This document discusses nasal polyposis, including its definition, epidemiology, etiology, pathogenesis, pathology, symptoms, signs, diagnosis and treatment. Some key points include: - Nasal polyps are soft, non-cancerous growths that develop in the nasal cavity or sinuses. The two main types are ethmoidal polyps and antrochoanal polyps. - Ethmoidal polyps are more common in adults and often associated with chronic rhinosinusitis, asthma or allergies. Antrochoanal polyps usually present in adolescents and originate in the maxillary sinus. - Symptoms include nasal obstruction, loss of smell, discharge and headaches. Diagnosis involves

1. NASAL POLYPOSIS
Dr Harjitpal Singh
Assistant Professor(ENT),
Dr RKGMC, Hamirpur

2. DEFINITION
• Polyp is Latin word meaning polypus, i.e. many
footed
• The polypus is a projection of hypertrophied
edematous mucous membrane.
• It consists of loose fibroedematous tissue
covered with columnar ciliated epithelium.
• They are divided into two types
1. Bilateral ethmoidal polypi.
2. Antrochoanal polyp.

3. EPIDEMIOLOGY
• The prevalence of nasal polyps (NP) in the
population has been grossly estimated as 1–4%.
• It increases with age, reaching a peak in those
aged 50 years and older.
• Male: Female = 2:1
• Nasal polyposis occurs with a high frequency in
groups of patients having specific airway
diseases
• Genetic inheritance has been proposed as a
possible etiology of NP.

4. NASAL POLYPOSIS

5. NASAL POLYPOSIS

6. NASAL POLYPOSIS

7. ENDOSCOPIC VIEW OF MULTIPLE
POLYPI

8. ENDOSCOPIC VIEW OF MULTIPLE
POLYPI

9. ETHMOIDAL POLYPS
AETIOLOGY
• Aetiology of nasal polyposis is very complex .
• They may arise in:
• Inflammatory conditions of nasal mucosa (rhinosinusitis),
• Disorders of ciliary motility or
• Abnormal composition of nasal mucus (cystic fibrosis).
• Various diseases associated with the formation of nasal polypi
are:
1. Chronic rhinosinusitis.
Polypi are seen in chronic rhinosinusitis of both allergic and
nonallergic origin.
Nonallergic rhinitis with eosinophilia syndrome (NARES) is a
form of chronic rhinitis associated with polypi.

10. ETHMOIDAL POLYPS
2. Asthma. Seven per cent of the patients with asthma of
atopic or non atopic origin show nasal polypi.
3. Aspirin intolerance. Some patients with aspirin
intolerance may show polypi.
Samter's triad consists of nasal polypi, asthma and aspirin
intolerance.
4. Cystic fibrosis. Twenty per cent of patients with cystic
fibrosis form polypi. It is due to abnormal mucus.
5. Allergic fungal sinusitis. Almost all cases of fungal
sinusitis form nasal polypi.

11. ETHMOIDAL POLYPS
6. Kartagener syndrome. This consists of bronchiectasis
sinusitis, situs inversus and ciliary dyskinesis.
7. Young syndrome. It consists of sinopulmonary disease
and azoospermia.
8. Churg–Strauss syndrome. Consists of asthma, fever,
eosinophilia, vasculitis and granuloma.
9. Nasal mastocytosis. It is a form of chronic rhinitis in
which nasal mucosa is infiltrated with mast cells but
few eosinophil's. Skin tests for allergy and IgE levels
are normal.

12. PATHOGENESIS
• Nasal mucosa, particularly in the region of middle
meatus and turbinate, becomes oedematous due to
collection of extracellular fluid causing polypoidal
change.
• Polypi which are sessile in the beginning become
pedunculated due to and excessive sneezing.

13. PATHOGENESIS

14. PATHOLOGY
• In early stages, surface of nasal polypi is covered by
ciliated columnar epithelium like that of normal nasal
mucosa.
• But later it undergoes a metaplastic change to
transitional and squamous type on exposure to
atmospheric irritation.
• Sub mucosa shows large intercellular spaces filled with
serous fluid.
• There is also infiltration with eosinophils and round
cells.

