Ethmoidal Polyp – 16 Previous Year DNB Question for Practice

ETHMOIDAL POLYP

Ethmoidal polyps are multiple, bilateral, painless, pearly white, grape like masses arising from the ethmoidal air cells.They are mostly seen in adults.Both sexes are affected.

ETIOLOGY OF ETHMOIDAL POLYP

The following conditions are associated with Ethmoidal polyp:

  • Bronchial asthma – In 20-50% of patients with polyps
  • Cystic Fibrosis – Allergic nasal polyps are rarely, if ever seen in childhood. They are only seen in childhood in association with mucoviscoidosis (Cystic Fibrosis).
  • Allergic rhinitis
  • AFS (Allergic fungal sinusitis)- Polyps in 85% of patients with AFS
  • Chronic rhinosinusitis.
  • Primary ciliary dyskinesia
  • Nasal mastocystosis
  • Aspirin intolerance – In 8-26% of patients with polyps.
  • Aspirin Sensitive Asthma:Samter’s Triad or Aspirin Sensitive Asthma, is a chronic medical condition that consists of asthma, recurrent sinus disease with nasal polyps, and a sensitivity to aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs).
  • Alcohol intolerance – In 50% of patients with nasal polyps
  • Kartegener’s Syndrome
  • Churg-Strauss syndrome – Nasal polyps in 50% of patients with Churg-Strauss syndrome
  • Young syndrome (ie, chronic sinusitis, nasal polyposis, azoospermia)
  • Nonallergic rhinitis with eosinophilia syndrome (NARES) – Nasal polyps in 20% of patients with NARES.
  • Several theories have been postulated to explain the pathogenesis of nasal polyps.
  • Bernoulli’s phenomenon: Pressure drop next to a constriction causes a suction effect pulling the sinus mucosa into the nose.

SITE OF ORIGIN IN A CASE OF ETHMOIDAL POLYP

  • Multiple nasal polypi arises from the lateral wall of nose usually from middle meatus.
  • Common sites are Uncinate process,Bulla ethmoidalis,Ostia of sinuses,Medial surface and Edge of middle turbinate.
  • Allergic nasal polypi almost never arises from the septum or floor of nose.

CLINICAL FEATURES IN A CASE OF ETHMOIDAL POLYP

  • Nasal obstruction: This is usually bilateral.
  • Ethmoidal polyp does not lead to epistaxis.
  • Anosmia(Loss of sensation of smell)-it may lead to loss of taste.
  • Watery nasal discharge
  • Headache also called “Vacuum Headache”
  • Watering of the eyes-Epiphora due to blockage of nasolacrimal duct
  • Sneezing is common as these polyps are allergic in origin.
  • Hyponasal voice (Rhinolalia Clausa) is present due to bilateral nasal obstruction.
  • Broadening of nasal bridge.

On anterior Rhinoscopy:

  • Polypi appears as smooth glistening grape like masses often pale in color.
  • They may be sessile or pedunculated.
  • It is generally bilateral
  • Insensitive to probing.
  • Don’t touch on bleeding.
  • Nasal cavity may show purulent discharge due to associated sinusitis.

INVESTIGATION IN A CASE OF ETHMOIDAL POLYP

  • CT Scan of paranasal Sinuses: This is the investigation of choice.
  • All polypi should be subjected to histology,especially in old age patient as a simple nasal poylp in an old patient may masquerade a malignancy underneath.

TREATMENT OF ETHMOIDAL POLYP

Medical treatment of polyps :

  • Antihistaminics
  • Steroids—
  • Oral and topical nasal steroid administration is the primary medical therapy for nasal polyposis.
  • Topical nasal steroid administration is helpful, either as the primary treatment or as a continual secondary treatment immediately after oral steroids or surgery to prevent recurrence
  • Decongestants such as epinephrine, phenylephrine, xylometazoline, etc.
  • Antifungals (e.g. Amphotericin B) have no role in treatment of polyps.

Surgical treatment:

  • Surgery is done when medical management in unsuccessful
  • Simple polypectomy: When there are one or two pedunculated polyps.
  • Intranasal ethmoidectomy: Indicated when polyps are multiple and sessile.
  • Extranasal ethmoidectomy: This is indicated when polyps recur after intranasal procedures.
  • Transantral ethmoidectomy: 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 ethmoidal air cells approached through the medial wall of the antrum.
  • FESS:These days, ethmoidal polypi are removed by endoscopic sinus surgery (FESS) which is the Surgery of choice.
  • Recurrence is common after removal.

Exam Question of

  • Ethmoidal polyp can cause bilateral  nasal obstruction and loss of taste.
  • Rhinorrhea may be present with Ethmoidal polyp.
  • Ethmoidal polyp may be associated with Cystic Fibrosis.
  • All polypi should be subjected to histology,especially in old age patient as a simple nasal poylp in an old patient may masquerade a malignancy underneath.
  • On examination, smooth, glistening, grape-like masses which are pale in color are seen in case of Ethmoidal polyp.
  • A patient with Ethmoidal polyp may present with is a history of asthma and allergies.
  • Ethmoidal polyp is not associated with epistaxis.
  • Ethmoidal polyp typically occurs in middle aged individuals and not in the first decade of life.
  • Recurrent polyps are seen in Ethmoidal polyp.
  • Epinephrine,Corticosteroids and Antihistamines is the medical treatment of multiple ,bilateral nasal polyp.
  • Extranasal ethmoidectomy should be done in a patient who presents with an Ethmoidal polyp,6 months later after undergoing polypectomy for  Ethmoidal polyp.
  • “Bernoulli’s theorem” explains Nasal Polyp.
  • Multiple nasal polyp in children should guide the clini­cian to search for underlying Mucoviscidosis.
  • Aspirin-sensitive asthma is associated with Nasal Polyp.
  • Most common nasal mass is polyp.
  • Nasal Steroids may be given post-operatively to prevent recurrence in a case of Ethmoidal polyp.

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Ethmoidal Polyp

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