Clinical Case Discussion: Ethmoidal Polyp

👃🏻 Clinical Case Discussion: Bilateral Ethmoidal Polyposis

Today, we'll be doing a clinical case discussion on Bilateral Ethmoidal Polyposis, a common case often encountered in examinations.

This case discussion format will be helpful for both undergraduates and postgraduates.

We'll go through the patient's history, discuss how history guides us to a provisional diagnosis, cover the clinical examination findings and their significance, summarize the case, arrive at a provisional diagnosis, and outline the management plan.

Let's begin!

📋 Patient History

Here's the history of our patient:

• Patient Name: Ravi
• Age: 32 years
• Sex: Male
• Location: Bangalore
• Religion: Hindu
• Occupation: Software Engineer

History of Present Illness (HPI):

Patient was apparently asymptomatic one year back when he started complaining of:

1. Bilateral Nasal Obstruction:
   • Onset: Insidious.
   • Duration: 1 year.
   • Side: Started on the right side first, followed by the left.
   • Progress: Gradually progressive in nature to reach the current state.
   • Degree: Partial obstruction on each side.
   • Increases while lying down and on exposure to dust.
   • No diurnal variation.
   • Aggravated by cold weather.
   • Temporarily relieved on using nasal drops.

Associated Symptoms:

• Nasal Discharge: Watery type, non-blood tinged, non-foul smelling.
• Reduced sensation of smell.
• Sneezing and watering of eyes.
• Snoring for the last 2 months.

Negative History (Rule-outs):

(Though not a formal heading, these points are crucial to ask and document within the History of present illness)

• No history of headache.
• No history of mouth breathing.
• No history of chronic irritation in throat and throat clearing
• No history of trauma.
• No history of bleeding from nose.
• No history of ear complaints.
• No history of fever.
• No history of cough.
• No history of double vision.
• No history of changes in voice.
• No history of loosening of tooth.
• No history of significant weight loss.

Past History:

• No history of similar complaints in the past.
• No history of Diabetes Mellitus, Hypertension, Bronchial Asthma, or Tuberculosis.
• No history of surgeries in the past.
• No history of known drug allergy.

Family History:

• No significant family history.

Treatment History:

• History of usage of nasal decongestant drops (with temporary relief).

Personal History:

• Sleep: Reduced
• Appetite - Normal
• Diet - Non-vegetarian
• Bladder/Bowel - Normal
• No addiction history

🗣️ Discussion of History Points

Let's analyze the significance of the history findings, considering the patient's demographics and the chief complaints.

1- Patient Particulars (Age, Sex, Occupation, Region):

• Age (32 years): Falls within the common age range for Ethmoidal Polyps, Rhinosporidiosis, and Inverted Papilloma.

What is importance of Age in history taking here?

Name 2 diseases of nose with Bimodal Age distribution.

• Gender (Male): Some nasal diseases are more common in males (JNA, Rhinosporidiosis, Carcinomas, Inverted Papilloma).

Ethmoidal polyps are common in both but slightly more in males in some studies.

What are some diseases of nose more common in females?

• Occupation (Software Engineer) / Region (Bangalore)

What are some occupations that are related to diseases of nose? Name the diseases.

What is the importance of knowing the region of residence of the patient? Name some diseases which occur more commonly in North and South India.

2- Nasal Obstruction (Bilateral):

• Bilateral Nasal Obstruction: This is a key point.

What are the possible causes of bilateral nasal obstruction?

• Gradually Progressive: Supports a benign process (polyp, benign tumor) rather than a rapidly progressive malignant mass.

• Increases While Lying Down: Consistent with a mobile nasal mass (polyp).

Why does nasal obstruction caused by a mobile nasal mass increase during expiration?

• On Exposure to Dust: Suggests an allergic component, common with Ethmoidal Polyps.

• No Diurnal Variation: Indicates a non-fixed, dynamic cause (polyp) rather than a structural lesion (DNS).