15. SITE OF ORIGIN
• Multiple nasal polypi always arise from the lateral wall
of nose, usually from the middle meatus.
• Common sites are uncinate process, bulla ethmoidalis,
ostia of sinuses, medial surface and edge of middle
turbinate.
• Allergic nasal polypi almost never arise from the
septum or the floor of nose

16. ETHMOIDAL POLYPS
Symptoms:
1. Multiple polypi can occur at any age but are mostly
seen in adults.
2. Nasal stuffiness leading to total nasal obstruction
may be the presenting symptom.
3. Partial or total loss of sense of smell.
4. Headache due to associated sinusitis.
5. Sneezing and watery nasal discharge due to
associated allergy.
6. Mass protruding from the nostril.

17. ETHMOIDAL POLYPS
Signs:
• Polypi appear as smooth, glistening, masses often pale
in colour.
• They may be sessile or pedunculated.
• Insensitive to probing and do not bleed on touch.
• Often they are multiple and bilateral.
• Long-standing cases present with broadening of nose
and increased intercanthal distance.
• Nasal cavity may show purulent discharge due to
associated sinusitis.
• May protrude from the nostril & appear pink, vascular
simulating neoplasm .

18. TELECANTHUS

19. NASAL POLYP PROTRUDING OUT

20. ETHMOIDAL POLYPS
Signs:
• Probing of a solitary ethmoidal polyp may be necessary
to differentiate it from hypertrophy of the turbinate
or cystic middle turbinate.
• Potential complications of nasal polypi includes
anosmia, cranial neuropathies, osteitis and proptosis.
• Staging Polyps can be staged as following according to
their size(Meltzer et al):
Stage I: Limited to the extent of middle turbinate. „
Stage II: Extending beyond the limit of middle
turbinate. „
Stage III: Approaching to inferior turbinate. „
Stage IV: Going up to the floor of nose.

21. ETHMOIDAL POLYPS

22. ETHMOIDAL POLYPS
Diagnosis:
• Diagnosis can be easily made on clinical examination.
• Computed tomography (CT) scan of paranasal sinuses is
essential to exclude the bony erosion and expansion
suggestive of neoplasia .
• Simple nasal polypi may sometimes be associated with
malignancy underneath, especially in people above
40 years and this must be excluded by histological
examination of the suspected tissue.
• CT scan also helps to plan Surgery.

23. ETHMOIDAL POLYPS
Differential Diagnosis:
1. Antrochoanal polypi.
2. Squamous or transitional cell papilloma.
3. Meningocele/meningoencephalocele.
4. Enlarged turbinates.
5. Malignancy of nose/PNS.
6. Nasopharyngeal fibroma.
7. Granulomatous masses.
8. Bleb of mucus plug.

24. ETHMOIDAL POLYPS
Treatment:
CONSERVATIVE
• Early polypoidal changes with oedematous mucosa may
revert to normal with antihistaminics and control of
allergy.
• A short course of steroids may prove useful in case of
people who cannot tolerate antihistaminics and/or
in those with asthma and polypoidal nasal mucosa.
• They may also be used to prevent recurrence after
surgery.
• Contraindications to use of steroids, e.g. hypertension,
peptic ulcer, diabetes, pregnancy and tuberculosis
should be excluded.

25. ETHMOIDAL POLYPS
Treatment:
CONSERVATIVE
Intranasal corticosteroids help in:
• Reducing polyp size
• Increase nasal patency
• Reduction in rhinitis symptoms
• Reduction in loss of sense of smell
• Reduction in recurrence of polyp
• Safety

26. ETHMOIDAL POLYPS
Treatment:
CONSERVATIVE
Side effect of Intra Nasal steroids:
• Excoriation and bleeding
• Beclomethasone dipropionate nasal spray is
associated with the onset of increased
intraocular pressure.
• Delay in growth in prepubescent children has
led to an FDA warning on all INS

27. ETHMOIDAL POLYPS
Treatment:
CONSERVATIVE
• Systemic Corrticosteroids can be given as
tablets and depot-injections.
• Oral prednisolone can be given at
25mg/daily for 10-14 days.
• As a depot-injection corresponds 100mg
prednisolone.
• It may serve as medical polypectomy.

