Nasal polyp

Question 1

Nasal polyp definition

Answer 1

Protrusions from edematous mucosa of paranasal sinuses

Question 2

Types

Answer 2

1. Antrochoanal
2. Ethmoidal

Question 3

Causes of bilateral nasal polyps in adults

Answer 3

1. Allergy
2. Aspirin exacerbated respiratory disease
3. Eosinophilic granulamatosis with polyangitis/Chrug strauss syndrome
4. Young’s syndrome

Question 4

Causes of bilateral nasal polyp in children

Answer 4

1. Cystic fibrosis
2. Primary ciliary dyskinesia

Question 5

Causes of unilateral nasal polyp in adults

Answer 5

1. Chronic bacterial sinusitis
2. Allergic fungal sinusitis

Question 6

Samter’s triad

Answer 6

Aspirin hypersensitivity, Asthma, Nasal polyp

Question 7

Young’s syndrome

Answer 7

Chronic sinusitis(+/- Nasal polyps), Brochiectasis, Azoospermia/Infertility

Question 8

Churg Strauss syndrome age of onset

Answer 8

30 - 50 years

Question 9

Presentation of churg strauss syndrome

Answer 9

Adult onset asthma
Systemic features: malaise, fever, weight loss, myalgia and polyarthralgia
Bilateral nasal polyps

Question 10

Investigation for churg strauss syndrome

Answer 10

Peripheral eosinophils > 10%
Biopsy: Eosinophilic granulomas, Necrotizing vasculitis

Question 11

Cystic fibrosis also known as

Answer 11

Mucoviscidosis

Question 12

Pathophysiology of cystic fibrosis

Answer 12

Abnormal chloride channels

Question 13

Clinical features of cystic fibrosis

Answer 13

Intestinal obstruction, Chronic sinusitis(Bilateral nasal polyps), Recurrent lung infections, Pancreatitis

Question 14

Test for cystic fibrosis

Answer 14

Sweat chloride test > 70 meq/l

Question 15

Primary ciliary dyskinesis also known as

Answer 15

Kartagener’s syndrome

Question 16

Pathophysiology of PCD

Answer 16

Absence of ciliary movement

Question 17

Clinical features of PCD

Answer 17

Chronic sinusits (+/- Nasal polyps), Bronchiectasis, Dextrocardia/situs inversus

Question 18

Normal ciliary movement rate
Time taken to clear pharynx

Answer 18

5-10 mm/min, 10-20 min

Question 19

Tests for mucociliary clearance

Answer 19

Invitro : Epithelial biopsy and study on electron microscope
In vivo : Saccharine test, Nuclear testing/Scintigraphy

Question 20

CT finding of Allergic fungal sinusitis

Answer 20

Double density/rail track sign

Question 21

Nasal polyp mimics

Answer 21

Concha bullosa
Meningocele
Meningoencephalocele
Glioma
Malignancy

Question 22

Tests to differentiate encephalocele from nasal polyp

Answer 22

Frustenberg test
Transillumination test

Question 23

Why is biopsy contraindicated in case of encephalocele

Answer 23

Biopsy can cause CSF leak

Question 24

Management of nasal polyp

Answer 24

1. Medical management : Steroid nasal spray, Saline nasal spray
2. Surgical management (if medical management is ineffective after 1-2 months): Excision of nasal polyp + FESS
3. Post operative management : Allergic fungal sinusitis : Steroid nasal spray, Antrochoanal polyp - No role of steroid

Question 25

Nasal polyp vs Concha bullosa

Answer 25

Nasal polyp : Bleeding : No pain : No Ability to pass bone all around : + Concha bullosa : +, +, -

Question 26

Difference between Ethmoidal and Antrochoanal polyp

Answer 26

Cause Origin Number Age group Colour Grows Nasal Obstruction Removal Recurrence

Question 27

Symptoms of Antrochonal polyp

Answer 27

Unilateral nasal obstruction which may become bilateral if polyp grows into nasopharynx and obstructs opposite choana Hyponasal voice Mucoid nasal discharge(unilateral or bilateral)

Question 28

Symptoms of Ethmoidal polyp

Answer 28

1.Multiple polyps 2. Nasal obstruction 3. Anosmia/Hyposmia 4. Headache due to associated sinusitis 5. Sneezing and watery nasal discharge due to associated allergy

Question 29

Investigations and tests

Answer 29

Cottle's Cold spatula Cotton wool test Test for olfaction Anterior rhinoscopy Posterior rhinoscopy Probe test PNS examination Nasal endoscopy X ray of PNS (to show the opacity involved antrum) CT scan of PNS X ray lateral view (differentiates between inverted papilloma and nasal polyp)

Question 30

Indications for FESS

Answer 30

1. Chronic bacterial sinusitis unresponsive to medical treatment 2. Recurrent acute bacterial sinusitis 3. Polypoid rhinosinusitis 4. Fungal sinusitis with fungal ball or nasal polypi 5. Antrochoanal polyp 6. Mucocele of frontoethmoid or sphenoid sinus 7. Control of epistaxis by endoscopic cautery 8. Removal of foreign body from nose or sinus 9. Endoscopic septoplasty

Question 31

Contraindications for FESS

Answer 31

1. Inexperience or lack of proper instrumentation 2. Osteomyelitis 3. Threatened introcranial or intraorbital complication

Question 32

Steps of FESS

Answer 32

1. Remove cotton pledgets kept nasal decongestion and topical anaesthesia 2. Inspect the nose with endoscope 3. Submucosal 1% lignocaine and 1:100000 adrenaline injection - on lateral wall, near the upper end of middle turbinate, just below the first injection, middle turbinate posterior aspect, posterior aspect of nasal septum 4. Uncinectomy 5. Identification and enlargement of maxillary ostia 6. Bullectomy 7. Penetration of basal lamella and removal of posterior ethmoid cells 8.Clearance of frontal recess and frontal sinusotomy 9. Sphenoidectomy 10. Nasal packs

Question 33

Post operative management

Answer 33

1. Removal of nasal packs after 24h 2. Antibiotics for 7-10 days 3. Antihistamines for allergic patients 4. Analgesics 5. Saline irrigation - started after 1 week post op - once or twice daily for 1 week 6. Steroid nasal sprays - in allergic cases 7. Endoscopic toilet

Question 34

Complications of FESS

Answer 34

Major: Orbital hemorrhage Loss of vision Diplopia CSF leak Meningitis Brain abscess Massive hemorrhage requiring blood transmission Intracranial hemorrhage Anosmia Injury to internal carotid artery in sphenoid sinus Minor: Periorbital ecchymosis, emphysema Postoperative epistaxis, infection Adhesions Hyposmia Dental pain

Question 35

Techniques of FESS

Answer 35

Anterior to posterior : Stammberger's technique Posterior to anterior : Wigand's technique