allergic polypi

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04/11/23 2

ALLERGIC NASAL POLYPI

Dr. Muhammad Farooq KhanMedical Officer

Department of Oto-Rhino-LaryngologyCapital Hospital, Islamabad

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CASE HISTORY


Patient: Mohammad JavedAge: 49 years male Occupation: Frash, CDA

Presenting Complaints: Nasal irritation}Runny nose}Sneezing}- 10 years Nasal blockade}- 6 yearsBronchial asthma}- 2 years

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GPEMiddle aged smoker of average height, Hypertensive,Pulse- 92bpm, regularB.P. 160/.100mm HgTemp. 98.6F

SYSTEMIC EXAMINATIONCNS-}CVS- } NADGIT- }Resp. System-

Scattered conducted sounds, with coarse crepts,inspiratory rhonchi bilateraly.

CASE HISTORY

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EARS: Both ears normal Ear Drums- intact bil. Hearing normal

.THROAT: Oro-pharyngeal mucosa consistant

with picture of Ch. Pharyngitis.

E.N.T EXAMINATION

CASE HISTORY

Contd.

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NOSE: Broadening of nose and Flaring of alar nasai, No tenderness over the maxillary and ethmoid areas. Pale allergic nasal mucosa,with bunch of pale yellow grape

like polypoidal swellings seen bilaterally,confirmed to be arising from middle meatus, turbinate and ethmoids, on probe testing.

Olfaction was found impaired. No polypi were seen in naso-pharynx on post. Rhinoscopy.

CASE HISTORY

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H/O allergic rhinitis for last 10 years. H/O mucus polyps for 6 years. 1st polypectomy done 5 years back, Recurrence of nasal polyposis 2 years back, Development of Bronchial Asthma 2 years back. Hypertension (untreated) 1 year.

PAST HISTORY

CASE HISTORY

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Blood CP: Hb% 15.5g/dl TLC 10500/cmm DLC 68%N, 24%L,

2%M, 6%E ESR 03mm/1st hr

Blood Glucose: 88mg/dl B.T/ C.T: WNL

LABORATORY FINDINGS

CASE HISTORY

X-RAY CHEST(PA view)- WNL

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CASE HISTORY

X-Ray PNS (O.M.view)-

Hazy maxillary & ethmoidal sinuses, with soft tissue shadows in nasal cavities but no bony erosions.

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MANAGEMENT

MEDICAL Control of Hypertension and Asthma Fitness for G/A

SURGICAL Polypectomy on 26th Oct. 2002 under General anaesthesia

through peroral endotracheal intubation with a pharyngeal pack.

Nasal pack removed after 48 hrs and patient discharged on 29th Oct. 2002 on following treatment:

o Nasal decongestants (local)o Antibotic covero Antihistamineo Oral Steroidso Antihypertensives and bronchodilator as advised

by medical department.

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FOLLOW UP

Weekly for 2 weeks: 1st Follow up- Air way clear, smell and breathing improved.

Fortnightly for 2 months: Last visit on 27th, Nov. 2002, Patient happy and

without recurrence.

CASE HISTORY

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A pedunculated portion of edematous mucosaof the nose or Para-nasal sinuses.


Also termed as Mucous Polyp/ Ethmoidal Polyps

POLYP

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Simple Allergic Vasomotor Inflamatory Mixed infective- allergic

Neoplastic Benign – Angiofibroma, Pappiloma Malignant – Sarcoma, Melanoma

CLASSIFICATION

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Ethmoidal- At any age.

Antrochoanal- Usually Children & young adults.


AGE INCIDENCE

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ANATOMY

Polyp usually arise from lateral wall of the middle meatus, middle turbinate or ethmoid, and hang down into the nasal cavity.

Polyp consists of a pedicle, a body and a fundus. Usually round, smooth, soft, translucent, yellow or pale

glistening structure attached to nasal mucosa with narrow stalk.

Occasionally cubical, or pavement in places.


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Multiple Ethmoidal polypi

SITES OF ORIGIN

Antrochoanal polyp filling the nasopharynx

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HISTOLOGY

Microscopically covered with ciliated columnar epithelium with large amount of fluid i.e. transudate, in the substance of Polypus.

Very few glands and blood vessels. Round cell infiltration and Eosinophils. No nerves.


