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Nasal Polyps

  1. Definition;
    Polyps are non-neoplastic masses which are sparsly cellular and are covered by normal epithelium. They are essentially hypertrophied, edematous, prolapsed mucosa.
  2. Features:
    They are soft, fleshy, pale, insensitive to pain and do not shrink with the use of vasoconstrictors
    1. Polyps seen before 2 years of age; Suspect meningococele or encephalocele, hence CT scan should be done.
    2. If seen between 2-10 yr of age: Suspect Cystic Fibrosis        
  3. Etiology:
  4. Theories of pathogenesis:                                     
    1. Bernoulli Phenomenon: Area of constriction → Velocity more & pressure low: Mucosa sucked out
    2. Polysaccharide changes:
      - An alternation in the polysaccharide of the ground substance of the lining mucosa of the turbinates predispose to polypoid changes
    3. Vasomotor imbalance:
    4. Infection
    5. Allergic
  5. Respiratory diseases which predispose the patient to nasal polyps are:
    1. Kartagener’s syndrome:     Primary ciliary dyskinesia
    2. Young Syndrome:
      Hyperviscosis (bronchiectasis, sinusitis, and azoospermia)
  1. Ethmoidal Polyps:
    1. Features:
      1. Age group: Adults (30-60 yrs)
      2. Sex: Males: Females =2:1 to 4:1
      3. Sites of origin:
        - Ethmoid sinuses (Commonest)
        - Others: Below the middle turbinate anteriorly and the above the middle turbinate posteriorly
      4. Are multiple, smooth, glistening, sessile masses, bilateral
      5. Lining: Ciliated columnar later due to trauma → squamous metaplasia
    2. Symptoms:
      1. Nasal blockade, rhinitis, sneezing
      2. Partial / complete loss of smell
      3. Pain over the nasal bridge/ forehead and cheeks
      4. Post nasal drip
      5. Epistaxis
    3. Signs:
      1. Hyponasal voice            
      2. Mouth breathing            
      3. Hypertelorism
    4. Investigation:
      1. X-ray: Paranasal sinuses
      2. ​CT scan
    5. Treatment:
      1. In % the cases: The lesions regress on their own
      2. Medical treatment intranasal corticosteroids for 4-6 weeks (steroid drops/ sprays): effective in 50% of the cases
      3. Surgical:
        1. Simple polypectomy; One/two polyps
        2. Intranasal polypectomy: multiple, sessile polyps (polypectomy and   ethmoidectomy using an endoscope)
        3. External ethmoidectomy : When polyps recur after intranasal procedures (Howarth’s incision given medial to the inner canthus of the eye)
        4.  Transantral ethmoidectomy: When polypoidal changes also in the maxillary        antrum
        5. Jansen- Morgan procedure (Caldwell- Luc in combination with a posterior ethmoidectomy)
        6. FESS (Functional Endoscopic Sinus Surgery) 
  2. Antrochoanal Polyp (Killian’s Polyp)
    1. Site of origin: Maxillary antrum (floor and lateral wall)
    2. Age group: < 40 yrs; children and young adults
    3. Sex: Males> Females
    4. Features: pale, white, translucent, U/L
    5. Parts:
      1. Antral               
      2. Nasal
      3. Choanal
    6. Symptoms:
      1. Nasal blockage (greater on expiration than on inspiration)
      2. Polyp (may not be visible on anterior rhinoscopy)
      3. Nasal Discharge
      4. Hypo nasal voice
    7. Treatment: No medical treatment
      Surgical Management:
      1. Intranasal polypectomy (young patients with incomplete) dentition.
      2. Caldwell-Luc (in adults)
      3. FESS

MCQ. Treatment of choice for antrochoanal polyp in a child is functional endoscopic sinus surgery (FESS) or intranasal polypectomy. Caldwell-Luc operation is avoided.

Table: Differences between antrochoanal and ethmoidal polyp

1. Age Antrochoanal polyp
Common in children
Ethmoidal polyp
Common in adults
2. Aetiology Infection Allergy or multifactorial
3. Number Unilatera Multiple, Bilateral
4. Origin Max. sinus near the ostium Ethmoidal sinuses, uncinate process,
middle turbinate and middle meatus
5. Growth Grows backwards to the choana; may hang   down behind the soft palate Mostly grow anteriorly and may present at the nares
6. Size & shape Trilobed with antral, nasal and choanal parts. Usually small and grape-like masses Choanal part may protrude through the choana & fill the nasopharynx obstructing both sides Polypectomy
7. Recurrence Uncommon, if removed completely Endoscopic surgery or ethmoidectomy
8. Treatment Polypectomy; endoscopic removal or                           
Caldwell-luc operation if recurrent   
(which may be intranasal, extra nasal or


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