03/13/13   1
ALLERGIC NASAL POLYPI    Dr. Muhammad Farooq Khan                     Medical Officer           Department of Oto-Rhino-La...
ALLERGIC NASAL POLYPICASE HISTORY  Patient: Mohammad Javed  Age: 49 years male  Occupation: Frash, CDA  Presenting Complai...
CASE HISTORY     GPE     Middle aged smoker of average height, Hypertensive,     Pulse- 92bpm, regular     B.P. 160/.100mm...
CASE HISTORY    E.N.T EXAMINATION           EARS:   Both ears normal                   Ear Drums- intact bil.             ...
CASE HISTORY    NOSE:     Broadening of nose and Flaring of alar nasai,      No tenderness over the maxillary and ethmoid...
CASE HISTORYPAST HISTORY   H/O allergic rhinitis for last 10 years.   H/O mucus polyps for 6 years.   1st polypectomy d...
CASE HISTORY   LABORATORY FINDINGS          Blood CP:                 Hb%   15.5g/dl                 TLC   10500/cmm     ...
CASE HISTORYX-Ray PNS (O.M.view)-Hazy maxillary & ethmoidalsinuses, with soft tissueshadows in nasal cavitiesbut no bony e...
MANAGEMENTMEDICAL          Control of Hypertension and Asthma          Fitness for G/ASURGICAL          Polypectomy on ...
CASE HISTORYFOLLOW UP   Weekly for 2 weeks:    1st Follow up- Air way clear, smell and breathing    improved.   Fortnigh...
ALLERGIC NASAL POLYPIPOLYP  A pedunculated portion of edematous mucosa       of the nose or Para-nasal sinuses.           ...
ALLERGIC NASAL POLYPICLASSIFICATION              Simple                         Allergic                         Vasomo...
ALLERGIC NASAL POLYPIAGE INCIDENCEEthmoidal- At any age.Antrochoanal- Usually Children & young adults.03/13/13            ...
ALLERGIC NASAL POLYPI     ANATOMY     Polyp usually arise from lateral wall of the middle meatus,      middle turbinate o...
ALLERGIC NASAL POLYPI                   SITES OF ORIGIN    Multiple Ethmoidal polypi     Antrochoanal polyp               ...
ALLERGIC NASAL POLYPI HISTOLOGY   Microscopically covered with ciliated columnar    epithelium with large amount of fluid...
ALLERGIC NASAL POLYPI PATHOPHYSIOLOG YHypersensitivity reaction; Type-I IgE mediated.      Release of Histamine from mast...
ALLERGIC NASAL POLYPIETIOLOGYFive theories:    Bernouli Phenomenon- (Gravitational Pull)    Polysacharide Changes- (Alte...
ALLERGIC NASAL POLYPI    ETIOLOGY    Allergy: Allergy is implicated because of histologic     picture of eosinophilia and...
ALLERGIC NASAL POLYPI SYMPTOMS   Nasal Obstruction   Thin profuse Nasal discharge   Anosmia   Headache/ loss of concen...
SIGNS:NASAL POLYPIALLERGICINTRANASAL SIGNSAnterior Rhinoscopy:  multiple grape like swellings(Polyps)   hanging from the ...
ALLERGIC NASAL POLYPI    SIGNS   Frog-nose, due to broadening of nasal bridge,   Typical faces of chronic mouth breather...
ALLERGIC NASAL POLYPICOMPLICATIONS     Nasal blockade     Repeated infections        Infective rhinnitis        Infect...
ALLERGIC NASAL POLYPI     LABORATORY FINDINGS    Periphiral Eosinophilia:3- 10 % eosinophils in the     nasal secretion i...
ALLERGIC NASAL POLYPIDIFFERENTIAL DIAGNOSIS03/13/13                 26(Contd.)
ALLERGIC NASAL POLYPI   D/D       Ethmoidal Polyp   Antrochoanal Polyp03/13/13                       27(Contd.)
ALLERGIC NASAL POLYPI  D/D Inverted Papilloma  Fleshy cauliflower like     mass with single attachment in the nose    comm...
ALLERGIC NASAL POLYPI      D/D     Sometimes need to be differentiated from     “Naso-Pharyngeal Fibroma”:              T...
ALLERGIC NASAL POLYPIDIAGNOSIS              Through clinical examination              Radiography of the sinuses        ...
