Wednesday, April 15, 2020

A Rare Cause of Unilateral Nasal Congestion: Antrochoanal Polyp

Painless Mass Lesions that Grow in the Nose: Nasal Polyps

What is a nasal polyp?

Nasal polyps or nasal polyps are benign (benign) mucosal and often multiple tissue growths that extend to the lumen in the nasal cavity, characterized by multifactorial-induced mucosal inflammation. They have a structure with feet, smooth surface, and consistency of pellets. The most common cause of mass in the nose are polyps. The incidence of nasal polylpine in the community is about 1-4% and it is more common in men than in women.Nasal polyps can usually be seen at any age between the ages of 20 and 40. But if the nasal polyp is seen before the age of 10, it is mostly associated with cystic fibrosis. 


Nasal polyps are rarely seen in children aged 2 and after 60 years old. Although many theories for the causes of nasal polyp have been proposed, the cause is not fully known. It is reported that allergic, infectious, mechanical, immunological and biochemical factors play a role in the formation of nasal polyp. Nasal polyps are usually located in the lateral wall of the nose and often in the middle meatus or along the upper and middle turbinate and mostly originate from the ethmoid sinuses.

Nomenclature


"What is a nasal polyp?" In order to answer the question, it is necessary to explain the meaning of the word polyp first. As is known, there are many organs or tissues in the human body filled with air. Lungs, stomach, mouth, nose, sinuses around the nose, external ear canal are examples. Sinus is generally the name given to the cavities that resemble an open pouch. Sinuses, whose inflammatory condition is known as “sinusitis” among the people, are air-filled cavities in the head bones associated with the nasal cavity and are called “paranasal sinuses”. There is a thin, superficial layer of tissue in the human body that covers all these cavities and consists of cells. The structures such as meat, which grow out of this tissue layer and grow differently from normal structures, are called "polyp". Polyps can develop in any hollow organ or tissue and are named according to their location. Names such as ear, vocal cord, stomach, intestinal polyp are good examples. Polyps can develop from damage to the tissues lining the inner surface of the sinuses around the nose with the inside of the nose or mouth opening into the nose. The structure formed in this case is named as "Nazal Polip" by defining the place of residence with the word "Nazal" in Latin. The disease state in which these polyps are present is called “Nasal Polyposis”. This term refers to the common polyps in the nose and associated sinuses. Nasal polyps are soft, pale colored, sagging inside the nose, painless to the touch, and can be replaced by gravity.


Antrochoanal Polyp

Anthrocoanal polyp

Anthrocoanal polyp is a type of nasal polyp that originates from the maxillary sinus located at both sides of the nasal entrance and can extend back to the nasal cavity and into the nasal airway passage. Sometimes they can reach large sizes, and when viewed through the mouth, they can be bubble-like, with a liquid-filled bubble that extends from top to bottom. It can move with head movements, repeating sinusitis attacks, nasal discharge, decreased smell (anosmia) can be added to the symptoms by disrupting sinus ventilation. Antrochoanal polyps are usually seen in children and are unilateral.

Anthrochoanal polyps are usually seen unilaterally during careful endoscopic examination. In patients with nasal enlargement and deviation of the septum, they may be accidentally overlooked on the side of the passaged obstruction.

Antrochoanal Polyp


What are the symptoms of nasal polyp?

Many patients with nasal polyp complain of severe nasal congestion that does not pass despite typical medications. The following signs and symptoms may occur in patients with nasal polyps
  • Transparent or colored runny nose
  • Decreased sense of smell and tasting and even disappearing completely
  • Headache
  • Sinus pressure
  • Facial pain is more common in people with chronic sinusitis than those with nasal polyps. 
In those with a serious nasal polyp problem, it may be possible to see the polyp in the nostrils. These structures have a jelly-like appearance. At the same time, allergy, asthma, genetic predisposition, chronic rhinosinusitis and genetic predisposition play a role in the formation of nasal polyps. These factors cause chronic inflammation in the nose, causing edema of the nasal mucosa and formation of polypoid structures with intense fluid accumulation.


Nasal polyps mechanically block the flow of air passing through the nose, causing nasal congestion. In addition, depending on whether there is any other accompanying disease, they can cause a runny nose that changes in consistency and color. A large part of this discharge is downward from the adolescent and can cause severe “Asthma” disease or asthma attacks. Since the air taken from the nose is blocked, the sense of smell may be lost or decreased. They can cause headaches due to the fullness of the sinuses or behind inflammatory conditions. Due to the resulting mouth-to-mouth action, there may be complaints such as snoring or sleep apnea, frequent throat tenderness and inflammation, and long lasting flu and flu. Considering that the discomforts in this emerging picture may cause other things, it is possible that the patient will face more pessimistic situations in the long term.


