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college presentation about nasal polp for reviews email at drsana.ak@gmail.com
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WelcomeTo The
Presentation
Of group “A”
“Table of Contents”1st part
“Anatomy of nasal cavity in relationship
with polp” 2nd part
Main topic :nasal polpi3rd part
Case study
PART-1“ANATOMY OF NASAL CAVITY IN
RELATION TO POLYP”
MEDIAL WALL OF NASAL SEPTUM
Skeleton of nasal septum is partly bone and partly cartilage.The bony part is formed by perpendicular plate of the ethmoid bone ,the vomer and small vertical ridges from the superior surfaces of the palatine bone and maxillaAnterior septum is formed by septal vomerine and alar cartilage
LATERAL WALL OF NASAL SEPTUMThe lateral wall of the nasal cavity consist of prominent elevation Superior concha Middle concha Inferior conchaConchas narrow the nasal passage create large surface area foricng inhaled air to pass around and over them which helps in warming n moisting of airChonca are projections of bones from lateral wall of the nasal cavity covered by mucous membrane
The spaces around concha are called meatusesThe inferior meatus lies below and lateral to inferior conchaMiddle meatus lies below and lateral to middle conchaSuperior meatus lies below n lateral to superior conchaSpace above sup erior concha is Sphenoethmoidal recess
Superior ethmoid bone that forms (upper and middle concha)Lower half by vertical process of palatine bone and the body of maxillary boneInerior concha is a separate boneAnteriorly the lateral wall is formed by nasal bone and lateral nasal and alar cartilages
The openings or ostia through which the sinuses communicate with nasal cavity are coved with overl ining concha but after removal of concha can be seen Frontal sinusdrains into infundibulum , a furnel like turnel that opens into the upper end of hiatus semilunaris .
Ethmoidal sinus:Can be divided into 3 partsAnterior part drain ant to hiatus semilunarisMiddle air cells drain into one or more openings in bubble like structure ethmoidal bullaPosterior air cells drain by one or more opening into the superior meatus
Sphenoidal sinus:One or more openings may be presnt drains into sphenoethmoidal sinus
Maxillary sinus drains into middle meatus by an opening in the inferior part of hiatus semilunaris
Nasolacrimal ductOpening at inferior meatus Carries tears from eyes
MUCOUS MEMBRANE
• Cilia and mucus along the inside wall of the nasal cavity trap remove dust and pathogens from the air as it flows through the nasal cavity.• The cilia move the mucus down the nasal cavity to the pharynx, where it can be swallowed.
• The nasal mucous membrane lines the nasal cavities, and is adherent to the periosteum or perichondrium.
The epithelium is divided into :• Respiratory epithelium:(consisting of mucous secreting goblet cells and ciliated cells)• Olfactory epithelium:(bipolar nerve cells the olfactory cells)
Nasal cavitiesThe nasal cavities consist of two extensive chambers and their associated nasal sinuses. The two main chambers are separated by midline wall the nasal septum.The cavities are lined by mucus membrane,contains sebaceous glands hair follicles called VIBRISSAE
PART -2NASAL POLYP
NASAL POLYP
According to wikipedia:“Nasal polyps are polypoidal masses arising mainly from the mucous membranes of the nose and paranasal sinuses. They are overgrowths of the mucosa that frequently accompany allergic rhinitis. They are freely movable and non tender.”
According to authentic medical dictionary “A polyp is the medical term for any overgrowth of tissue from the surface of a body organ. Polyps come in all shapes—round, droplet, and irregular being the most common. Nasal polyps are teardrop-shaped while growing and resemble peeled grapes when they have reached their full size. The condition of nasal polyps is sometimes called nasal polyposis.”
OR
ORText book describes it as:“Nasal polypi are non –neoplastic masses of oedematous nasal or sinous mucosa.”
Classification of polyp according to location1.Bilateral ethmoid polypi
2.antrochoanal polyp1.Bilateral Ethmoidal polypi• Bilateral,multiple in number,usually
small grape like mass• Usually found in adults.• Originate from ethmoidal
sinuses,uncinate process, middle turbinate and middle meatus
• Mostly grow anteriorly may present at nares
• Reoccurence common
ETIOLOGY:• A)chronic rhinosinusitis • B)Asthma (risk factor)• C)Asprin intolerence• D)cystic fibrosis• E)Allergic fungal sinusitus
F)Kartagener’s syndrome
G)young’s syndrome
H)Churg-Strauss syndrome
I)nasal mastocytosis
PATHOGENESIS:
Nasal mucosa ,perticularly in the region of middle meatus and turbinate becomes oedematus due to collection of ECF.
