Nasal polyposis

Nasal polyposis consists of a chronic inflammation affecting the nasal cavity and the pasarasanal sinuses (Figure 1) (Figure 2).

Initially the ethmoid is affected, but on the long-term also the maxillary, the frontal and the sphenoid sinuses may become involved. The origin of nasal polyps still is still unkown. There are several hypotheses: allergy, fungal, genetic, environmental pollution, changes in the aerodynamic flow of air, the autonomic nervous system dysfunction, infections, ciliary abnormalities, impaired metabolism and cell homeostasis of sinonasal mucosal, and factors of local edema. Initial symptoms are usually nasal obstruction or congestion and loss of sense of smell (hyposmia or anosmia). For the diagnosis is often sufficient visualization of polyps by nasal rhinoscopic or endoscopic examination (Figure 3).

 Fig 1: right nasal polyp Fig 2: right nasal polyp Fig 3: nasal polyps classification

In cases of polypoosis refractory to medical treatment a preoperative CT scan helps in assessing the extension of the polyposis (Figure 4) (Figure 5) (Figure 6) (Figure 7) (Figure 8) (Figure 9) (Figure 10) (Figure 11).

Fig 4: mild nasal polyps Fig 5: mild nasal polyps Fig 6: moderate nasal polyps Fig 7: moderate nasal polyps
 Fig 8: moderate nasal polyps   Fig 9: severe nasal polyps Fig 10: severe nasal polyps Fig 11: severe nasal polyps

The bilateral nasal polyposis must be differentiated from other pathologies.

1. Antrochoanal polyp or Killian (Figure 12) (Figure 13) (Figure 14)
2. Etmoidocoanal sphenochoanal polyp (Figure 15) (Figure 16)
3. Anatomical variations
4. Allergic fungal sinusitis
5. Chronic infections (TBC)
6. Neoplastic processes in childhood
– Rhabdomyosarcoma
– Nasoangiofibroma (Figure 17)
– Encephalocele / Meningocele
– Dermoid cyst
– Hemangioma
7. Neoplastic processes in adults
– Inverted papilloma (Figure 18)
– Encephalocele / Meningocele
– Esthesioneuroblastoma olfactory
– chondrosarcoma
– Chordoma
– Lymphoma
– Teratoma
– Melanoma

 Fig 12: antrochoanal polyp Fig 13: right antrochoanal polyp Fig 14: right antrochoanal polyp Fig 15: left sphenochoanal polyp
 Fig 16: left sphenochoanal polyp Fig 17: juvenil angiofibroma Fig 18: invertid papilloma Fig 19: treatment algorithm

Chronic rhinosinutis with polyposis is mainly submitted to a “sandwich”- medical – surgical – medical treatment. Drugs with evidence based results are topical and oral steroids, as well as long-term antibiotic treatments. Refractory cases are submitted to an endoscopic removal of the polyps and enlargement of the natural openings of the paranasal sinuses (Figure 19) (Video Clip 1) (Video Clip 2).

Potential surgical steps are:

ï  Infundibulotomía and meatotomy.

ï  Anterior ethmoidectomy.

ï  Posterior ethmoidectomy.

ï  Opening of the frontal recess.

ï  Esfenoidotomía.