28. ETHMOIDAL POLYPS
Treatment:
CONSERVATIVE
Risks of systemic steroid:
• Insomnia
• Personality change
• Truncal obesity
• Weight gain
• Glaucoma
• Cataracts
• Osteoporosis (requires greater than 3 months usage)
• Peptic ulcer disease
• Increased incidence of infection

29. ETHMOIDAL POLYPS
Treatment:
Surgical
• Polypectomy. One or two polyps which are
pedunculated can be removed with snare. .
• Intranasal ethmoidectomy. When polypi are
multiple and sessile, they require uncapping of
the ethmoidal air cells by intranasal route, a
procedure called intranasal ethmoidectomy.

30. ETHMOIDAL POLYPS
Treatment:
• Extranasal ethmoidectomy. This is indicated when
polypi recur after intranasal procedures and
surgical landmarks are ill-defined due to previous
surgery. Approach is through the medial wall of the
orbit by an external incision, medial to medial
canthus.
• Jansen Horgan’s transantral ethmoidectomy: It is
done in case maxillary antra also needs to be
cleared along with the ethmoids. Ethmoids are
approached through medial wall of maxillary antra.

31. ETHMOIDAL POLYPS
Treatment:
• Endoscopic sinus surgery. These days, ethmoidal
polypi are removed by endoscopic sinus surgery
more popularly called functional endoscopic sinus
surgery (FESS). It is done with various endoscopes
of 0°, 30° and 70° angulation. Polypi can be
removed more accurately when ethmoid cells are
removed, and drainage and ventilation provided to
the other involved sinuses such as maxillary,
sphenoidal or frontal.
• Polypectomy using microdebrider is another addition
in the treatment of nasal polypi

32. USE OF DEBRIDER IN POLYPECTOMY

33. ETHMOIDAL POLYPS
Histologic finding:
NPs are characterised by
• Pseudo stratified ciliated columnar epithalium
• Thickening of epithelial basement membrane
• Stroma of NP is oedematous
• Vascularization is poor and lacks innervation
• Hyperplasia of seromucous gland when comparing with
inferior or middle turbinate.
• Eosinophil's are most commonly found inflammatory cell in NP
(found in 80-90% of polyps)
• Another inflammatory cell, neutrophil, occurs in 7% cases.
This type of NP associates with CF, primary ciliary
dyskinesia or Young syndrome.

34. ANTROCHOANAL POLYP(KILLIAN’S POYP)
• This polyp arises from mucous membrane of the
floor and medial wall of maxillary sinus close to the
accessory ostium.
• Comes out of it and starts growing towards the
choana and nasal cavityum.
• Thus it has three parts.
• Antral, which is a thin stalk.
• Nasal, which is flat from side to side.
• Choanal, which is round and globular.

35. ANTROCHOANAL POLYP

36. ANTROCHOANAL POLYP

37. ANTROCHOANAL POLYP

38. ANTROCHOANAL POLYP
Aetiology:
• Exact cause is unknown.
• Nasal allergy coupled with sinus infection is
incriminated.
• Antrochoanal polypi are commonly seen in
adolescence
• For an unknown reason, ACP predominates in
male population,.
• Usually they are single and unilateral.

39. ANTROCHOANAL POLYP

40. ANTROCHOANAL POLYP
Symptoms:
• Unilateral nasal obstruction is the presenting symptom.
• Obstruction may become bilateral when polyp grows
into the nasopharynx and starts obstructing the
opposite choana.
• Voice may become thick and dull due to hyponasality.
• Nasal discharge, mostly mucoid, may be seen on one or
both sides.
• Conductive deafness due to eustachian tube
dysfunction
• Snoring

41. ANTROCHOANAL POLYP
Signs:
• As the antrochoanal polyp grows posteriorly, it may be
missed on anterior rhinoscopy initially.
• Posterior rhinoscopy may show a smooth, greyish
white, spherical mass in the choana and may be seen
projecting below the soft palate
• When large, a smooth greyish mass covered with nasal
discharge may be seen.
• It is soft and can be moved up and down with a probe.
• A large polyp may protrude from the nostril and show a
pink congested look on its exposed part .