PATHOLOGY:
A) Early :surface of nasal polp I is covered byciliated coloumnar epithelium (normal nasal mucosa)
B) Late : it undergoes metaplastic change to transitional and squamous type on exposure to atmospheric irritation
Submucosa shows large intercellular spaces filled with serous fluid.
Infiltration with eosinophills
SYMPTIOMS:
Nasal stiffness that leads to nasal obstruction
Partial or total loss of smell
Headache due to associated sinusitis
• Sneezing and watery nasal discharge due to associated allergy
• Mass protruding from the nostrils.
SIGNS:
Anterior rhinoscopy : Polpi appears as smooth, glistering,
grape-like mass often pale in colour . May be sessile or penduculated. Insensitive to probing. Do not bleed on touch.
DIAGNOSIS:
1) Clinical examination
2) CT scan for correct analysis of extent and also helps to plan surgery
TREATMENT
• CONGESTIVE TREATMENT “That is designed to avoid radical medical therapeutic measures or operative procedures.”• Control of allergy• Anti histaminics
Short course of steroids (for those who cant tolerate anti histaminics or asthma)
CONTRAINDICATION OF STEROIDS
1. Hypertension
2. peptic ulcer
3. Diabetes
4. Pregnancy
5. Tuberculosis
TREATMENT• SURGERICAL TREATMENT“Surgery is an ancient medical specialty that uses operative manual and instrumental techniques
on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.”
For removal of nasal polyps:
1.Polypectomy
2.Intranasal ethomoidectomy
3.Extranasal ethmoidectomy
4.Transnasal ethmoidectomy
5.Endoscopic sinus surgery
Polypectomy
• 1 or 2 polyps which are pedunculated are removed with snare.
• Multiple and sessile polypi reqire special forceps.
Intranasal ethmoidectomy
• Done for multiple and sessile polypi
• Uncapping of ethmoidal air cells by intranasal route required
External nasal ethmoidectomy
• Done if reoccurance of polyps occur after surgery
• Approach is through the medial wall of the orbitby an external incision ,medial to medial canthus
Transnasal ethmoidectomy
• Done if infection and polypoidal changes are also seen in maxillary antrum
• Caldwell-luc approach is used
Endoscopic sinus surgeryFESS(functional endoscopic sinus
surgery
• Presently used• Polypi can be removed
more accurately when ethmoidal cells are removed, and drainage and ventilation provided to the othe involved sinuses.
• Done with endoscope of 0,30,70 degree
Classification of polyps according to site of origion
• 1. Antrochoanal– a. Single, Unilateral– b. Can originate from maxillary
sinus near ostium– It has 3 parts
Antral which is a thin stalk
Choanal which is round and globular
Nasal which is flat from side to side– c. Usually found in children.– Grows backward to choana may
hang down behind the soft palaet.– Trilobed with antral, nasal and
choana & fill the nasopharynx obstruction both sides
– Reoccurrence uncommon, if removed completely
ETIOLOGY:• Nasal Allergy• Sinus infection
SYMPTOMS:• Unilateral nasal obstruction
May be bilateral if polyp grows in nasopharynx
• Voice may be thick and dull due to hyponasality
• Nasal discharge
SIGNS:
Anterior rhinoscopy:• As it grows posteriorly can be missed at
anterior rhinoscopy• A smooth greyish mass can be seen,it is
soft and can be moved up and down with a prob.
