMOIDAL POLYPI
POLYPECTOMY + INTRANASAL ETHMOIDECTOMY
In rapidly recurring cases
 Polypectomy
 Citelli’s forceps is used for uncapping
ethmoidal bulla and removing every trace of
oedematous mucosa from the air cells, with
special attention paid to agar nasi cells.
 Operating microscope.
03/13/13 46

47. ETHMOIDAL POLYPI
POLYPECTOMY + EXTERNAL
ETHMOIDECTOMY
Done in advanced cases producing proptosis.
Howarth’s Operation:
Slightly curved incision and concave towards the
medial canthus of eye is made.
03/13/13 47

48. ETHMOIDAL POLYPI
POLYPECTOMY + Cald Well Luc
Nasal polyposis associated with
sinusitis.
 POLYPECTOMY + TRANSANTRAL
ETHMOIDECTOMY
03/13/13 48

49. ETHMOIDAL POLYPI
 ENDOSCOPIC SINUS SURGERY
Indicated:
In recurrent polypi esp. those with allergies
that are difficult to control.
Those in whom previous external
procedures have been performed or
landmarks removed.
Accomplished By:
2.7 mm rigid telescopes with 25 or 30
deg.angled lens.
03/13/13 49

50. ETHMOIDAL POLYPI
 SURGICAL COMPLICATIONS
 Haemorrhage
 Adhesions & Scar formation.
 Anosmia
 Damage to orbital contents
 Exposure of Orbital fat
 Haemorrhage within the orbit
 Injury to EOMs, globe or
 Injury to Optic nerve.
 Injury to the Intracranial Structures
 CSF LEAKAGE
 Damage to brain, membranes
 Intracranial Haemorrhage.
03/13/13 50

51. ETHMOIDAL POLYPI
NOTE:
“To reduce the operative complications,
surgeon must take care to keep his
instruments below the cribriform plate,
medial to the orbital periosteum and
infront of the optic foramen”
03/13/13 51

52. Deptt.
03/13/13 52