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