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PATHOPHYSIOLOGY

Hypersensitivity reaction; Type-I IgE mediated. Release of Histamine from mast cells and basophils

in the submucosa of nasal cavity. Vasodilation, smooth muscle contraction and

increased capillary permeability. Odema, Polyp formation.


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Five theories: Bernouli Phenomenon- (Gravitational Pull) Polysacharide Changes- (Alteration in the ground

substance has been postulated but analysis shows no collagen changes).

Vasomotor Imbalance- (Sympathetic- Parasympathetic imbalance with parasympathetic dominance).

Infection- Rhinitis & Sinusitis play a role. Purulent Hyperplastic

Allergic- See next slide

ETIOLOGY


Contd.

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ETIOLOGY

Allergy: Allergy is implicated because of histologic picture of eosinophilia and association with asthma.

Nasal Allergy- an expression of pathologic hypersensitivity, mediated by antibody upon exposure to an antigen.

Two types of Antibodies: Humoral- associated with immediate reaction, e.g, Hay Fever, Urticaria, Somatic antibodies- associated with delayed

reaction, e.g, Tuberculosis, Allergic reaction to infection.


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SYMPTOMS

Nasal Obstruction Thin profuse Nasal discharge Anosmia Headache/ loss of concentration Epiphora Conductive deafness Rhinolalia clausa - Dull, toneless speech due

to nasal blockage


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SIGNS:

Anterior Rhinoscopy: multiple grape like swellings(Polyps)

hanging from the roof. Smooth and shinny, covered with thin

discharge, non tender, can be moved with blunt nasal probe.

Posterior Rhinoscopy: Engorged posterior tips of the inferior

turbinates and septal turbinates.


INTRANASAL SIGNS

Contd.

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SIGNS

Frog-nose, due to broadening of nasal bridge, Typical faces of chronic mouth breather, Allergic shiners caused by dark circles under the eyes

due to venous stasis by engorged nasal membranes. Rabbit nose due to wrinkling of the end of the nose. Allergic Salute- due to repeated wiping of runny nose.


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COMPLICATIONS

Nasal blockade Repeated infections

Infective rhinnitis Infective sinusitis– Bacterial/ Fungal

Epistaxis Anosmia Hyper telorism Eustachian tube dysfunction- with middle ear

effusion. Facial deformity– Frog nose (adults) Rabbit nose (children) Asthma.


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LABORATORY FINDINGS

Periphiral Eosinophilia:3- 10 % eosinophils in the nasal secretion is diagnostic of allergic rhinitis.

Nasal secretion cytology reveals presence of eosinophils.

Elevated IgE serum levels seen in 50% patients. Allergic Skin testing, by methods like Prick test,

Scratch test and Intradermal test.


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DIFFERENTIAL DIAGNOSIS


(Contd.)

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Ethmoidal Polyp Antrochoanal Polyp

(Contd.)

D/D


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Inverted PapillomaFleshy cauliflower like

mass with single attachment in the nose

commonly arising from the septum.

(Contd.)


D/D

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Sometimes need to be differentiated from “Naso-Pharyngeal Fibroma”:

Teen age males, H/O recurrent & severe epistaxis, Lobulated mass with irregular surface, Bleeds easily on touch.


D/D

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Through clinical examination Radiography of the sinuses Biopsy C.T/ M.R.I Scan


DIAGNOSIS

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TREATMENT:ALLERGIC NASAL POLYPI

MANAGEMENT

Conservative Surgical

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Avoidance of allergens/Irritants. Environmental control. Immunotherapy Intermittent use of anti-histamines, locally or per oral. Local decongestants, as drops or sprays. Topical steroid therapy- to avoid recurrence. Anti-biotic therapy, where indicated.


CONSERVATIVE MANAGEMENT

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TREATMENT:

Removal of polypi under local or general

anesthesia with non-cutting nasal polypus snare.

Recurrent cases- Intranasal ethmoidectomy Removal of cause- Allergy sinusitis, DNS.


SURGICAL MANAGEMENT

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ETHMOIDAL POLYPI

SUMMARYSURGICAL MANAGEMENT

SURGICAL COMPLICATIONS

Dr. Ghulam SaqulainM.B.B.S., D.L.O., F.C.P.S.

E.N.T Surgeon, Capital HospitalISLAMABAD

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SUMMARY

Bil. Nasal polyps usually originate from ethmoid sinuses and are sometimes associated with nasal allergy.

These polypi are usually multiple and nasal airway obstruction caused by them is occasionally the prime symptom forcing the patient for an E.N.T consultation.

