to download please visit www.drpulkitagarwal.weebly.com
Published on: Mar 4, 2016
Transcripts - Polyp
Sinonasal polyp refers to Hypertrophied, oedematous prolapsed nasal or sinus mucosa due to
infection, inflammation or allergy.
Polyp has a grape like appearance with a body and a stalk.
Ethmoidal – grape like, bluish, soft, B/L, multiple smooth, mobile, sessile or pedunculated,
insensitive to touch and doesn’t bleed on touch
Prevalence 2%, increases with age reaching peak at 50yrs.
Usually occurs after 2 yrs age
M:F = 2:1
The polyp recurrence rate depends upon the type of disease. It is low in cystic fibrosis and high in
patients with nonsteroidal anti-inflammatory drug (NSAID) intolerance and asthma i.e.
Allergic fungal sinusitis >80% asso with polyp
Polyp asso with Cystic Fibrosis, Churg strauss syndrome, Samters triad, primary ciliary
dyskinesia (Kartageners syndrome), youngs syndrome (chronic rhinosinusitis, nasal polyps,
bronchiectasis and azoospermia)OR AGGRAVATING FACTOR IN NASAL POLYPOSIS.
Osteomeatal complex is most common site of development of polyp.
It is proposed that 'Touching mucous membranes' in the narrow ostiomeatal complex results in
the release of pro inflammatory cytokines from epithelial cells.
Another possibility is an influence of special airflow, air current and pressure in the upper part of
the nose Bernaulli’s phenomenon.
Finally, it may be of significance that the nerve endings near the borderline between the nose
and paranasal sinuses are thin and may easily become damaged by cytotoxic proteins, released
The major part of the polyp surface is covered by a ciliated pseudostratified epithelium, but, in
addition, transitional and squamous epithelia are found.
Respiratory mucosa of nasal cavity aka Schneiderian membrane developed from ectoderm
Goblet cells <10 times less in polyp then normal mucosa and unevenly distributed.
Vascularity of polyp is minimal
IL 5 plays a dominant role in eosinophil dominant
CLASS. / STAGING OF NASAL POLYPOSIS
1. Endoscopic Staging by Lund Kennedy. (PED)
2. CT staging by Lund Mac Kay.
3. Hadley’s nasal functional scoring system
4. Questionnaire Based Scoring system
5. Histological Classification (Eosino and non
ENDOSCOPIC Lund Kennedy system
involves meticulous endoscopy study. PED (Polyp, Edema, Discharge on left and right) for polyp
0,1, 2, 3 rest 0,1, 2
Post operative – Scarring and Crusting left, right – 0,1,2.
Questionnaire included Nasal obstruction, nasal discharge, Postnasal Drip, Olfaction, facial
THEORIES OF NASAL POLYPOSIS
Most Accepted theory
THEORY OF EPITHELIAL RUPTURE
I.e. Inflammation and Tissue oedema Epithelial rupture prolapse of Lamina propria
Adjacent epithelium tries to cover up the defect forming lining of polypoidal tissue If not
covered up fast lamina propria continues to grow leading to polyp formation.
Other theories include :
1. Adenoma theory of Billroth
2. Fibroma theory of Hoppman
3. Necrotising Ethmoiditis theory of Woakes
4. Glandular Cystic Theory
5. Glandular Hyperplasia Theory (Krajina)
6. Mucosal Exudate Theory of Hayek
7. Blockade theory of Jenkins
8. Periphlebitis and perilymphangitis theory (Eggston and Wolff)
Allergy, Infective, both, Bernaulli’s, vasomotor rhinitis, polysaccharide theory (due to endocrine
enzymatic abnormality, polysaccharides accumulate which absorb water leading polyp),
polypeptide (Substance P accumulates, a vasodilator and so water accumulates), cystic fibrosis
association, aspirin sensitivity.
CLINICAL SYMPTOMS :
B/L progressive nasal obstruction
Nasal discharge (purulent if asso. with sinusitis)
Hyperosmia / Anosmia
Rhinorrhoea or sneeze
Post nasal drip
Pain (bridge of nose, forehead and cheeks)
(Hyposmia doesn’t revert back to normal after treatment )
Frog nose appearance (increased intercanthal distance)
Cold Spatula test
DIFFERENTIAL DIAGNOSIS :
DNE, CT, MRI, test for Cystic fibrosis and co morbid conditions
Intranasal Corticosteroids – best medical modality
Reduces size though may not eliminate polyp.
Rhinitis symptoms also reduce by 50%
Sometimes inadequate distribution may necessitate Oral steroids.
Systemic steroids proved better than intranasal. (25 mg Prednisolone daily for 10-14 days)
Topical steroids can delay the recurrence of polyps after surgery
A short course of systemic steroid is equally effective as simple polypectomy with a snare and it
may serve as a 'Medical Polypectomy'.
Surgery cannot cure disease
Thus Surgery should always be added to medical therapy.
Endoscopic removal (should be done after intranasal use of Corticosteroid for 1 month and Oral
for 10 days)