Name some diseases where you see no diurnal variation in nasal obstruction.

• Temporarily Relieved on Using Nasal Drops: Crucial!

Nasal decongestant drops cause vasoconstriction and shrink vascular/mucosal tissues (like hypertrophied turbinates or allergic mucosa). Temporary relief suggests there is a component of mucosal swelling involved (consistent with allergy or inflammation associated with polyps), but it's not complete relief, indicating the presence of a non-shrinking mass (the polyp itself).

Name a condition where excessive nasal decongestant use causes rebound congestion.

3- Associated Symptoms:

a. Watery Nasal Discharge, Non-blood Tinged, Non-foul Smelling:

What are the causes of watery discharge from the nose?

What are the different types of nasal discharge? Name a few causes of each.

• Non-foul Smelling: Points away from infection with specific bacteria, extensive osteomyelitis, neglected foreign body, atrophic rhinitis, fungal sinusitis, myiasis.

• Non-blood Stained: Points away from highly vascular lesions or those with significant ulceration/friability (JNA, neglected FB, Rhinolith, Rhinosporidiosis, Malignancy, Trauma, Granulomatous diseases).

What is the most common cause of Unilateral foul smelling, purulent nasal discharge in children?

What is the most common cause of Unilateral foul smelling, purulent nasal discharge in adults?

b. Reduced Sensation of Smell: Common with nasal masses, especially bilateral ones, as they obstruct airflow to the olfactory epithelium. Consistent with polyps.

Define the following Terms related to Smell: Anosmia, Hyposmia, Parosmia, Cacosmia, Hyperosmia.

What are the causes of Anosmia?

What is the anosmia seen in Atrophic Rhinitis called as? Why?

c. Sneezing and Watering of Eyes: Classic symptoms of allergic rhinitis, strongly linking the polyps to an allergic etiology.

d. Snoring: Indicates significant airway obstruction, consistent with bilateral masses obstructing the nasal cavity/nasopharynx. Reduced sleep is a consequence.

4- Negative History Significance:

• No Headache/Chronic Irritation/Throat Clearing: While polyps can cause these, their absence suggests no significant associated chronic sinusitis or post-nasal drip in this case.

• No Bleeding: Rules out many other nasal masses (JNA, Inverted Papilloma, Malignancy, Rhinosporidiosis, etc.).

• No Ear Complaints: Suggests the polyps are not significantly obstructing the Eustachian tube opening in the nasopharynx yet.

• No Systemic/Malignancy Symptoms: Rules out malignancy (weight loss, voice change, loosening of teeth, double vision, severe pain, etc.), TB (fever, cough), other systemic/granulomatous diseases (rash, joint pain, etc.).

What are the sites of headache in different sinus involvement?

What is Office Headache? Why is it called so?

What is Sludder's Neuralgia?

What are the features of Adenoid Facies?

What is Rhinolalia Clausa? Name some causes.

What is Rhinolalia Aperta? Name some causes.

5- Past History Significance:

• No Similar Complaints: Suggests this is the first major episode requiring attention.

• Diabetes Mellitus & Hypertension:

  • Important for preoperative evaluation.
  • Epistaxis in Hypertensive patient.
  • Fungal infections of nose are common in Diabetic patients.

• No Asthma History:

  • Important to rule out Samter's Triad
  • Knowing asthma status is vital for preoperative assessment (bronchospasm risk with anesthesia/drugs).

What is Samter's Triad?

• No TB History: Rules out nasal TB.

What are the features of Nasal Tuberculosis?

• No Surgeries: Rules out post-operative complications.

6- Treatment History:

• Usage of decongestant drops with temporary relief supports the presence of mucosal swelling, consistent with allergic inflammation associated with polyps.

7- Personal History:

• Reduced Sleep: Due to obstruction/snoring.

• No Addiction: Lowers suspicion for tobacco/alcohol-related malignancies.

✨ Clinical Examination Findings

Let's discuss the significance of the findings on physical examination.

