Neoplasms of nasal cavity and nasal polypi

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2. Tumours of nasal cavityBenign MalignantSquamous papilloma CarciomaInverted papilloma -Squamous cell CaSchwannoma - AdenocarcinomaMeningioma Malignant melanomaHaemangiomaOlfactory neuroblastomaChondromaHaemangiopericytomaAngiofibroma LymphomaEncephaloceleSolitary plasmacytomaGlioma Various types of sarcomaDermoid 3. BENIGN1. Squamous papilloma : Verrucous lesions similar to skin warts arisefrom the nasal vestibule or lower part of nasalseptum. Single or multiple, pedunculated or sessile. Treatment : local excision with cauterisation ofthe base. Cryosrugery Laser. 4. 2) Inverted papilloma (transitional cell papilloma orRingertz tumour) Microscopically neoplastic epithelium is seen togrow towards underlying stroma rather than on thesurface. 40-70 years male preponderance (5:1). Arises from the lateral wall of nose Always unilateral, red or grey masses Translucent and oedematous marked tendency torecur after surgical removal. Associated with squamous cell carcinoma in 10-15% of patients. Treatment : Wide surgical excision by lateralrhinotomy or medial maxillectomy and en blocethmoidectomy. 5. 3) Pleomorphic adenoma : Arises from the nasal septum. Treatment : Wide surgical excision.4) Schwannoma and meningioma : Treatment : Surgical excision by lateralrhinotomy.Both the above mentioned are raretumours 6. 5) Haemangioma :a)Capillary haemangioma (bleeding polypus ofthe septum : Soft, dark red, pedunculated orsessile tumour arising from anterior part ofnasal septum.Present with recurrent epistaxis and nasalobstruction.Treatment : Local excision with a cuff ofsurrounding mucoperichondrium.b)Cavernous haemangioma : Arises from theturbinates on the lateral wall of nose.Treated by surgical excision with preliminarycryotherapy. 7. Capillary haemangioma (bleedingpolypus of the septum 8. 6)Chondroma :Arise from the ethmoid, nasal cavity or nasal septum. Treatment is surgical excision.7)Intranasal Meningoencephlocele : Herniation of brain tissues and meninges through foramen caecum or cribriform plate. Smooth polyp in the upper part of nose between the septum and middle turbinate. Seen in Infants and young children. Mass increases in size on crying or straining. CT scan is essential to demonstrate a defect in the base of skull. Treatment is frontal craniotomy, severing the stalk form the brain, and repair of dural and bony defect. Intranasal mass is removed as secondary procedure after cranial defect has sealed. 9. 8) Gliomas : Seen in infants and children.9) Nasal dermoid : Widening of upper part of nasal septumwith splaying of nasal bones andhypertelorism. 10. MALIGNANT1) Carcinoma of nasal cavity : Primary carcinoma per se is rare. May be an extension ofmaxillary or ethmoid carcinoma. Squamous cell variety, adenoid cystic carcinoma or anadenocarcinoma. a.Squamous cell carcinoma : From the vestibule, anterior part of nasal septum or the lateral wall of nasal cavity. In men past 50 years of age.i. Vestibular : It arises from the lateral wall of nasal vestibule.ii.Septal : Arises from mucocutaneous junction. Nose-pickers cancer.iii. Lateral wall : Site most commonly involved. Easily extends into ethmoid or maxillary sinuses. Presents as a polypoid mass in the lateral wall of nose.Treatment : Combination of radiotherapya nd surgery. b.Adenocarcinoma and adenoid cystic carcinoma. Arises from the glands of mucous membrane. Involve upper part of the lateral wall of nasal cavity. 11. 2) Malignant melanoma : Seen in persons about 50 years of age. Bothsexes equally affected. Grossly, it presents as aslaty-grey or bluish black polypoid mass. Withinthe nasal cavity, most frequent site is anteriorpart of nasal septum followed by middle andinferior turbinate. Tumour spreads by lymphatics and bloodstream. Treatment : Wide surgical excision.3) Olfactory neuroblastoma : Tumour of olfactory placode. Either sex at anyage group. Cherry red, polypoidal mass in theupper third of the nasal cavity. Lymph node or systemic metastases can occur. Treatment : Surgical excision followed byradiation. 12. 4) Haemangiopericytoma : Tumour of vascular origin. Arises from thepericyte. Age group of 60-70 presents withepistaxis. Treatment : Wide surgical excision.5) Lymphoma : Rarely a non-Hodgkin lymphoma presents onthe septum.6) Plasmacytoma : Males over 40 years. Treatment : Radiotherapy followed three monthslater by surgery if total regression does notoccur.7) Sarcomas 13. NASAL POLYPI 14. Nasal polypi are non neopalstic masses of oedematous nasal or sinus mucosa.Two main varietiesa) Bilateral ethmoidal polypib) Antrochoanal polyp. 15. Bilateral ethmoidal polypiEtiology : Arise in inflammatory conditions of nasal mucosa (Rhinosinusitis), disorders of ciliary motility or abnormal composition of nasal mucus (cystic fibrosis).Diseases associated with nasal polypii. Chronic rhinosinusitis : Both allergic and non- allergic origin.ii.Asthmaiii. Aspirin intolerance : Sampters triad-nasal polypi, asthma and aspirine intolerance. 