Nasal polyps....


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Nasal Polyps:

Nasal Polyps Owais Mattoo Postgraduate Student Deptt. Of ENT & HNS GMC , SGR 1


Introduction Pale grey smooth surfaced benign lesions that emanate from portion of nasal mucosa or paranasal sinuses Benign polyps Other benign or malignant tumours 2

Nasal polyps:

Nasal polyps Endoscopic view of left nasal cavity. Polyp protruding from uncinate process 3

Nasal polyps:

Nasal polyps Left anterior nasal cavity showing an antro-choanal polyp. Sucker is pushing inferior turbinate to one side. 4

Aetiology :

Aetiology Unknown Chronic rhinosinusitis. Asthma and aspirin intolerance. Allergic fungal sinusitis. Cystic fibrosis Kartagener’s syndrome , Churg-Strauss syndrome Nasal mastocytosis 5

Chronic Rhinosinusitis:

Chronic Rhinosinusitis Allergic Non-allergic NARES. 6


Pathophysiology 20-50% have asthma 8-26% have aspirin intolerance 50% have alcohol intolerance 7


Pathophysiology Non allergic conditions Cystic Fibrosis 6-48% have polyps Kartagener’s syndrome Young syndrome Churg-Strauss syndrome 8

Cystic Fibrosis:

Cystic Fibrosis Also known as Mucoviscidosis. A chronic, progressive, and frequently fatal genetic disease of the body’s mucus glands. Affects the respiratory and digestive systems in children and young adults. An average person has a lifespan of 40 years with the right treatment. 9


Causation Cystic Fibrosis is caused by a defective CFTR gene which codes for a Na+ and Cl- transporter found on the surface of epithelial cells of lungs and other organs. As many as 1300 mutations in the CFTR gene have been observed worldwide. The severity of the disease is directly related to the characteristic effects of the particular mutations that have been inherited by the individual sufferer. 10

CF Lung:

CF Lung Chloride does not get into airway; more sodium leaves; mucus is thick 11

The Sweat Test:

The Sweat Test “Gold Standard” for testing over 40 years - painless - inexpensive - gives definite answers 12

The Sweat Test:

The Sweat Test Cl - ≥ 60 mEq/L 40-60 mEq/L ? 13

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Kartagener’s syndrome. Young syndrome. Churg-Strauss syndrome. Mastocytosis. 14


Pathogenesis Polypoidal degeneration Mucosa initially covered with respiratory epithelium Changes in course of time to squamous or transitional(exposure to atmospheric irritation) Submucosa shows eosinophils , round cells and serous fluid. 15

Histological findings:

Histological findings Pseudostratified ciliated columnar epithelium Thickened epithelial basement membrane Oedematous stroma 16

Histological findings:

Histological findings Eosinophils in 80-90% of polyps Eosinic granules - LTs, ECP, PAF, peroxidases, etc Epithelial damage, ciliostasis LT-A4 mucosal swelling and hyperresponsiveness Increased lifespan (12 days vs 3 days) ?due to IL5 blockage of Fas receptors 17

Histological findings:

Histological findings Neutrophils in 7% of polyps CF, primary ciliary dyskinesia, Youngs syndrome Poor response to standard treatment Non IgE mediated degranulation 18

Histological findings:

Histological findings Histamine - level in polyps 10-1000 times higher than serum levels Immunoglobulins normally unaffected. IgA2 and IgE higher in middle and inferior turbinate polyps 19


Frequency Adults 1-4% Children 0.1% All races and social classes M/F 2-4:1 in adults Increasing incidence with age 20

Types of Nasal Polyps:

Types of Nasal Polyps Ethmoidal polyposis Age Aetiology Number Laterality Growth Size and shape Recurrence and treatment options. Antrochoanal polyp 21

Nasal polypectomy:

Nasal polypectomy Nasal polyp. Stalk attached to medial maxillary wall 22

Sites of origin :

Sites of origin Uncinate process Bulla ethmoidalis Ostia of sinuses Medial surface and edge of middle turbinate. Accessory ostia of maxillary sinus Polyps almost never arise from floor or septum of nose. 23


Pathophysiology Various theories Allergy. Infection. Combination of above. Bernoulli’s phenomenon. Polysaccharide theory. Cystic Fibrosis association. Vasomotor theory. Polypeptide theory. Aspirin sensitivity. 24


Presentation Asymptomatic Airway obstruction Postnasal drip Dull headaches Snoring Rhinorhoea Hyposmia / Anosmia Epistaxis (often other lesion) Obstructive sleep apnoea Hyponasal speech Broadening of nose 25