General & External Nose:

• Facial symmetry, skin, osteocartilaginous framework, alla, columella, vestibule: All normal. - Rules out external deformities)

What is Vestibule? Name some diseases of Vestibule.

Anterior Rhinoscopy (Bilateral):

• Septum midline. Floor normal. Inferior turbinate not visualized properly.

• Bilateral, multiple, pale, glistening, polypoidal masses filling the nasal cavities appearing like a bunch of grapes - This appearance is classic for Ethmoidal Polyposis.

• Characteristics on Probe Test :

  • Smooth surface.

  • Mobile. (Indicates they are not fixed structures like turbinates or tumors).

  • Insensitive to touch. (Typical of polyps, due to lack of nerve endings; differentiates from sensitive turbinates or malignant tumors).

  • Does NOT bleed on touch. (Typical of simple polyps, due to avascular nature; differentiates from vascular/friable masses like JNA, Inverted Papilloma, Rhinosporidiosis, Malignancy).

  • Soft in consistency (gelatinous, edematous). (Typical of polyps; differentiates from firmer tumors, Rhinolith).

  • Can be probed all around. (Confirms they are not fixed anteriorly or to the septum/lateral wall in the probed area; helps determine origin).

• Nasal mucosa pale (suggests allergy/edema rather than acute infection).

• Left side findings same as right.

What is the name of the instrument used to perform Anterior Rhinoscopy?

How do you perform Anterior Rhinoscopy?

What are the structures seen on Anterior Rhinoscopy?

Differentiate a nasal polyp from a hypertrophied turbinate on probe test.

Name conditions where a nasal mass bleeds easily on touch (friable/vascular).

Posterior Rhinoscopy:

• Normal. (Suggests polyps are not extending significantly into the choanae or nasopharynx to be visible on posterior rhinoscopy).

This contrasts with large Antrochoanal polyps or Nasopharyngeal masses.

What is Posterior Rhinoscopy? How is it performed?

What is the size of Posterior Rhinoscopy mirror?

What are the methods of preventing fogging of Posterior Rhinoscopy mirror on introducing it into oral cavity?

What structures are seen on Posterior Rhinoscopy?

Paranasal Sinuses:

• No redness or swelling. Non-tender. (Rules out acute sinusitis tenderness).

Functional Tests:

• Cottle's test shows no improvement bilaterally. Indicates the obstruction is likely due to causes other than the internal nasal valve area.

What is Cottle's Test? How do you perform it? What does a negative Cottle's Test indicate?

What are the boundaries of Internal Nasal Valve?

What is Cottle's line? What is it's importance?

What are Cottle's Areas?

• Cold Spatula test decreased misting, Cotton Wool test reduced movement - Directly demonstrate reduced airflow bilaterally.

• Smell absent: Confirms anosmia due to obstruction of airflow to olfactory area.

What objects are used to test smell?

Why should you NOT use Ammonia to test smell?

What is the Gold standard test for smell?

Other Examinations:

• Eye, Oral Cavity, Oropharynx, Indirect Laryngoscopy, Ear, Neck: All normal. (Rules out local extension of mass to these areas, neck nodes suggestive of malignancy, ear complications from ET obstruction).

  • Importance of Oropharyngeal exam: To see if the polyp hangs down below the soft palate.

  • Importance of Ear exam: To check for Serous Otitis Media/CHL due to ET obstruction by a mass in the nasopharynx.

  • Importance of Neck exam: To check for cervical lymphadenopathy (key in suspected malignancy).

📝 Case Summary

A 32 year old male came with the chief complaint of both sided nasal obstruction for 1 year. Nasal obstruction is insidious in onset, started on the right side first followed by the left, gradually progressive in nature to reach the present state, partial obstruction on each side, increases while lying down and on exposure to dust, no diurnal variation, aggravated by cold weather, temporarily relieved on using nasal drops. a/w watery nasal discharge, non blood tinged, non foul smelling. a/w reduced sensation of smell, sneezing, watering of eyes, snoring. On Examination, Bilateral, multiple, pale, glistening polypoidal masses seen filling the left and right nasal cavity appearing like a bunch of grapes. Has a smooth surface, mobile, insensitive to touch, doesn't bleed on touch, soft in consistency, can be probed all around. Nasal mucosa on the both sides is pale. Cotton wool test shows reduced movement on both sides. Cold spatula test show reduced misting. Smell is absent on both sides.

