Nasal Polyp

Definition:
Non-Neoplastic mass of edematous nasal/sinus submucosa forms when the
oedematous stroma ruptures and herniates through the basement membrane

Theory (not proven):the exact etiology is not known yet

Fibrosis causing lymphatic obstruction
Histopathology:
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marked edema of the connective tissue stroma

Inflammatory mediators such a: s histamine, prostaglandins and leukotrienes.
marked eosinophilic and histiocytic infiltrate
epithelium displays goblet cell hyperplasia
lining mucosa is ciliated columnar but due to atmospheric irritation it may
undergo squamous cell metaplasia

Features:
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Bilateral: simple inflammatory polyp usually are bilateral

soft
gelatinous
initially sessile then Pedunculated
pale
do not bleed on probing / do not shrink with the use of vasoconstrictor
insensitive to pain
Long-standing cases present with broadening of nose and increased intercanthal
distance (frog face deformity)

Features suggestive of malignancy in a polyp:

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2.
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6.

Unilateral
Fleshy
ulcerated
Produce bloody discharge
Cause pain
Cervical metastasis

Potential Complications of Nasal Polyposis:

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2.
3.
4.

Anosmia
Osteitis
Cranial nerve neuropathy
proptosis

Profile:
A. M more than F
B. Age 30-60: if there is nasal polyp in a child suspect
Cystic fibrosis/ Immune Deficiency
C. Occur mainly in non-allergic noninfectious eosinophilic Rhinitis

Site of origin

Always arise from the lateral wall of nose (ethmoid sinus).

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
Staging of the polyp:

Types:

1. Bilateral ethmoidal polyp.

2. Antrochoanal polyp
Ethmoidal polyps:
1. Chronic rhinosinusitis:
Polypi are seen in chronic rhinosinusitis of both allergic and non-allergic
origin. Non-allergic rhinitis with eosinophilia syndrome (NARES) is a
form of chronic rhinitis associated with polyp.
2. Allergic fungal sinusitis:
Almost all cases of fungal sinusitis form nasal polyp.
3. Asthma:
7% of pt with asthma will develop polyp
4. Aspirin intolerance:
36% of the patients with aspirin intolerance may show polypi.
Sampter's triad consists of:
1. nasal polypi
2. asthma
3. aspirin intolerance.
Have more sever symptoms
Higher risk of recurrence post surgery
May benefit from low Salicylate diet (avoid potato,olive oil,wine)
5. Churg-Strauss syndrome:
Consists of asthma, fever, eosinophilia, vasculitis and granuloma.
6. Cystic fibrosis:
20% of patients with CF form polyp. It is due to abnormal mucus.
7. Kartagener's syndrome:
consists of bronchiectasis ,sinusitis, situs inversus and ciliary dyskinesis.
8. Young's syndrome:
It consists of sinopulmonary disease and azoospermia.
9. Nasal mastocytosis:
It is a form of chronic rhinitis in which nasal mucosa is infiltrated with
mast cells but few eosinophils.
Skin tests for allergy and IgE levels are normal.
Diagnosis
Diagnosis can be easily made on clinical examination.
CT scan of paranasal sinuses is essential to exclude the bony erosion and expansion
suggestive of neoplasia

Treatment of simple polyp:

a. medical management:
1. topical corticosteroids
decrease capillary permeability
decrease excretion in response to cholinergic stimulation
suppress cytokine synthesis in eosinophil, basophil and
lymphocytes
inhibit influx of eosinophil and basophil into nasal epithelium and
decrease
production of inflammatory mediators arachidonic acid production
2. oral corticosteroids
used for recurrent conditions
short high burst with rapid taper

b. surgical management:
1. polypectomy
2. FESS
indication:
Failure to response to medical treatment
Require frequent oral steroid
Treatment of antrochoanal polyp
1. Trans-nasal endoscopic removal is tried first
2. in case of recurrence to Caldwell luc surgery
Note the opening of the antrum is wide open