Differential Encephalocoeles Gliomas Dermoid tumours Haemangiomas Papillomas / transitional cell papillomas Nasopharyngeal angiofibromas Rhabdomyosarcomas Lymphomas Neuroblastomas Sarcomas Chordomas Nasopharyngeal carcinomas 26


Differential Intranasal glioma in a 5 year old 27


Differential Nasal papilloma arising from septum 28


Differential Rhabdomyosarcoma affecting posterior ethomids, orbit, left middle fossa and skull base of cavernous sinuses 29

Management :

Management Clinical Examination. Investigations Treatment options. Referral to Pulmonologist , endocrinologist , General Physician forms an important part of the management. 30

Clinical Examination:

Clinical Examination External Examination. Broadening of nose(frog nose appearance) Woak’s syndrome(nasal polyps in childhood , broad nose and aplasiaof frontal sinus) Increased intercanthal distance Mass seem externally Anterior Rhinoscopy. Pale grey masses Reddish masses Pulsatile mass Criteria for sizing of nasal polyps coupled with CT scan-class I , II , III 31

Stages of killian’s polyp:

Stages of killian’s polyp Grade I Within antrum Grade II Out in the nasal cavity Grade III In the nasopharynx 32

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Oral Examination. Posterior rhinoscopy. Otologic examination. Examination of Olfactory nerve. Nasal Endoscopy. 33


Investigations CT nose and paranasal sinuses. Xrays. Nasal swab for fungal culture Nasal smear. Skin allergy tests Allergen specific IgE levels (RAST) Sweat Chloride tests.] Blood sugar tests. Chromosomal tests. 34

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Nasal smear Microbiology Eosinophils (allergic component) Neutrophils (chronic sinusitis) 35

Computed Tomography:

Computed Tomography Advantages: Information of OMC. Information about orbit , lamina payraceae Turbinates Fovea ethmoidalis Angle between medial orbital wall and fovea in 88% is 55 0 , in 10% is 45-55 0 , in 2% is less than 45 0 . Disadvantages: Expensive Radiation exposure 36

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The extent of study is from anterior wall of frontal sinus to posterior wall of sphenoid sinus. And from hard palate to roof of frontal sinus. 37

Coronal cuts:

Coronal cuts Displays structures in plane closest to the surgeon (Surgeon’s view). Anatomical variations in ostiomeatal complex can be well delianated. Relation of cribriform plate , fovea ethmoidalis , lamina papyraceae , optic bulge , ICA bulge. 38

Axial cuts:

Axial cuts Anterior and posterior walls of frontal sinus Relationship between posterior ethmoids and sphenoid. Relation of optic nerve to posterior ethmoids or sphenoids. Pterygopalatine fossa Sphenoethmoidal recess. 39

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Infraorbital meatal baseline 4 mm cuts Scan time 5 sec Head has to be kept hyperextended If patient is not able to hyperextend , coronal cuts are taken and the indirect reconstruction of coronal cuts is made . Erosion of thin plate of bone should not be diagnosed on CT scan unless an adjacent soft tissue mass can be demonstrated. 40


Investigations Coronal CT scan is the investigation of choice.. 41

Frontal Sinus:

Frontal Sinus The frontal sinuses are funnel-shaped cavities that show marked individual variation. There is usually a central septum dividing the frontal sinus into two parts but several septa may also be seen. The frontal recess, the drainage pathway of the frontal sinus, usually drains into the : middle meatus (62%) or into the ethmoid infundibilum (38%). This pathway is bordered by the agger nasi cell anteriorly, lamina papyracea laterally and middle turbinate medially. On coronal CT, the frontal recess is seen superior and medial to the agger nasi cell . This drainage pathway measures on the average 13mm (range 2-20mm). 42

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Coronal CT shows localised mucosal thickening in the left frontal recess (arrow) as well as in the right frontal recess. The relationship of the left frontal recess with the lamina papyracea (white arrow), the opacified agger nasi (A) and the middle turbinate. (arrowhead). 43

Agger Nasi Cell:

Agger Nasi Cell Anterior and inferior to the frontal recess are the agger nasi cells (Latin for "nasal mound"). The agger nasi cells are extramural cells and represent the most anterior ethmoid cells. On coronal CT, they appear" inferior to the frontal recess and lateral to the middle turbinate . The agger nasi cells are important surgical landmarks and opening these cells usually provides an excellent view of the frontal recess . 44