42. ANTROCHOANAL POLYP
Diagnosis:
• X-rays of paranasal sinuses may show opacity of
the involved antrum.
• X-ray (lateral view), soft tissue nasopharynx,
reveals a globular swelling in the postnasal space.
• It is differentiated from angiofibroma by the
presence of a column of air behind the polyp.
• Computed tomograhy (CT) scan PNS, particularly
osteomeatal complex both coronal and axial
sections.

43. ANTROCHOANAL POLYP

44. ANTROCHOANAL POLYP
Treatment:
• An antrochoanal polyp is easily removed by avulsion
either through the nasal or oral route.
• Recurrence is uncommon after complete removal.
• 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 coexistent maxillary sinusitis.
• Polyp is removed and inferior meatal antrostomy is made
for subsequent cleaning and drainage.
• These days, endoscopic sinus surgery has superceded
other modes of polyp removal. Caldwell–Luc operation is
avoided.

45. NASAL POLYPOSIS
Points to remember:
• If a polypus is red and fleshy, friable and has granular
surface, especially in older patients, it suggests
malignancy.
• Simple nasal polyp may masquerade a malignancy
underneath. Hence all polypi should be subjected to
histopathology.
• A simple polyp in a child may be a glioma, an
encephalocele or a meningoencephalocele.
• It should always be aspirated and fluid examined for
CSF. Careless removal of such polyp would result in
CSF rhinorrhoea and meningitis.

46. NASAL POLYPOSIS
• Multiple nasal polypi in children may be
associated with mucoviscidosis.
• Epistaxis and orbital symptoms associated with
a polyp should always arouse the suspicion of
malignancy.
• Samter’s triad: It consists of nasal polyps,
bronchial asthma and aspirin sensitivity

47. DIFFERENCES
ANTROCHOANAL POLYP
1.Common in children.
2.Aetiology is infection.
3. Single mass and trilobed.
4.Unilateral.
5.Site of origin is maxillary
sinus near the ostium.
6. Recurrence is uncommon, if
removed completely
ETHMOIDAL POLYPS
1.Common in adults.
2.Aetiology allergic/multifactorial
3.Multiple, like a bunch of grapes
4.Bilateral
5. Ethmoidal sinuses, uncinate
process, middle turbinate
and middle meatus.
6.Recurrence is common.

48. CAUSES OF UNILATERAL NASAL
OBSTRUCTION
Vestibule
• Furuncle
• Vestibulitis
• Stenosis of nares
• Atresia
• Nasoalveolar cyst
• Papilloma
• Squamous cell carcinoma

49. CAUSES OF UNILATERAL NASAL
OBSTRUCTION
Nasal cavity
• Foreign body
• Deviated nasal septum (DNS)
• Hypertrophic turbinates
• Concha bullosa
• Antrochoanal polyp

50. CAUSES OF UNILATERAL NASAL
OBSTRUCTION
• Synechia
• Rhinolith
• Bleeding polypus of septum
• Benign and malignant tumours of nose and
paranasal sinuses
• Sinusitis, unilateral
• Unilateral choanal atresia

51. CAUSES OF BILATERAL NASAL
OBSTRUCTION
• Vestibule-Bilateral vestibulitis
• Collapsing nasal alae
• Stenosis of nares
• Congenital atresia of nares

52. CAUSES OF BILATERAL NASAL
OBSTRUCTION
Nasal cavity
• Acute rhinitis (viral and bacterial)
• Chronic rhinitis and sinusitis
• Rhinitis medicamentosa
• Allergic rhinitis
• Hypertrophic turbinates
• DNS
• Nasal polypi
• Atrophic rhinitis
• Rhinitis sicca
• Septal haematoma
• Septal abscess
• Bilateral choanal atresia

53. CAUSES OF BILATERAL NASAL
OBSTRUCTION
Nasopharynx
• Adenoid hyperplasia
• Large choanal polyp
• Thornwaldt’s cyst
• Adhesions between soft palate and posterior
pharyngeal wall
• Large benign and malignant tumours

54. THANKS