Tuesday, December 28, 2010

Bilateral Ethmoidal Polypi

Aetiology. Aetiology of nasal polypi is very complex
and not well-understood. They may arise in inflammarory
conditions of nasal mucosa (rhinosinusitis), disorders of
ciliary motility or abnormal composition of nasal mucus
(cystic fibrosis). Various diseases associated with the formation
of nasal polypi are:
(i) Chronic rhinosinusitis. Po lypi are seen in chronic
rhinosinusitis of both allergic and non-allergic origin.
Non-allergic rhinitis with eosinophilia syndrome
(NARES) is a form of chronic rhinitis
associated with polypi.
(ii) Asthma. 7% of the patients with asthma of atopic
or non-atopic origin show nasal polypi.
(iii) Aspirin intolerance. 36% of the patients with aspirin
intolerance may show polypi. Sampter's triad consists
of nasal polypi, asthma and aspirin intolerance.
(iv) Cystic fibrosis. 20% of patients with cystic fibrosis
form polypi. It is due to abnormal mucus.
(v) Allergic fungal sinusitis. Almost all cases of fungal
sinusitis form nasal polypi.
(vi) Kartagener's syndrome. This consists of bronchiectasis
sinusitis, situs inversus and ciliary dyskinesis.
(vii) Young's syndrome. It consists of sinopulmonary disease
and azoospermia.
(viii) Churg-Strauss syndrome. Consists of asthma, fever,
eosinophilia, vasculitis and granuloma.
(ix) Nasal mastocytosis. It is a form of chronic rhinitis
in which nasal mucosa is infiltrated with mast cells
but few eosinophils. Skin tests for allergy and IgE
levels are normal.
Pathogenesis. Nasal mucosa, particularly in the
region of middle meatus and turbinate becomes oedematous
due to collection of extracellular fluid causing polypoidal
change. Polypi which are sessile in the beginning
become pedunculated due to gravity and the excessive
Pathology. In early stages, surface of nasal polypi is
covered by ciliated columnar epithelium like that of normal
nasal mucosa but later it undergoes a metaplastic change
to transitional and squamous type on exposure to atmospheric
irritation. Submucosa shows large intercellular
spaces filled with serous fluid. There is a(so intlItration
with eosinophils and round cells.
Site of origin. Multiple nasal polypi always arise from
the lateral wall of nose, usually from the middle meatus.
Common sites are uncinate process, bulla ethmoidalis, ostia
of sinuses, medial surface and edge of middle turbinate.
Allergic nasal polypi almost never arise from the septum
or the floor of nose.
1. Multiple polypi can occur at any age but are mostly
seen in adults.
2. Nasal stuffiness leading ro total nasal obstruction may
be the presenting symptom.
3. Partial or total loss of sense of smell.
4. Headache due to associated sinusitis.
5. Sneezing and watery nasal discharge due to associated
6. Mass protruding from the nostril.
Signs. On anterior rhinoscopy, polypi appear as smooth,
glistening, grape-like masses often pale in colour. They
may be sessile or pedunculated, insensitive to probing
and do not bleed on touch. Often they are multiple and
bilateral. Long-standing cases present with broadening of
nose and increased intercanthal distance. A polyp may
protrude from the nostril and appear pink and vascular
simulating neoplasm . Nasal cavity may show
purulent discharge due to associated sinusitis.
Probing of a solitary ethmoidal polyp may be necessary
to differentiate it from hypertrophy of the turbinate
or cystic middle turbinate.
Diagnosis. Diagnosis can be easily made on clinical
examination. CT scan of paranasal sinuses is essential to
exclude the bony erosion and expansion suggestive of neoplasia.
Simple nasal polypi may sometimes be associated
Fig. 32.1 A polyp protruding from the left nostril in a
patient with bilateral ethmoidal polypi.
with malignancy underneath, especially in people .lbove
40 years and this must be excluded by histol gical examination
of the suspected tissue. CT scan also helps to
plan surgery.
1. Early polypoidal changes with oedematous mucosa
may revert to normal with antihistaminics and control
of allergy.
A short course of steroids may prove useful in case of
people who cannot tolerate antihistaminics and/or
in those with asthma and polypoidal nasal mucosa.
They may also be used to prevent recurrence after
surgery. Contra indications to use of steroids, e.g.
hypertension, peptic ulcer, diabetes, pregnancy and
tuberculosis should be excluded.
1. Polypectomy. One or two polyps which are pedunculated
can be removed . with snare. Multiple and
sess ile polypi require special forceps.
2. Intranasal ethmoidectomy. When polypi are multiple
and sess ile they require uncapping of the ethmoidal
air cells by intranasal route, a procedure called
intranasal ethmoidectomy.
3. Extranasal ethmoidectomy. This is indicated when
polypi recur after intranasal procedures and surgical
landmarks are ill-defined due to previous surgery.
Approach is through the medial wall of the orbit by
an external incision, medial to medial canthus.
4. Transantral ethmoU:l.ectomy. This is indicated when
infection and polypoidal changes are also seen in the
maxillary antrum. In this case, antrum is opened by
Caldwell-Luc approach and the ethmoid air cell
approached through the medial wall of the antrum.
This procedure is also superceded by endoscopic sinus
5. Endoscopic sinus surgery. These days, ethmoidal
polypi are removed by endoscopic sinus surgery more
popularly called FESS (functional endoscopic sinus
surgery). It is done with various endoscopes 0(00 ,300
and 70° angulation. Polypi can be removed more accurately
when ethmoid cells are removed, and drainage
and ventilation provided to the other involved sinuses
such as maxillary, sphenoidal or frontal.

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