Ethmoidal Polyp
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👃 Ethmoidal Polyp
Ethmoidal polyp is a common OPD case and an important long case or short case in practical exams.
📝 Definition of a Nasal Polyp
A nasal polyp is an inflammatory, non-neoplastic, hypertrophied, edematous mucosa prolapsing out of the nose or paranasal sinuses.
Two Types
1- Antrochoanal polyp
2- Ethmoidal polyp
🔍 Origin of the Ethmoidal Polyp
Arises from multiple air cells of the ethmoidal labyrinth.
⭐ Ethmoidal polyps are bilateral and multiple, whereas the antrochoanal polyp is solitary and unilateral.
What are the common sites of origin of the Ethmoidal Polyp?
What are the differences between Antrochoanal Polyp and Ethmoidal Polyp?
🔍 Etiology of Ethmoidal Polyp
⭐ The etiology is complex and not well understood.
It has been hypothesized that ethmoidal polyps arise from:
- Inflammatory conditions of the nasal mucosa
- Disorders of ciliary motility
- Abnormal composition of the nasal mucus
Diseases Associated with Nasal Polyposis
| Disease | Association |
|---|---|
| Chronic rhinosinusitis | Both allergic and non-allergic origin |
| Asthma | 7% of asthma patients develop nasal polyp |
| Aspirin Exacerbated Respiratory Disease | 36% of patients with aspirin sensitivity develop nasal polyp |
| Cystic fibrosis | 20% of patients develop polyp |
| Allergic fungal rhinosinusitis | Almost all cases develop polyp |
| Primary ciliary dyskinesia | 27% of patients exhibit nasal polyp |
| Young's syndrome | Rare; obstructive azoospermia, bronchiectasis and sinusitis with polyp |
| Churg-Strauss syndrome (now called Eosinophilic Granulomatosis with Polyangiitis) | 50% of patients develop nasal polyp |
| Nasal mastocytosis |
⭐ In a child with bilateral ethmoidal polyp, screen for cystic fibrosis.
What is Samter's Triad?
What is Kartagener's Syndrome? What are the features seen in Kartagener's Syndrome?
Theories of Etiology
- Bernoulli's Phenomenon
- Vasomotor Imbalance Theory
- Jackson's Mucopolysaccharide (Ground Substance) Theory
- Polypeptide Theory
- Allergy
Describe the different theories of etiology of Ethmoidal Polyp in detail.
🔬 Pathology of Ethmoidal Polyp
Epithelium
- Covered by ciliated columnar epithelium, the normal nasal mucosa
- May undergo metaplastic change to transitional or squamous type on exposure to atmospheric irritation
Submucosa
- Large intercellular spaces filled with serous fluid
- Infiltration with round cells and abundant eosinophils
- IgE is raised, especially in polyps of allergic origin
🗣️ Clinical Features of Ethmoidal Polyp
Age Group - Adults
Which age group is more common for Antrochoanal Polyp?
Symptoms of Ethmoidal Polyp
-
Bilateral Nasal Obstruction
-
Nasal Discharge
-
Hyposmia or Anosmia
-
Features of Associated Sinusitis
- Post nasal drip
- Hawking
- Headache
-
Rhinolalia Clausa
-
Features of Nasal Allergy
-
Mass Protruding Out of the Nostril
-
Snoring and Mouth Breathing
-
Broadening of the Nose
Which deformity of face is seen in long standing cases of Ethmoidal Polyp?
What is Rhinolalia Clausa?
What is Rhinolalia Aperta?
Signs of Ethmoidal Polyp
External Nose (Inspection)
- Broadening of the nose
- Widening of the intercanthal distance
Anterior Rhinoscopy
Bilateral, multiple, pale or greyish, smooth, glistening masses, appearing like a bunch of grapes.
- Mobile
- May be sessile or pedunculated
On Probing
- Soft in consistency
- ❌ Does not bleed on touch, as it is not a vascular mass
- ❌ Insensitive to touch, as there are no nerve fibres
- ✅ Probe can be passed all around
On Vasoconstriction - ❌ Does not shrink
Why is Ethmoidal polyp insensitive to touch?
How will you differentiate Ethmoidal polyp from Inferior Turbinate Hypertrophy?
Posterior Rhinoscopy
- Usually no abnormality.
🧪 Investigations of Ethmoidal Polyp
1- Diagnostic Nasal Endoscopy
- Site of origin of the polyp
- Extent of the polyp
- Any additional pathology or anatomical variations
2- CT Paranasal Sinuses
- Shows hypodensity in the ethmoidal region
- Assesses the origin and extent of the polyp
- Identifies invasion of surrounding structures
3- Allergic Testing
🩻 Treatment of Ethmoidal Polyp
💊 Medical Treatment
⭐ Every patient can undergo a trial of medical therapy.
1- Intranasal Corticosteroids
What is the role of Intranasal corticosteroids in Treatment of Ethmoidal Polyp?
2- Systemic Steroids
- Used only in severe cases or very large polyps
3- Antihistamines
- For cases of allergy
4- Leukotriene Inhibitors
- Particularly helpful in patients with aspirin sensitivity
5- Nasal Douching and Saline Nasal Spray
- Clears mucus and removes allergens
- Gives symptomatic relief
✂️ Surgical Treatment
📌 Indication
Patients not responding to medical treatment.
Surgery of Choice
👉 Functional Endoscopic Sinus Surgery (FESS)
What are the steps of FESS for Ethmoidal Polyp?
External Ethmoidectomy
⭐ Done only for very large polyps where FESS is not possible.
⭐ Prognosis
⚠️ High chance of recurrence, because of:
- The allergic etiology
- Incomplete removal
What is the Differential Diagnosis of Ethmoidal Polyp?
🧠 Viva Pearls
- A nasal polyp is an inflammatory, non-neoplastic, hypertrophied edematous mucosa prolapsing from the nose or paranasal sinuses.
- Ethmoidal polyps arise from multiple air cells of the ethmoidal labyrinth.
- Ethmoidal polyps are bilateral and multiple; antrochoanal polyp is solitary and unilateral.
- Ethmoidal polyp is associated with allergy, antrochoanal polyp with infection.
- A child with bilateral ethmoidal polyp should be screened for cystic fibrosis.
- Almost all cases of allergic fungal rhinosinusitis develop polyps.
- Submucosa shows abundant eosinophils, and IgE is raised in allergic polyps.
- Most common symptom is bilateral nasal obstruction of slow onset.
- Anterior rhinoscopy shows bilateral, multiple, pale greyish, smooth glistening masses like a bunch of grapes.
- Posterior rhinoscopy usually shows no abnormality.
- FESS is the surgery of choice.
- Ethmoidal polyp has a high rate of recurrence.
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