Broadening of the nose could be a prominent feature in advanced cases. Hypertelorism and proptosis is often seen associated with them if left untreated.

Cases have been reported where nasal polypi have invaded the anterior cranial fossa.

ETHMOIDAL POLYPI

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SUMMARY Aggressive, invasive and recurrent polyp formation

could not possibly have only allergic basis. It may be due to allergic and infective processes acting together including fungal infection.

Aspergillus is the most common organism responsible for the sinusitis and recurrent polypi.

Polyps with onset in childhood may be very aggressive and lead to splay the bones producing widened bridge. They are however nearly always associated with cystic fibrosis.

ETHMOIDAL POLYPI

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MEDICAL TREATMENT Case Awaiting Surgery. Incomplete and

aimed at relieving symptoms of polypi

Post Surgical Definitive Medical Treatment.

TREAT THE CAUSE

ETHMOIDAL POLYPI

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SURGICAL MANAGEMENT

Asymptomatic Small Polypi No active surgical intervention required Local steriods have a role.

Large symptomatic polypi Surgical options need to be considered.

ETHMOIDAL POLYPI

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SURGICAL MANAGEMENTAIMS Establish normal nasal airway patency Complete removal of polypoidal mucosa,

avoiding damage to neighbouring structures.

ETHMOIDAL POLYPI

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SURGICAL OPTIONS

Nasal polypectomy Nasal polypectomy + intranasal Ethmoidectomy Nasal polypectomy + External Ethmoidectomy Nasal polypectomy +CWL Nasal polypectomy + Transantral ethmoidectomy. Endoscopic Sinus Surgery.

ETHMOIDAL POLYPI

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NASAL POLYPECTOMY - Pernasal Removal

Repeat Nasal polypectomies: Accepted until this necessitates an unreasonable

amount of hospitalization and mobidity

ETHMOIDAL POLYPI

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ANAESTHESIA:

Local Anaesthesia Little bleeding Polypi shrink into the ethmoids –High recurrence

rate. General Anaesthesia

Cuffed peroral endotracheal tube Pharyngeal pack.

Better Clearance of polypi Excellent access to the ethmoids. More bleeding.

ETHMOIDAL POLYPI

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POLYPECTOMY

Position: Reversed Trendelenburg position

Procedure: Access is obtained using a Thudicum or Killian nasal speculum and polypi removed with:

Removal with a snare

ETHMOIDAL POLYPI

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Removal with Henkel’s Forceps

Removal of remnants with Citilli’s Forceps

ETHMOIDAL POLYPI

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Ethmoidal Polypi

ETHMOIDAL POLYPI

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POLYPECTOMY + INTRANASAL ETHMOIDECTOMY

In rapidly recurring cases Polypectomy Citelli’s forceps is used for uncapping

ethmoidal bulla and removing every trace of oedematous mucosa from the air cells, with special attention paid to agar nasi cells.

Operating microscope.

ETHMOIDAL POLYPI

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POLYPECTOMY + EXTERNAL ETHMOIDECTOMY

Done in advanced cases producing proptosis. Howarth’s Operation:

Slightly curved incision and concave towards the medial canthus of eye is made.

ETHMOIDAL POLYPI

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POLYPECTOMY + Cald Well Luc

Nasal polyposis associated with sinusitis.

POLYPECTOMY + TRANSANTRAL

ETHMOIDECTOMY

ETHMOIDAL POLYPI

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ENDOSCOPIC SINUS SURGERYIndicated:

In recurrent polypi esp. those with allergies that are difficult to control.

Those in whom previous external procedures have been performed or landmarks removed.

Accomplished By:2.7 mm rigid telescopes with 25 or 30

deg.angled lens.

ETHMOIDAL POLYPI

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SURGICAL COMPLICATIONS

Haemorrhage Adhesions & Scar formation. Anosmia Damage to orbital contents

Exposure of Orbital fat Haemorrhage within the orbit Injury to EOMs, globe or Injury to Optic nerve.

Injury to the Intracranial Structures CSF LEAKAGE Damage to brain, membranes Intracranial Haemorrhage.

ETHMOIDAL POLYPI

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NOTE:

“To reduce the operative complications, surgeon must take care to keep his instruments below the cribriform plate, medial to the orbital periosteum and infront of the optic foramen”

ETHMOIDAL POLYPI

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Deptt.

allergic polypi

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