Nasal polyps

1. Nasal Polyps
Dr. Krishna Koirala
MBBS, MS ENT-HNS
Associate professor
MCOMS, Pokhara,
Nepal29-06-2020

2. Definition
• Hypertrophied, edematous, pedunculated mucosa
prolapsing out of the nose or paranasal sinus
• Classification
– Antrochoanal Polyp
– Ethmoidal polyps
• Properties of Nasal Polyps
– Pale /grey in color, glistening, pedunculated, smooth
surface, mobile, insensitive to touch, do not bleed on
probing

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

4. • 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

5. 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

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

7. Clinical presentation
• Common in children and
adolescent age
• Unilateral nasal obstruction
• Unilateral nasal discharge
• Occasionally nasal mass seen
on anterior rhinoscopy
• Mass bulging in the choana /
oropharynx, seen on posterior
rhinoscopy

8. 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

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

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

11. Investigations
• Diagnostic Nasal Endoscopy
• Plain X-ray of nose and PNS (Waters view)
• X-ray nasopharynx lateral view: presence of air
between skull base and polyp
• CT scan nose and PNS (coronal and axial cuts)

12. Diagnostic Nasal Endoscopy

13. Plain X-ray Nose and Paranasal Sinuses C.T. scan of nose and Paranasal Sinuses

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

15. Middle meatal antrostomy

16. Caldwell – Luc Operation

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

18. Ethmoidal Polyps

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

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

21. Associated diseases
• Samter’s triad
– Aspirin intolerance , bronchial asthma, ethmoid polyps
• Cystic fibrosis
• Allergic fungal sinusitis
• Kartagener’s syndrome (ciliary dyskinesia)
− Situs inversus, chronic sinusitis, and bronchiectasis
• Young’s syndrome (hyperviscous mucous)
− Bronchiectasis, chronic rhinosinusitis and infertility

22. 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

23. CT Scan Paranasal Sinus

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

25. Pre - steroid vs. Post- steroid

26. 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

27. F.E.S.S.

28. F.E.S.S. instruments

29. Micro-debrider

30. 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)

31. Bilateral FESS cavities

32. Post FESS CT scan

33. 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