OMC The ostio-meatal unit (OMU) comprises the maxillary sinus ostium, the ethmoid infundibilum, anterior ethmoid cells and the frontal recess. The ethmoid infundibilum is bounded laterally by the inferomedial wall of the orbit, superiorly by the hiatus semilunaris and ethmoid bulla, and medially by the uncinate process. The maxillary sinus ostium and ethmoid infundibilum constitute the common drainage for the anterior paranasal sinuses. One of the aims of FESS is to re-establish the normal ventilation and the sinus drainage in the OMU. 45

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On CT, Hiatus Semilunaris is bounded superiorly by the ethmoid bulla, laterally by the medial bony orbit, inferiorly by the uncinate process and medially the middle meatus. 46

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Coronal CT shows the ostium of the right maxillary sinus (O), ethmoid bulla (B), uncinate process (white arrow), basal lamella (arrowhead) and sinus lateralis (asterisks). The left ethmoid infundibulum (black arrow). The gap between the tip of the uncinate process and the ethmoid bulla constitutes the hiatus semilunaris (curved arrow). 47

Uncinate process:

Uncinate process The relations of the uncinate process is different from the three-dimensional view through an endoscope and the two-dimensional view portrayed on CT. Anteriorly, it is attached to the nasolacrimal apparatus; inferiorly to the inferior turbinate; posteriorly it has a free margin; and superiorly, its attachment is variable. 48

Uncinate process variants:

Uncinate process variants The free edge of the uncinate process may be deviated medially , laterally, pneumatised or bent . Lateral deviation may obstruct the infundibulum while medial deviation may narrow the middle meatus. Pneumatisation may be seen in 4% of patients but this uncinate process variant rarely compromises the infundibulum." A bent uncinate process may simulate a double middle turbinate on endoscopy. The term "atelectatic uncinate process" refers to the situation where the edge of the uncinate process approximates the orbital floor or the inferior aspect of the lamina papyracea. This phenomenon is usually associated with a hypoplastic ethmoid bulla or maxillary sinus. Uncinectomy may therefore result in injury to the orbital contents. 49

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On CT, the uncinate process can be seen attached inferiorly to the inferior turbinate with the free edge representing the posterior free margin. Anteriorly, the uncinate process may be attached to the lamina papyracea, the skull base or the middle turbinate. This variable superior attachment results in different clinical implications. 50

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If the uncinate process inserts into the lamina papyracea , the ethmoid infundibulum would be effectively closed superiorly by a blind-ending pouch known as the recessus terminals . In this instance, the frontal recess and the ethmoid infundibulum are separated and this explains why ethmoid infundibular inflammation does not result in concomitant frontal sinusitis. However, if the uncinate process is attached superiorly to the skull base or the middle turbinate , the frontal sinus opens into the ethmoid infundibulum and infection in the infundibulum may affect the frontal sinus, resulting in the involvement of the frontal, ethmoid and maxillary sinuses. 51

The ethmoid bulla :

The ethmoid bulla The ethmoid bulla is a prominent anterior ethmoid cell, constituting a reliable anatomical landmark. The degree of pneumatisation varies considerably ranging from failure of pneumatisation (torus ethmoidalis) to a giant ethmoid bulla insinuating between the middle turbinate and uncinate process, displacing the uncinate process medially The ethmoid bulla is bordered inferomedially by the infundibulum and hiatus semilunaris; laterally by the lamina papyracea and superoposteriorly by the sinus lateralis and basal lamina . 52

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Coronal CT shows bilateral well-pneumatised ethmoid bullae (stars). The associated flattening of the uncinate processes (white arrow) medially may potentially narrow the middle meatus. 53

Middle turbinate:

Middle turbinate Attachments. Anterior and posterior ethmoidal air cells. Stability of middle turbinate. Curvature of middle tubinate. Concha bullosa. 54

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Coronal CT shows a small right ethmoid bulla (arrow) and bilateral concha bullosa (asterisks). 55

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Coronal CT shows the delicate attachment of the left middle turbinate (arrow) to the cribriform plate. The inflammatory changes in the right frontal recess and anterior middle meatus (star). 56

Sinus lateralis :

Sinus lateralis The gap between the ethmoid bulla and the basal lamina is known as the sinus lateralis and it opens into the middle meatus The relationships of the sinus lateralis are as follows: the ethmoid bulla anteriorly, the skull base superiorly, the basal lamina posteriorly, and the lamina papyracea laterally. Disease affecting the sinus lateralis is usually obvious radiologically but is often difficult to identify endoscopically 57

Sphenoid sinus:

