Definition of nasal polyp : 

Nasal polyp : Nasal polyps are hypertrophied oedematous mucosa & submucosa of the nose & paranasal sinuses resulting in a pedunculated mass.

Types of nasal polyps according to site of origin :

1. Antro – choanal polyp.
2. Ethmoidal polyp.

Antro-choanal polyp 

Definition : It is that type of nasal polyp which arises from maxillary antrum, comes out into nasal cavity & grows towards choana & nasal cavity.

Aetiology :

1. Single & unilateral.
2. Nasal allergy coupled with sinus infection.
3. Seen in children and young adults.

Symptoms of antro – choanal polyp : 

1. History of nasal allergy, i.e. sneezing & rhinorrhoea.
2. Unilateral nasal obstruction.
3. Obstruction may become bilateral when polyp grows into the nasopharynx and starts obstructing the opposite choana.
4. Voice may become thick and dull due to hyponasality.
5. Nasal discharge: Mostly mucoid, may be seen on one or both sides.
6. Headache
7. Hyposmia.

Signs of antro – choanal polyp : 

1. Anterior rhinoscopy : A single bluish white polyp at the deeper part of nasal cavity.
2. On posterior rhinoscopy : A globular mass filling the choana or the nasopharynx. A large polyp may hang down behind the soft palate and present in the oropharynx.
3. Examination of the nose with an endoscope may reveal a choanal or antrochoanal polyp hidden posteriorly in the nasal cavity.
4. Probing : It is insensitive to touch, does not bleed on touch, soft in consistency & mobile. Probe can be passed all around the mass except lateral wall.

Investigations of antro – choanal polyp :

1. X-rays of paranasal sinuses occipito-mental view: Opacity of respective antrum.
2. X-ray nasopharynx (lateral view): A globular swelling in the postnasal space.
3. Non-contrast CT scans and paranasal sinuses show the extent of the polyp.

Treatment of antro – choanal polyp :

.In recent advances, FESS (Functional Endoscopic Sinus Surgery).

If not available : 

• In children (Below 14 years of age): Simple polypectomy followed by antral wash out
• In adult (Above 14 years of age) : Cald – Well – Luc operation (Sublabial antrostomy).

Parts of antro-choanal polyp :

1. Antral : It is a thin stalk.
2. Choanal : It is round and globular.
3. Nasal : It is flat from side to side.

2 constrictions of antrochoanal polyp :

1. Where it pass through maxillary ostium.
2. In the posterior choanal aperture where into nasopharynx from nasal cavity.

3 dilatations are found in :

1. Within maxillary antrum.
2. Within nasal cavity.
3. Within nasopharynx.

Ethmoidal polyp

Origin : From the lateral wall of nose, usually from the middle meatus (ethmoidal air sinus).

Incidence :

1. Middle aged & elderly people
2. Both male & female are involved, but male more.

Symptoms of ethmoidal polyp :

1. Multiple polypi can occur at any age but are mostly seen in adults.
2. Nasal stuffiness leading to 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 allergy.
6. Mass protruding from the nostril.
7. On anterior rhinoscopy : Polypi appear as smooth, glistening, grape-like masses often pale in colour.
8. On probing : Insensitive to touch, dose not bleeds on touch, mobile soft in consistency smooth surface.
9. Nasal cavity may show purulent discharge due to associated situsitis.
10. Often they are multiple and bilateral
11. A polyp may protrude from the nostril and appear pink and vascular simulating neoplasm.
12. In long standing cases there may be expansion or broadening of the external nose know Frog-face deformity.

Investigation of ethmoidal polyp :

1. X-ray PNS occipito-frontal view : Hazy frontal air sinus & hazy maxillary sinus but no opacity.
2. Computed tomography (CT) scan of paranasal sinuses.

Treatment of ethmoidal polyp : 

Conservative :

• 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.

Surgical : 

•  Endoscopic sinus surgery : FESS (functional endoscopic sinus surgery)
• Prior to the advent of endoscopic sinus surgery, following operations were commonly done:

1. Polypectomy
2. Intranasal ethmoidectomy.
3. Extranasal ethmoidectomy
4. Transantral ethmoidectomy.

Site of ethmoidal polyp : 

• They are mostly bilateral.
• 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.
• Number : They are multiple in numbers.

Pathology of ethmoidal polyp

1. Due to allergy : Prolonged oedema at the submucosa.
2. Accumulation of intracellular serous fluid & oedematous hypertrophy.
3. Interfere with lymphatic flow
4. Gravity & narrowing at the meatus promotes down ward extension →→Polyp formation.

Aetiology of ethmoidal polyp :

1. Chronic rhinosinusitis.
2. Asthma
3. Aspirin intolerance,
4. Cystic fibrosis.
5. Allergic fungal sinusitis.
6. Kartagener syndrome.
7. Young syndrome.
8. Churg-Strauss syndrome.
9. Nasal mastocytosis.

Advice during discharge of a patient following ethmoidal polyp operation :

• Rest for one to two weeks.
• The nose will feel blocked due to post-operative swelling and can take a few weeks to settle down. Apply nasal drops/spray to decongest the nose and follow the recommended method of installation.
• There may have a blood-stained watery discharge from the nose. This is normal and should settle after a few days.
• Scabbing within the nose may occur as it heals. Do not pick this off as the area will bleed.
• For the first few days, avoid very hot drinks, meals, baths or showers.
• For one week, avoid blowing your nose and sneeze with your mouth wide open. These all help to reduce any risk of bleeding.
• Avoid or cut down on smoking as smoking affects the body’s ability to heal and imitates the inside of the nose.
• Avoid crowded or dusty places and people with coughs and colds, as infection can be picked up in the nose.
• Avoid contact sports for four weeks due to the risk of trauma and bleeding.
• If fresh, steady bleeding occurs, pinch the fleshy part of the nose, lean forward and apply ice to the forehead & bridge of nose. A frozen bag of vegetables is a good alternative if you don’t have ice in the freezer.
• Avoid swallowing any blood as it can make you feel sick. If the bleeding does not stop after 30 minutes. ring the ward for advice.

Some important points to remember in a case of nasal polyp :

• if a polypus is red and fleshy, friable and has granular surface, especially in older patients, think off malignancy.
• Simple nasal polyp may masquerade a malignancy underneath. Hence all polypi should be subjected to histology.
• A simple polyp in a child may be a glioma, an encephalocele or a meningoencephalocele. It should always be aspirated and fluid examined for CSF. Careless removal of such polyp would result in CS rhinorrhoea and meningitis.
• Multiple nasal polypi in children may be associated with mucoviscidosis (cystic fibrosis).

Aetiology of nasal polyps : 

Allergy : Majority of the nasal polyps are initially allergic in origin. Eosinophil & plasma cells are found.

Vasomotor or vascular phenomenon: Similar to allergy but no allergen is found.

Infection : Bacteria or viral infection.

Mixed : Allergy & infection

Concentration of immunoglobulin IgE in serum & also eosinophil infiltration may play some part.

Bernoulli phenomenon : Negative pressure develops in a constricted arch of nasal cavity around middle meatus which reduces extra vascular fluid pressure & leads to formation of tissue fluid.