Causes of nasal polyp


The causes of nasal polyp are multifactorial. Commonly reported causes of nasal polyp include infections, allergic causes, immunological factors, metabolic causes, and hereditary transition. Young syndrome, Churg-Straus syndrome, and Kartagener syndrome, which are accompanied by ciliary anomaly, are among the causes that can be seen especially in the nasal polyposis associated with asthma.

Mucosal edema is a major pathological condition that causes polyps to form. Infection, allergy, asthma, aspirin and pain reliever sensitivity, cystic fibrosis, any inflammatory agent may cause mucous edema causing polyps. Some genetic syndromes also cause nasal polyps. In addition, some drugs are held responsible for nasal polyp formation.

How nasal polyps are formed?

It is not known exactly how polyps are formed and which mechanisms are effective in their formation, and it is still being explored by scientists. Damage due to various causes in the superficial tissue lining the nose and sinuses, and its persistence is the most likely reason. The most important factors causing damage are inflammatory conditions and allergies. Continuous contact or inhalation of some harmful substances or some familial-hereditary causes may also play a role in the formation of polyps. These conditions that cause polyp formation can be alone or all together. As a result, the superficial tissue lining the sinuses swells and grows from the mouth of the sinuses into the nose. Nasal polyp usually occurs on both sides. Nasal polyp may also occur in some known diseases such as "Asthma" and "Cystic Fibrosis".

What is sinonasal polyposis?

If polyps develop both in the air spaces near the nose called sinus and through the nose, they are called sinonasal polyp or sinonasal polyposis. Nasal polyp or sinonasal polyposis develops in 1 in 3 of patients with chronic rhinosinusitis.Nasal polyp and sinonasal polyposis are actually the same disease. The only difference between them is where they form in the body. These names are given to describe the prevalence of the disease in the body.

Diagnosis of nasal polyp

In cases with nasal polyps, the diagnosis is made by the patient's history, physical examination (a complete otolaryngology examination) and nasal endoscopic examination, laboratory tests and radiological imaging (computed tomography and magnetic resonance imaging), allergy tests and histopathological evaluation.

The nasal polyp is seen in an anterior rhinoscopic examination as a smooth, pale, transparent and round mass. They are soft, painless and moving masses during manual examination and do not bleed easily. Nasal polyps are mostly masses with two faces.The nasal polyps can be in appearance ranging from extensive mucosal edema to a single polypoid mass or diffuse polyposis that fills all the paranasal sinuses, and polyps can even fill out the nasal cavity and come out of the nares. Diagnostic nasal endoscopy is the most valuable method used in diagnosis.

Paranasal sinus computed tomography (PNS-CT) is taken in coronal and axial plans to see the prevalence of sinonasal disease that does not respond to treatment after 4-6 weeks of medical treatment and to evaluate patient-specific anatomical features.

Magnetic resonance imaging (MRI), on the other hand, is a valuable method to allow the evaluation of soft tissues with lower radiation risk and to make a differential diagnosis of mucus and polyp. However, it is difficult to distinguish retention in the sinuses and mucosal thickening from the nasal polyp In the differential diagnosis, pathological examination is important to distinguish nasal polyps (intranasal polyps) from inverted papillomas, lymphomas, carcinoma and sarcomas, encephalocele and angiofibromas.

Nasal Polyp Treatment and Drugs

Two types of treatment of nasal polyps are possible:

1.Medical treatment


The majority of nasal polyps are shrunk with intranasal and systemic corticosteroid treatment and improvement in nasal congestion, increase in smell and decrease in nasal discharge can be achieved.

Nasal streoid sprays and drops


Topical nasal steroid sprays are used to reduce the size of the nasal polyp and prevent the growth of polyps after nasal polyp surgery. Drops are preferred instead of spray since it reaches the nasal passage and polybe better.

Corticosteroids


Oral corticosteroids quickly reduce the size of the nasal polyp. However, in cases where the cause of nasal polyps is fungal sinusitis, it may be necessary to use low doses of oral corticosteroids for months to prevent the polyps from growing again after nasal polyps surgery.

Antileukotriene drugs


Antileukotriene drugs are especially useful in the treatment of nasal polyps in those with allergies to aspirin.

Nasal lavage


Saline nasal lavage is especially useful in people with nasal polyp and chronic sinus infections. With this method, it also washes the sinuses along with the nasal passages. 

Allergy shots (immunotherapy)


Nasal polyps that grow again after nasal polyp surgery use allergy shots by some doctors for the purpose of treatment or prevention.

2. Surgical Treatment


If nasal polyps block the sinus passages, if there is chronic infection and inflammation due to drainage disorder in the sinuses, if there are polyps that fill the nasal cavity completely and do not respond to medical treatment, the treatment is surgery. Surgical intervention is performed with an intranasal approach in the form of endoscopic sinus surgery. Depending on the extent of the disease and whether there is an accompanying additional pathology, only polypectomy or enlarged sinus interventions can be performed, in which nasal polyps are removed.