TREATMENT:ALLERGIC NASAL POLYPIMANAGEMENT                Conservative                Surgical03/13/13                   ...
ALLERGIC NASAL POLYPICONSERVATIVE MANAGEMENT   Avoidance of allergens/Irritants.   Environmental control.   Immunothera...
TREATMENT:ALLERGIC NASAL POLYPISURGICAL MANAGEMENT   Removal of polypi under local or general    anesthesia with non-cutt...
ETHMOIDAL POLYPI         SUMMARY   SURGICAL MANAGEMENT  SURGICAL COMPLICATIONS           Dr. Ghulam Saqulain              ...
ETHMOIDAL POLYPISUMMARY     Bil. Nasal polyps usually originate from ethmoid      sinuses and are sometimes associated wi...
ETHMOIDAL POLYPISUMMARY   Aggressive, invasive and recurrent polyp formation    could not possibly have only allergic bas...
ETHMOIDAL POLYPIMEDICAL TREATMENT   Case Awaiting Surgery. Incomplete and    aimed at relieving symptoms of polypi      ...
ETHMOIDAL POLYPI   SURGICAL MANAGEMENT      Asymptomatic Small Polypi          No active surgical intervention required ...
ETHMOIDAL POLYPISURGICAL MANAGEMENT  AIMS   Establish normal nasal airway patency   Complete removal of polypoidal mucos...
ETHMOIDAL POLYPISURGICAL OPTIONS    Nasal polypectomy    Nasal polypectomy + intranasal Ethmoidectomy    Nasal polypect...
ETHMOIDAL POLYPI   NASAL POLYPECTOMY - Pernasal RemovalRepeat Nasal polypectomies:    Accepted until this necessitates an...
ETHMOIDAL POLYPIANAESTHESIA:Local Anaesthesia  Little bleeding  Polypi shrink into the ethmoids –High recurrence   rate....
ETHMOIDAL POLYPIPOLYPECTOMYPosition: Reversed Trendelenburg positionProcedure: Access is obtained using a Thudicum  or Kil...
ETHMOIDAL POLYPIRemoval with Henkel’s Forceps  Removal of remnants with      Citilli’s Forceps03/13/13                    ...
ETHMOIDAL POLYPI           Ethmoidal Polypi03/13/13                      45
ETHMOIDAL POLYPIPOLYPECTOMY + INTRANASAL ETHMOIDECTOMY  In rapidly recurring cases   Polypectomy   Citelli’s forceps is ...
ETHMOIDAL POLYPIPOLYPECTOMY + EXTERNAL  ETHMOIDECTOMYDone in advanced cases producing proptosis.   Howarth’s Operation:   ...
ETHMOIDAL POLYPIPOLYPECTOMY + Cald Well Luc    Nasal polyposis associated with    sinusitis.   POLYPECTOMY + TRANSANTRAL ...
ETHMOIDAL POLYPI   ENDOSCOPIC SINUS SURGERYIndicated:    In recurrent polypi esp. those with allergies       that are dif...
ETHMOIDAL POLYPI   SURGICAL COMPLICATIONS       Haemorrhage       Adhesions & Scar formation.       Anosmia       Dam...
ETHMOIDAL POLYPINOTE:   “To reduce the operative complications,   surgeon must take care to keep his   instruments below t...
