Sino-Nasal Polyposis

By
Dr. Khurshid Anwar
Associate Professor ENT Department, KGMC/MTI HMC,
Peshawar
Learning Objectives

After the presentation, the students of 4th year MBBS will be able
to:
1. Define sino-nasal polyposis and know its various types.
2. Identify the aetiological factors for development of sino-nasal
polyposis.
3. Differentiate between A/C and ethmoid polypi.
4. Identify the clinical features of sino-nasal polyposis.
5. Diagnose sinonasal polyposis
6. Choose an appropriate modality of treatment for sino-nasal
polyposis or its complications.
 Sinonasal Polyposis

 Definitions

 Nasal Polyp is a non-neoplastic mass of oedematous &

pedunculated nasal or sinus mucosa.
 Sinonasal polyposis; The presence of nasal polyps in
the nose and paranasal sinuses.
Types of Nasal Polypi

 1. Ethmoidal polypi

 2. Antrochoanal polypus
 Aetiology; Ethmoidal polypi

These may arise in;

A. Inflammarory conditions of nasal mucosa;
1. Chronic rhinosinusitis; both allergic & non-allergic types
2. Non-allergic rhinitis with eosinophilia syndrome (NARES)
3. Nasal mastocytosis; Nasal mucosa is infiltrated with mast cells but
few eosinophils
B. Allergic;
4. Allergic rhinitis
5. Asthma; polyps in 7% of the patients with atopic or non-atopic
asthma.
6. Allergic Fungal Rhinosinusitis: Polyps present in almost all.
7. Samter Triad; Nasal polypi, asthma and aspirin intolerance. Polypi
are present in 36%.
 Aetiology; Ethmoidal polypi

C. Disorders of ciliary motility;

Kartegener’s syndrome; (Syn: Immotile cilia syndrome, primary
ciliary dyskinesia), autosomal recessive.
Bronchiectasis, chronic sinusitis, situs inversus
Young's syndrome; Sinusitis, bronchiectasis & azoospermia.
D. Abnormal composition of nasal mucus
Cystic fibrosis: Defective chloride transport across the cell
membrane, 20% of patients with cystic fibrosis present with
polypi.
 Pathogenesis

 Persistent inflammation  Lymphocytic & eosinopholic

infiltrationcollection of extracellular fluid  oedema of
nasal/sinus mucosa increased oedema Polypoidal change.
 Sessile polypi become pedunculated due to gravity and
excessive sneezing.
 Middle meatus is the region particularly involved.
 Color changes; Chronicity may lead to squamous metaplasia of
surface epithelium.
 Sites of Origin
Multiple nasal polypi arise from;
 The middle meatus in the lateral wall of nose.
Common sites;
 Uncinate process
 Bulla ethmoidalis
 Ostia of sinuses
 Middle turbinate;
Medial surface and edge
 Maxillary sinus
A/C polyp
 Clinical Features of Ethmoidal polypi; Symp

1. Common in adults.
2. Nasal discharge
3. Nasal obstruction.
4. Hyposmia or anosmia.
5. Headache due to associated sinusitis.
6. Sneezing and watery nasal discharge due to associated allergy.
7. Mass protruding from the nostril.
 Clinical Features of Ethmoidal polypi; Signs

1. Smooth, glistening, grape-like masses, pale in colour.

2. Sessile or pedunculated, insensitive to probing and do not bleed
on touch.
3. Multiple and bilateral.
4. Nasal discharge.
Clinical Features of Ethmoidal polypi; Signs

5. Long-standing cases present with broadening of nose and increased

intercanthal distance.
6. A polyp may protrude from the nostril.

7. Probing essential to differentiate it from hypertrophic turbinate.

Diagnosis of Ethmoidal Polypi

 History
1. Allergic Rhinitis
2. Chronic rhinitis
 Clinical examination
Nasendoscopy
 Lab Tests
1. Nasal smear examination
2. Skin prick test
3. Radioallergosorbent test (RAST)
4. CT scan/MRI of paranasal sinuses
Treatment of Ethmoidal Polypi

Conservative;
a. Avoidance of allergen
b. Antibiotics to treat concomitant sinusitis
c. Early polyps may revert to normal with antihistaminics &
INCS.
d. Systemic corticosteroids;
1. It is termed as medical polypectomy.
2. Used to prevent recurrence after surgery.
 Treatment of Ethmoidal Polypi

Surgical Treatment;
 Standard ;
Functional endoscopic sinus surgery (FESS)
 Other procedures;
1. Snare removal (very old technique).
2. Intranasal ethmoidectomy.
3. External ethmoidectomy. When the intranasal technique has
failed or no surgical landmarks.
4. 4. Transantral ethmoidectomy; When infection and polypoidal
changes are also seen in the maxillary antrum.
Antrochoanal Polyp; Features

Aetiology;
 Exact cause unknown.
 Nasal allergy & sinus infection.
 Common in children and young adults.
 Usually single and unilateral.
 Site of Origin of Antrochoanal Polyp

Origin;
 Arises from the mucosa of maxillary sinus near its accessory ostium,
comes out of it and grows posteriorly in the choana and anteriorly
into nasal cavity.

 It has three parts

1. (a) Antral: which is a thin stalk.
2. (b) Choanal: which is round and globular.
3. (c) Nasal: which is flat from side to side.
 Clinical features of A/C Polyp

Symptoms;
1. Nasal obstruction; Unilateral and later bilateral.
2. Hyponasal Voice.
3. Nasal discharge.
Signs;
4. Large, smooth grayish mass covered with nasal discharge.
5. Feels soft and can be moved up and down with a probe.
6. A large polyp may protrude from the nostril.
7. Posterior rhinoscopy may reveal a globular mass filling the
choana or the nasopharynx.
 Diagnosis and Treatment
 History,Clincal examination & Investigations
 X-Ray PNS OM View/X-Ray postnasal space lateral view
 Nasendoscopy
 CT/ MR imaging
 Treatment;
Conservative;
 Antibiotics, antihistaminics & vasoconstrictors, INCS
Surgical;
 FESS. Standard procedure
 Removal through the nasal or oral route
 Cald–well luc operation for recurrence
Differential Diagnosis

 Hypertrophied turbinate; probe testing.

 A blob of mucus; It would disappear on nose blowing.
 Angiofibroma; History of profuse recurrent epistaxis, firm in
consistency and bleeds on probing.
 Glioma/meinigocoele/meningoencephalocoele
 Other neoplasms; Fleshy pink appearance, friable nature and
tendency to bleed favour malignancies.
 Fungal Rhinosinusitis
Endoscopic removal of all forms of sinonasal masses is
the most modern, effective and acceptable technique.
THANKS