16. Bilateral ethmoidal polypi 17. iv. Cystic fibrosis : Due to abnormal mucus.v.Allergic fungal Kartageners syndrome : Bronchiectasissinusitis, situs inversus and ciliary dyskinesis.vii.Youngs syndrome : Sinopulmonary diseaseand azoospermia.viii. Churg-Strauss syndrome : Asthma, fever,eosinophilia, vasculitis and granuloma.ix. Nasal mastocytosis : Chronic rhinitis in whichnasal mucosa is infiltrated with mast cells. 18. Pathogenesis : Nasal mucosa, particularly in theregion of middle meatus and turbinate becomesoedematous due to collection of extracellular fluidcausing polypoidal change. Polypi, sessile in the beginning becomepedunculated due to gravity and the excessivesneezing. Pathology : Surface of nasal polypi is covered byciliated columnar epihtelium. Later it undergoes a metaplastic change totransitional and squamous type on exposure toatmospheric irritation. Submucosa: large intercellular spaces filled withserous fluid. Infiltration with esoinophils and roundcells.Site of origin : Lateral wall of nose, usually from the middlemeatus. 19. HIGH PSEUDOSTRATIFIED CILIARY EPITHELIUM WITHMANY GOBLET CELLS 20. MIGRATION OF EOSINOPHILS (ARROWS) THROUGH THE EPITHELIUMOF A NASAL POLYP. THE EOSINOPHILS ARE CONCENTRATEDMAINLY BENEATH THE BASAL MEMBRANE 21. Symptoms : Signs : Mostly seen in adults Anterior rhinoscopy Nasal suffiness, total polypi appear as smooth,nasal obstruction. glistering, grape-like masses often pale in Loss of sense of smell colour. Headache, sinusitis. Sessile or pedunculated Sneezing and watery Insensitive to probing, donasal discharge due to not bleed on touch.associated allergy. Multiple and bilateral. Mass protruding from the Broadening of nose andnostril. increased intercanthal distance. Nasal cavity may show purulent discharge due to associated sinusitis. 22. Diagnosis : Clinical examination CT scan of paranasal sinuses to excludethe bony erosion and expansionsuggestive of neoplasia. Histological examination of the tissue. 23. TreatmentConservative :1.Antihistaminics and control of allergy.2.A short course of steroids may also be used to preventrecurrence after surgery.Surgical :1.Polypectomy using a Snare, Multiple and sessile polypirequire special forceps.2.Intranasal ethmoidectomy when polypi are multiple andsessile. Uncapping of the ethmoidal air cells by intranasalroute.3.Extranasal ethmoidectomy when polypi recur afterintranasal procedures. Approach is through the medial wallof the orbit by an external incision, medial to medialcanthus.4.Transantral ethmoidectomy This is indicated wheninfection and polypoidal changes are also seen in themaxillary antrum.5.Endoscopic sinus surgery FESS done with variuosendoscopes of 0, 30 and 70 angulation. 24. Antrochoanal polyp ( KilliansPolyp) This polyp arises form the mucosa ofmaxillary antrum near its accessoryostium, comes out of it and grows in thechoana and nasal cavity. Three parts.i)Antral: Which is a thin stalk.ii) Choanal : Which is round and globulariii)Nasal : Which is flat from side to side. 25. Aetiology : Unknown Nasal allergy coupled with sinus infection. Seen in children and young adults. Usually they are single and unilateral.Symptoms : Unilateral nasal obstruction. Obstruction, bilateral when polyp growsinto the nasopharynx. Voice thick and dull due to hyponasality. Nasal discharge, mostly mucoid. 26. Signs : Anterior rhinoscopy: A smooth greyishmass covered with nasal discharge. Softand can be moved up and down. A largepolyp may protrude from the nostril andshow a pink congested look on itsexposed part. Posterior rhinoscopy: globular mass fillingchoana or the nasopharynx. May hangdown behind the soft palate and present inthe oropharynx. 27. Antrochoanal polyp 28. X-rays of paranasal sinuses. Opacity of the involved antrum. X-ray, (lateral view) soft tissue nasopharynx aglobular swelling in the postnasal space.Treatment : Removed by avulsion either through the nasal ororal route. In cases which do recur, Caldwell-Luc operationmay be required to remove the polyp completelyfrom the site of its origin and to deal with co-existingmaxillary sinusitis. Endoscopic sinus surgery. 29. Differential diagnosis :1. A blob of mucus2. Hypertrophied middle turbinate is differentiated by its pink appearance and hard feel of bone on probe testing.3. Angiofibroma has history of profuse recurrent epistaxis. Firm in consistency easily bleeds on probing.4. Other neoplasms may be differentiated by their fleshy pink appearance, friable nature and their tendency to bleed. 30. Differences between antrochoanal andethmoidal polypiAntrochoanal polypi Ethmoidal polypiAgeCommon in childrenCommon in adultsAetiologyInfection Allergy or multifactorialNumber SolitaryMultipleLaterality UnilateralBilateralOrigin Max.sinus near the ostium Ethmoidal sinuses, uncinate process, middle turbiante and middle meatus.Growth Grows backwards to theMostly grow anterior