Deptt.03/13/13            52
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Allergic polypi

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Allergic polypi

  1. 1. 03/13/13 1
  2. 2. ALLERGIC NASAL POLYPI Dr. Muhammad Farooq Khan Medical Officer Department of Oto-Rhino-Laryngology Capital Hospital, Islamabad03/13/13 2
  3. 3. ALLERGIC NASAL POLYPICASE 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 years03/13/13 3
  4. 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. 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. 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. 7. CASE HISTORYPAST 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. 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)- WNL03/13/13 8
  9. 9. CASE HISTORYX-Ray PNS (O.M.view)-Hazy maxillary & ethmoidalsinuses, with soft tissueshadows in nasal cavitiesbut no bony erosions. 03/13/13 9
  10. 10. MANAGEMENTMEDICAL  Control of Hypertension and Asthma  Fitness for G/ASURGICAL  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. 11. CASE HISTORYFOLLOW 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. 12. ALLERGIC NASAL POLYPIPOLYP A pedunculated portion of edematous mucosa of the nose or Para-nasal sinuses. Also termed as Mucous Polyp/ Ethmoidal Polyps03/13/13 12
  13. 13. ALLERGIC NASAL POLYPICLASSIFICATION  Simple  Allergic  Vasomotor  Inflamatory  Mixed infective- allergic  Neoplastic  Benign – Angiofibroma, Pappiloma  Malignant – Sarcoma, Melanoma03/13/13 13
  14. 14. ALLERGIC NASAL POLYPIAGE INCIDENCEEthmoidal- At any age.Antrochoanal- Usually Children & young adults.03/13/13 14
  15. 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. 16. ALLERGIC NASAL POLYPI SITES OF ORIGIN Multiple Ethmoidal polypi Antrochoanal polyp filling the nasopharynx03/13/13 16
  17. 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. 18. ALLERGIC NASAL POLYPI PATHOPHYSIOLOG YHypersensitivity 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. 19. ALLERGIC NASAL POLYPIETIOLOGYFive 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 slide03/13/13 19 Contd.
  20. 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. 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 blockage03/13/13 21
  22. 22. SIGNS:NASAL POLYPIALLERGICINTRANASAL SIGNSAnterior 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. 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. 24. ALLERGIC NASAL POLYPICOMPLICATIONS  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. 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. 26. ALLERGIC NASAL POLYPIDIFFERENTIAL DIAGNOSIS03/13/13 26(Contd.)
  27. 27. ALLERGIC NASAL POLYPI D/D Ethmoidal Polyp Antrochoanal Polyp03/13/13 27(Contd.)
  28. 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. 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. 30. ALLERGIC NASAL POLYPIDIAGNOSIS  Through clinical examination  Radiography of the sinuses  Biopsy  C.T/ M.R.I Scan03/13/13 30
  31. 31. TREATMENT:ALLERGIC NASAL POLYPIMANAGEMENT  Conservative  Surgical03/13/13 31
  32. 32. ALLERGIC NASAL POLYPICONSERVATIVE 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. 33. TREATMENT:ALLERGIC NASAL POLYPISURGICAL 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. 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 ISLAMABAD03/13/13 34
  35. 35. ETHMOIDAL POLYPISUMMARY  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. 36. ETHMOIDAL POLYPISUMMARY 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. 37. ETHMOIDAL POLYPIMEDICAL TREATMENT  Case Awaiting Surgery. Incomplete and aimed at relieving symptoms of polypi  Post Surgical Definitive Medical Treatment. TREAT THE CAUSE03/13/13 37
  38. 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. 39. ETHMOIDAL POLYPISURGICAL MANAGEMENT AIMS  Establish normal nasal airway patency  Complete removal of polypoidal mucosa, avoiding damage to neighbouring structures.03/13/13 39
  40. 40. ETHMOIDAL POLYPISURGICAL 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. 41. ETHMOIDAL POLYPI NASAL POLYPECTOMY - Pernasal RemovalRepeat Nasal polypectomies: Accepted until this necessitates an unreasonable amount of hospitalization and mobidity03/13/13 41
  42. 42. ETHMOIDAL POLYPIANAESTHESIA: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. 43. ETHMOIDAL POLYPIPOLYPECTOMYPosition: Reversed Trendelenburg positionProcedure: Access is obtained using a Thudicum or Killian nasal speculum and polypi removed with: Removal with a snare03/13/13 43
  44. 44. ETHMOIDAL POLYPIRemoval with Henkel’s Forceps Removal of remnants with Citilli’s Forceps03/13/13 44
  45. 45. ETHMOIDAL POLYPI Ethmoidal Polypi03/13/13 45
  46. 46. ETHMOIDAL POLYPIPOLYPECTOMY + 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. 47. ETHMOIDAL POLYPIPOLYPECTOMY + EXTERNAL ETHMOIDECTOMYDone 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. 48. ETHMOIDAL POLYPIPOLYPECTOMY + Cald Well Luc Nasal polyposis associated with sinusitis. POLYPECTOMY + TRANSANTRAL ETHMOIDECTOMY03/13/13 48
  49. 49. ETHMOIDAL POLYPI ENDOSCOPIC SINUS SURGERYIndicated: 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. 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. 51. ETHMOIDAL POLYPINOTE: “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. 52. Deptt.03/13/13 52

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