TREATMENT:
Polypectomy,endoscopic removalor caldwell-luc operation
PART-3CASE STUDY
CASE NUMBER 1:A 36 years old patient presented with complaints of nasal obstruction
which was mainly on the left side for last 1 year .It was often associated with left sided facial pain, left side watering of eye,frontal headache and thick, clear nasal discharge. reliving factor include medication and his symptoms were relived upto short extent of time. Anterior rhinoscopy
showed soft, smooth and pale mass in left nasal cavity
• IMPORTANT POINTS IN HISTORY TAKING:
• Nasal obstruction• (onset, duration, progression, unilateral
or bilateral, continuous or intermittent, aggravating and relieving factors)
• Nasal discharge(colour ,frequency, consistency)
• Allergy or asthma, excessive sneezing, watery rhinorrhea, dyspnoea
• Watering from eyes• Nasal surgery
EXTERNAL EXAMINATION:external examination of nose, face and eyes (watery eyes positive)
CLINICAL EXAMINATION:• ANTERIOR RHINOSCOPY : presence of mass in left nasal cavity filling it completely• PROBE TEST : mass was soft, mobile, polypoidal, insensitive to touch, but did not bleed• NASAL PATENCY TEST: absent on left side• POSTERIOR RHINOSCOPY : mass was not visible
INVESTIGATIONS:1)X-rays PNS(water’s view) will show opacification in left maxillary sinus and with soft tissue in left nasal cavity.2) CT Scan show soft tissues arising from left maxillary sinus involving nasal cavity and nasopharynx3)For general anaesthesia e.g blood CP, prothrombin time, activated partial thromboplastin time andUrine D/R :all were in normal limits
DIAGNOSIS:Antrochoanal polp involvinf left maxillary sinus nasal cavity and nasopharynx
TREATMENT :Convensional intranasal polypectomy ORFunctional endoscopic sinus surgery
CASE -2A 28 years old female patient came with complaints of bilateral nasal obstruction ,excessive sneezingAnd watery rhinorrhoea for past 8 to 10 years now nasal obstruction has increased markedly to become almost continuous and she can not breath through her nose. On clinical examination the nose was pale, multiple and bilateral polypi were present in nasal cavities.
• IMPORTANT POINTS IN HISTORY TAKING:
• Nasal obstruction(onset, duration, progression, unilateral or bilateral, continuous or intermittent, aggravating and relieving factors)• Nasal
discharge(colour ,frequency, consistency)
• Allergy or asthma, excessive sneezing, watery rhinorrhea, dyspnoea
• Watering from eyes• Nasal surgery
EXTERNAL EXAMINATION:external examination of nose, face and eyes (no positive findings)
CLINICAL EXAMINATION:• ANTERIOR RHINOSCOPY: It revealed multiple, pale, smooth and shiny grape like polypi
completely filling both nasal cavities• PROBE TEST : mass was soft, mobile, polypoidal, insensitive to touch, but did not bleed• NASAL PATENCY TEST: absent on both side• POSTERIOR RHINOSCOPY : nasopharynx was clear
INVESTIGATIONS:1) CT Scan shows presence of polypi in both nasal cavities with involvement of both ethmoidal air cells and maxillary sinuses 2)For general anaesthesia e.g blood CP, prothrombin time, activated partial thromboplastin time andUrine D/R :all were in normal limits3)Peripheral eosinophil count and total serumIge level both were increasedDIAGNOSIS:Bilateral ethmoidal nasal polypi TREATMENT :Convensional intranasal polypectomy ORFunctional endoscopic sinus surgeryHistopathological examination of polyp
Bilateral ethmoidal
Point to remember:1- if polypus is red flshy, friable and has granular surface, especially in older patients think about
MALIGNENCY
2-All polyps should be subjected to histology
3-A simple polp in achild may be a glioma , an encephalocele or a meningoencephalocele.It should always be aspirated and fluid examination for CSF should be done.careless removal of such Polyp would cause CSF rhinorrhoea and meningitis .
4-Multiple nasal polyps in children may be associated with mucoviscidosis
5-Epistaxis and orbital syndrome associated with polyp should always arouse the suspicion of malignancy
malignancy
DIFFERENTIAL DIAGNOSIS:1- A blob of mucus often looks like polypi but it would disappear on blowing the nose 2-Hypertrophied turbinate is differentiated by its pink appearance and hard fell on probe testing3-Absence or presence of bleeding history e.g angiofibroma has history of profuse recurrent epistaxis.4- Other neoplasm can be differentiated by their fleshy pink appearance, friable nature and their tendency to bleed
Neoplasm epistaxisHypertrophied turbinate
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