Sphenoid sinus Axial CT shows a dehiscent right carotid artery wall and associated bulging of the artery into the sphenoid sinus (arrow). The inflammatory changes involving the left sphenoid sinus (star). 58

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Axial CT shows the common wall between the right anterior sphenoid sinus wall and the posterior wall of the posterior ethmoid cell (arrows). The ostium (curved arrow) of right sphenoid sinus (star) opens into the sphenoethmoidal recess. The attachment of the sphenoid septum to the thin wall of the right carotid canal (black arrow). 59

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Coronal CT shows the relationship of the right maxillary nerve (straight arrow) with the sphenoid sinus. The inflammatory changes in the left sphenoid sinus (curved arrow) adjacent to the left maxillary nerve which may result in trigeminal neuralgia. 60

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Axial CT shows the relationship between the right optic nerve (asterisks), posterior ethmoid sinus (small star) and sphenoid sinus (large star). 61

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An Onodi cell is a posterior ethmoid cell that extends lateral and superior to the sphenoid sinus and abuts the optic nerve. Kainz and Stammberger defined an Onodi cell as a posterior ethmoid cell with an endoscopically visible bulge of the optic canal. The vulnerability of the optic nerve with or without the presence of an Onodi cell is further compounded by the thin lamina papyracea in the posterior ethmoid area 62

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Coronal CT shows paradoxical left middle turbinate (arrow). The ostium of the right sphenoid sinus (curve arrow) which is usually better demonstrated on axial images. 63

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Axial CT shows sphenoe-thmoidal recess mucosal thickening (curve arrow) resulting in left posterior ethmoid (asterisk) and sphenoid sinusitis (star). 64

Ethmoid roof:

Ethmoid roof Asymmetry in the height of the ethmoid exposes the lower side to inadvertent intracranial penetration during endoscopy. The ethmoid roof is of critical importance for two reasons : Firstly, the bone is thin rendering this area vulnerable to cerebrospinal fluid leaks when breached . Secondly, the anterior ethmoidal artery is vulnerable to injury which may cause catastrophic bleeding into the orbit. The anterior ethmoidal artery is a branch of the ophthalmic artery. From the orbit, it passes through a canal into the anterior ethmoid sinus just posterior to the frontal recess. 65

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It then crosses the sinus and enters the anterior cranial fossa before exiting and re-entering the nasal cavity via the cribriform plate. This is the site where the artery is most liable to injury. The roof of the ethmoid is formed by the fovea ethmoidalis of the frontal bone laterally and the cribriform plate of the ethmoid bone medially. Due to the delicate attachment of the middle turbinate to the cribriform plate anteriorly, surgery in this area should be performed with care as detachment of the middle turbinate may damage the dura , resulting in cerebrospinal fluid leak . 66

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TREATMENT Medical Antihistaminics. Mast cell stabilisers. Leukotriene antagonists Oral steroids and topical steroids. Surgical FESS is the treatment of choice. Polypectomy with a polypectomy snare Ethmoidectomy (intranasal , extranasal , transantral) Calwell-Luc operation 79


Treatment Oral and nasal steroids High dose prednisolone and nasal steroid for 20 days will eliminate 50% of polyps Poor response in certain groups Contraindications. Immunotherapy. Diet (no effect). 80

Functional Endoscopic Sinonasal Surgery::

Functional Endoscopic Sinonasal Surgery: Proper understanding of the anatomy of the Lateral nasal wall, Osteomeatal complex Anterior skull base is mandatory to achieve Early and precise diagnosis of sinonasal lesions Safe and effective endoscopic sinonasal surgery 81

Osteomeatal complex : OMC:

Osteomeatal complex : OMC Suprabullar recess Frontal ostium Lateral sinus Frontal recess Retrobullar recess HSS HSI Maxillary ostium Infundibulum 82

Uncinate process:

Uncinate process 83

Skull base: anterior ethmoids & AEA:

Skull base: anterior ethmoids & AEA Crista galli Septum Cribriform plate Middle turbinate Lateral lamella Fovea ethmoidalis 84

Skull base: anterior ethmoids:

Skull base: anterior ethmoids 85

Middle turbinate, basal lamella:

Middle turbinate, basal lamella 86

Basal lamella and ethmoids:

Basal lamella and ethmoids Basal lamella: Anterior ethmoids Posterior ethmoids 87

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Summary Common condition in adults Aetiology not fully understood Majority are not allergic in nature Medical treatment can be effective Even with surgery, recurrence is common 129

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THANKS Other approaches to sinuses follow 130

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