Nasal Polyps

1. Definition

• Nasal polyps are non-neoplastic (non-cancerous) masses arising from edematous mucosa of the nasal cavity or sinuses.

2. Types of Nasal Polyps

• Bilateral Ethmoidal Polyps: Common in adults.

• Antrochoanal Polyps: Common in children and young adults.

• Visual Representations:

  • Lateral views showing ethmoid and maxillary sinus polyps.

Bilateral Ethmoidal Polyps

3. Aetiology

Divided into two frames:

• General Causes:

  • Inflammatory nasal conditions: Rhinosinusitis.

  • Ciliary motility disorders: e.g., Kartagener syndrome.

  • Mucus composition abnormalities: e.g., Cystic fibrosis.

• Associated Diseases:

  • Chronic rhinosinusitis

  • Asthma

  • Aspirin intolerance

  • Allergic fungal sinusitis

  • Young syndrome

  • Churg-Strauss syndrome

  • Nasal mastocytosis

4. Pathogenesis

• Stages:

  • Nasal mucosa becomes edematous due to excess extracellular fluid (ECF).

  • Formation of sessile polyps, which become pedunculated from gravity and sneezing.

• Histological Features:

  • Lined initially by ciliated columnar epithelium.

  • Exposure leads to metaplasia: transitional to squamous.

  • Submucosa shows:

    • Large intercellular spaces with serous fluid.

    • Eosinophilic and lymphocytic infiltration.

5. Site of Origin

• Arise mostly from the lateral nasal wall, especially:

  • Uncinate process

  • Bulla ethmoidalis

  • Sinus ostia

  • Middle turbinate’s medial edge

6. Clinical Presentation

Symptoms:

• Nasal blockage (partial → total)

• Loss of smell (anosmia)

• Headache (due to sinusitis)

• Sneezing and watery discharge (if allergic)

• Visible nasal mass

Signs:

• Anterior rhinoscopy: Pale, smooth, grape-like, non-bleeding masses (sessile or pedunculated).

• May be bilateral and multiple.

• Possible facial widening or increased intercanthal distance.

• May simulate a neoplasm if large and vascular.

7. Diagnosis

• Clinical Evaluation

• Imaging:

  • CT scan of paranasal sinuses to plan surgery or rule out tumors.

• Histology:

  • Especially important in patients aged >40 years.

8. Treatment

Conservative

• Antihistamines & Allergen Control: May reverse early polyp changes.

• Steroids: Short-term use, especially in asthmatics or those intolerant to antihistamines.

Surgical

• Polypectomy

• Endoscopic sinus surgery (preferred)

• Ethmoidectomy: intranasal, extranasal, or transantral

Antro choanal Polyp

9. Antrochoanal Polyp (ACP)

Origin

• Arises near the accessory ostium of the maxillary antrum.

• Grows backward into the choana and nasal cavity.

• Has three parts:

  1. Antral (stalk)

  2. Choanal (globular)

  3. Nasal (flat, lateral spread)

Aetiology

• Exact cause unclear.

• Often due to allergy + sinus infection.

• More common in children.

Symptoms

• Starts with unilateral nasal blockage, may become bilateral if it reaches contralateral choana.

• Hyponasal speech

• Mucoid nasal discharge

Signs

• Anterior rhinoscopy: May miss the polyp due to its posterior growth.

• Visible, soft, mobile greyish mass with discharge.

• Posterior rhinoscopy: Shows a globular polyp in choana or even oropharynx.

10. Investigations

• Nasal Endoscopy: Best to detect hidden choanal or antrochoanal polyps.

• X-ray of PNS: May show:

  • Opacity in the maxillary antrum.

  • Posterior mass shadow with air behind it.

11. Differential Diagnoses

1. Mucus blob: Disappears on nose blowing.

2. Hypertrophied middle turbinate: Pink, firm, bone palpable.

3. Angiofibroma: Common in young males, bleeds easily, firm.

4. Neoplasms: Fleshy, friable, tend to bleed.

12. Antrochoanal Polyp – Treatment

• Avulsion via nasal/oral route.

• Low recurrence if fully removed.

• Caldwell-Luc operation for recurrent cases.

• Endoscopic sinus surgery is now preferred.

Comparison Table: Ethmoidal vs Antrochoanal Polyps

Full YouTube Lecture;

Antrochoanal; https://youtu.be/fMkZsntSxok?si=uVIFXF0wCKSJTO7d

Ethmoidal; https://youtu.be/n4uQs-R4q9M?si=08lUJmi3xWqbqsAY