🩺 Provisional Diagnosis

Bilateral Sinonasal Mass, likely Bilateral Ethmoidal Polyposis.

What are the points in favour of your diagnosis?

What is the definition of a Nasal Polyp?

What are the stages of Polyp formation?

Why are polyps from Ethmoid multiple?

What are the scoring systems for Grading polyps?

🤔 Differential Diagnosis:

• Deviated Nasal Septum (Severe S-shaped) with Compensatory Turbinate Hypertrophy
• Chronic Sinusitis
• Allergic Fungal Sinusitis
• Inverted Papilloma
• Sinonasal Malignancy
• Rhinosporidiosis
• Other Granulomatous Diseases (TB, Wegener's, Sarcoidosis, Leprosy, Syphilis)

What are the clinical features seen in the above mentioned conditions? How would you rule out each in this case?

🏥 Management Plan

Management ALWAYS involves two key aspects: Investigations and Treatment.

🔬 Investigations

To confirm the diagnosis, assess extent, and plan treatment:

1- Routine Blood Investigations: For preoperative evaluation (e.g., CBC, blood sugar, renal/liver function).

2- Diagnostic Nasal Endoscopy:

• To see origin and extent of polyp
• Any additional pathology
• Discharge can be sent for C/S, Fungal hyphae can be sent for KOH mount

What are the 3 pass in performing Diagnostic Nasal Endoscopy? What structures do you see in each of them?

What anesthesia is used for Diagnostic Nasal Endoscopy?

What is the diameter of endoscopes used in Diagnostic Nasal Endoscopy?

What angled endoscopes are usually used in Diagnostic Nasal Endoscopy?

3- CT Scan of Nose & Paranasal Sinuses (Coronal, Sagittal, Axial views):

• To see origin and extent of polyp
• Assess invasion of surrounding structures
• Any anatomical deformities

If you could order only one CT view for sinus surgery, which one and why?

In which CT view do you see the Optic Nerve's relation to the Sphenoid sinus?

What is a Haller cell?

What is Concha Bullosa?

What is a Double Density Sign on CT?

What is Onodi cell?

🏥 Treatment Plan

Treatment involves both medical and surgical treatment, as Ethmoidal Polyposis often has an underlying inflammatory/allergic basis but requires surgical removal of the established polyps.

• Medical Treatment (Initial/Adjunct): Aims to reduce inflammation, shrink polyps (partially), and control underlying allergy/inflammation.

  • Nasal Steroid Sprays: - Cornerstone for long-term control of inflammation and reducing polyp recurrence.

  • Oral Steroids: (e.g., Prednisolone for 1-2 weeks) - Can cause significant temporary reduction in polyp size, improving symptoms and surgical visualization. Used for significant obstruction or pre-operatively.

  • Antihistaminics: For associated allergic symptoms.

  • Reduce exposure to allergens (dust avoidance).

  • Medical treatment alone rarely cures established polyposis but helps manage it and reduces recurrence post-surgery.

What is Medical Polypectomy?

• Surgical Treatment: Indicated when polyps cause significant obstruction or symptoms despite adequate medical management.

Functional Endoscopic Sinus Surgery (FESS) is the standard of care.

Define FESS.

What are the Indications of FESS?

What are the Steps of FESS for Ethmoidal Polyp?

What are the complications of FESS?

What is the most dreaded injury in FESS?

What is the most common extraocular muscle injured in FESS?

This concludes our clinical case discussion on Ethmoidal Polyp. We've walked through the history, examination, provisional diagnosis, and management principles.