Treatment consists of endoscopic sinus surgery and removal of this polyp. The sinus mouth from which the polyp originates is already extended by the polyp. Endoscopically, aspiration of the sinus content from which the polyp originates at the same time is performed to reduce the risk of re-polyp development.

Nasal polyp surgery has shown important changes in parallel with the technological developments in recent years. By planning on the images given by the computerized tomography in millimetrically, surgical procedures that were performed inside the mouth or in some cases outside the face can be performed endoscopically through the nose today. In the endoscopic method, the light source is entered through the nose using the camera and monitor, and the polyps and damaged tissues in the nasal and sinuses are cleaned. After the polyps are cleaned, the areas of the sinuses opening into the nose are checked and if necessary, the sinuses are returned to normal by opening. The surgery can be performed both through regional anesthesia and asleep under general anesthesia. These surgeries are commonly called “Endoscopic Sinus Surgery”. Thanks to the very thin tools used in the endoscopic method, some undesired results that may occur in close organs such as the eyes and brain can be prevented. These new methods not only ensure that the existing structures are not degraded, but also reduce the recurrence rate of the disease by removing even the smallest polyps. Since no incision is made from the outside of the nose, there is no stitch, stitch scar and a visible scar.

Nasal polyps treatment is drug therapy and surgical treatment. In cases where the nasal passage is completely clogged with polyps, at least 3 weeks of antibiotherapy (antibiotic therapy), 1-2 weeks of corticosteroids (cortisone, prendnisone, dexamethasone and similar group drugs), decongestants and cromolin sodium treatment are given. Antihistamine group drug treatments are also added to patients with allergy problems. With the coronal computed tomography taken 4-6 weeks after the start of drug treatment, the response of the polyp to drug treatment evaluates the extent of the disease and the patient's nasal anatomy. Surgical treatment is performed with the aim of removing surgical polyps completely, improving nasal ventilation and providing drainage in sick sinuses in cases where drug treatment is insufficient.Endoscopic treatment approaches are generally used in the surgical treatment of nasal polyps (nasal polyps). By continuing to use drops, sprays and similar drugs in the postoperative period, recurrence of polyps can be delayed or prevented.

What are the risks of the polyp surgery?


The most common problem in endoscopic surgery is bleeding that may occur during and after surgery. However, since intervention to bleeding tissues and vessels is facilitated by developing methods, bleeding can be successfully managed during surgery. Therefore, most of the time, no tampons are placed even after surgery. Apart from that, unnecessary damage (complications) may occur in the body, although it is rarely seen because there are important organs around the nose and sinuses. The most serious of these are the penetration of the eyeball and nerve by entering the eye cavity, the penetration of the brain fluid through the puncture of the brain membrane, injury of the large vessels, damage to the brain tissue and inflammatory events that may occur after these. Some injuries may require serious treatments, while others can be treated with minor interventions. It should be remembered that some undesirable consequences of anesthesia may also occur.

About success rate of nasal polyp surgery


The success rate of patients who have nasal polyp with simple symptoms without any apparent disease and therefore operated on is above ninety percent. However, the success rate decreases with or in common cases with other diseases such as allergy, asthma, cystic fibrosis and aspirin allergy. In these people, nasal polyps may occur again despite everything. In such patients, the post-operative aim is to delay the formation of polyps as much as possible with drug therapy. If necessary, surgery can be repeated.


Postoperative care after nasal polyp surgery


The most important issue after polyp surgery with the endoscopic method is the regular dressing in the form of cleaning the nose properly. Patients are discharged in a very short time, except for special cases, since tampons are not usually used. It is necessary to go to your doctor every few days after the operation, then less frequently. The timing of dressing varies depending on the conditions encountered in the surgery and the doctor's preference. Your doctor will determine the next meeting time after each dressing. Meanwhile, medical treatment should be used regularly. Usually, the doctor will ask the patient to wash his own nose with saline in the first days to try to prevent adhesion and deposits.


Bosphorus - Istanbul - Turkey - ENT Doctor Istanbul - ENT Specialist Istanbul - Nose Job Istanbul - Rhinoplasty Istanbul - ENT Office Istanbul - Dr.Murat Enoz - ENT Clinic Istanbul - ENT Doctor in Istanbul - Nose Job in Turkey
Bosphorus - Istanbul - Turkey - ENT Doctor Istanbul - ENT Specialist Istanbul - Nose Job Istanbul - Rhinoplasty Istanbul - ENT Office Istanbul - Dr.Murat Enoz - ENT Clinic Istanbul - ENT Doctor in Istanbul - Nose Job in Turkey

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul
Private Office:
Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
Appointment Phone: +90 212 561 00 52
E-Mail: muratenoz@gmail.com
Mobile phone: +90 533 6550199
Fax: +90 212 542 74 47




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