Monday, August 25, 2014

NASAL POLYPS WITH ORBITAL INVOLVEMENT

NASAL POLYPS WITH ORBITAL INVOLVEMENT
Dr. V. P. Sood New Delhi.
Past President : Association of Otolaryngologists of India.
Past President : All India Rhinology Society.

Although patients with nasal polyps are common in E.N.T. practice but the aetiology of this condition still remains a mystery. The etiopathogenesis of nasal polyps has long been a subject of study, yet there is little agreement as to the mechanism of polyp formation. So far two main theories have emerged, allergic & infectious. Recently, sensitivity to aspirin and fungal infections have also been implicated as etiologic factors. Nasal polyps has been referred to as "benign allergic polyps" but research suggests that they are not more common in allergic patients. But now allergy has again been considered and there is a possibility that localized nasal allergy may have a role in the aetiology of polyps. The role of fungal infection in the aetiology of nasal polyps has been the source of great debate amongst rhinologists, since allergic fungal sinusitis has recently come to limelight.

In long standing infective polyposis most of the time there is bony necrosis of medial wall of maxillary sinus, lamina papyracia, ethmoid cells and anterior wall of the sphenoid sinuses. Chronic infective polyps degenerate to form into cheesy and muddy material, a condition referred to as necrotising ethmoiditis which should rather be called necrotising sinusitis since disease process is not only localized to ethmoid sinuses but can involve all the sinuses. The extent of endoscopic surgery should be planned and adapted to the requirement of individual cases. For circumscribed pathology minimum invasive endoscopic interventions are indicated. For diffuse polyposis of all sinuses a complete endoscopic ethmoidectomy together with the fenestration of the frontal, sphenoidal and maxillary sinuses is done. The disease is cleared from within the sinus cavities through the enlarged opening of the respective sinus. The end result should be as open ethmoidal cavity lined by moist mucosa and having free communication with the frontal, sphenoidal and maxillary sinuses. In multiple nasal polyps initial clearing is generally done with the help of microdebrider. Surgical results improve by carefull pre-operative planing, use of systemic antibiotics and steroids pre and post operatively. Use of thru-cut forceps and microdebrider also helps to preserve mucosa to achieve better results. Reconstructing adequate antrostomy is also conductive for better results. In diffuse polyposis a short course of systemic steroids pre operatively and post operatively is mandatory followed by topical steroid sprays.

Local application of amphotercin-B is now used especially when polyps are associated with fungal infections. Even in extensive polyposis, I prefer to do endoscopic sinus surgery under L.A. because the pupillary reflexes can be monitored and patient's subjective feedback of excessive pain sensation when the instruments are touching the orbital plate, cribriform plate or fovea ethmoidalis can be warning signals to the surgeon, which increase the safety index in endoscopic sinus surgery. I follow up my patients endoscopically for suction clearance of crusts and discharge. If I find any adhesion in middle meatus that is incised. If any small polyp is visible that is also removed without any pain or discomfort to the patient.

The follow up of patients in our country is poor. Patient must be told about importance of follow up. Modem technology, CT scanning and endoscopy enables us to make an early and appropriate diagnosis of nasal polyposis and Endoscopic Sinus Surgery offers precise and complete removal of polyps. Image guided surgery increase the safety index during endoscpoic sinus surgery. In future, the key to successful management of nasal polyps will be an understanding of the underlying mucosa inflammation, mechanism of polyp formation and the genetic control of etiopathogenesis of nasal polyps.. 

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