Nasal polyps

Nasal polyps

By:
Tutut SRIWILUDJENG T.
Dr. Wahidin Sudiro Husodo Mojokerto

INTRODUCTIONRice polyp is an abnormal lesion originating from the nasal mucosa or paranasal sinuses. Usually the end result of various disease processes in the nasal cavity. Polyps are white translucent or grayish -, shiny, soft as many contain liquids (polyps edematosa). Polyps that can turn into long straw - brass or pink - reddish, dim and more jenyal (fibrous polyps).Polyps were mostly from etmoid sinus mucosa, usually multiple and can be bilateral. Polyps originating from the maxillary sinus is often singular and grow towards the rear, appear koanal dinasofaring and called polyps, usually out of the sinus tract.The cause of nasal polyps is unclear, but it has to do with allergies, asthma, infections and fibrosik. Complaints of patients who come to a blockage of the nose on the nose that the longer the more severe, disturbances of smell and headaches.
 Handling polyp is a combination of medical therapy and surgery. Indications of surgery are usually due to failure of medical therapy.The purpose of this paper is to review the diagnosis and tatalaksanaan nasal polyps.
1. IncidentIncidence in the general population to reach 4%. In children keadian very rare 0.1%, while in adults 1-4%. Manifestation usually occurs at the age above 20 years, more often at the age of 40 years whereas in children under 10 years are very rare. The ratio of men - men and women 2-4: 1, whereas in children have not obtained the report.
2. EtiologyThe basic mechanism of polyps is not known with certainty. Some factors that play a role as a cause of such allergies, chronic inflammation vasomotor imbalance, changes in polysaccharides.Nasal polyps are usually formed as a result of hypersensitivity reactions or allergic reactions in the nasal mucosa. Role of infection in the formation of nasal polyps is not known with certainty but there is doubt - doubt that the infection in the nose or paranasal sinuses are often found along with the polyp.Polyps originating from swelling of the surface layer of the nasal mucosa or sinuses, which then stand out and down into the nasal cavity by gravity. Polyp contains many intercellular fluid and inflammatory cells (neutrophils and eisinofil) and has no nerve endings or blood vessels.
 3. PathophysiologyAt the beginning of the level found in the mucosal edema that mostly contained in the meatus medius. Then the stroma will be filled by the intercellular fluid, so that the swollen mucosa becomes polipoid. If the process continues, the swollen mucosa continues to expand and then going down into the nasal cavity while forming stem, forming polyps.Polyps in the pouch of rice formed by a long process of inflammation. The most common cause is chronic sinusitis and allergic rhinitis. In the long term, long vasodilation of submucosal blood vessels causing edema of the mucosa. Mucosa will be irregular and pushed into the sinus and eventually form a structure called polyps. It usually occurs in the maxillary sinus, and sinus etmoid. After polyp growing in antrum, will descend into the rice pouch. This happens because a sneeze and a recurring expenditure secret that is often experienced by people who have a history of allergic rhinitis due to perennial allergic rhinitis which is widely available in Indonesia due to the lack of variation so that the allergen season there throughout the year. Once in the pouch of rice, polyps will continue to expand and cause obtruksi bias in the media meatus.
4. Clinical symptomsThe main symptoms caused by nasal polyps is a sense of blockage in the nose. These blockages are not intermittent and increasingly heavy complaints, depending on their location and size of polyps. In severe blockage can cause symptoms hiposmia or anosmia. When polyps obstruct the paranasal sinuses, it will occur as complications of sinusitis with symptoms of headache and rinore. If the cause is allergies, then the main symptoms are sneezing and irritation in the nose.Manifestation of symptoms depends on the size of the polyps. Small polyps do not cause symptoms and usually only known after a routine examination. The symptoms will arise when there obtruksi airway.Polyps can cause massive obtruksi nasal cavity and nasopharynx. This is what causes the symptoms obtruksi during sleep and breathe through your nose.
5. ExaminationExamination begins with rinoskopi anterior. For children using otoskop and speculum. Otoskop placed in nostrils to see the Konka inferior, anterior septum and other areas in the nostril which is an extension of Konka medius and partial septum. The lateral part of the meatus medius can only be viewed using the anterior rinoskopi.In children can be used flexible fiberoptic nasopharyngoscope a less traumatic for children who are not cooperative.In rinoskopi anterior. For children using otoskop da speculum. Otoskop placed in nostrils to see the Konka inferior, anterior spektum and other areas in the nostril which is an extension of Konka medius and partial septum. The lateral part of the meatus medius can only be viewed using the anterior rinoskopi.In children can be used flexible fiberoptic nasopharingoscope a less traumatic for children who are not cooperative.In rinoskopi anterior nasal polyps often be distinguished from Konka nasal polyp-like (Konka polipoid). The difference between polyps and Konka polipoid is stemmed, low effort, kondidtensi soft, not tender, not easy to bleed, the use of vasoconstrictors. (Cotton adrenaline) is not shrinking.
Figure 2: Nasal polyps in the right middle meatusQuoted from: Drake - Lee AB. Nasal polyps. Hospytal Med 2004; 65: 264-7
6. RadiologicalPlain sensitive and not worth to diagnose nasal polyps because it only shows picture radioopak on the affected sinus. Standard criteria for evaluating nasal nose is thin pieces 1-3 mm CT scan of maxillofacial region with axial and coronal sinus pieces. MRI is used when there is suspicion of involvement danperluasan until intrakarnial.
Figure 3: CT scan coronal cut, looks enlargement of the maxillary centralQuoted from: McClay J Nasal http://emedicine.medscape.com/anticle/994274-overview.
7. HistologyColumnar epithelial polyps studded pseudo-closed, some areas are experiencing a apitel skuamus metaplasi with a thick base membrane, thereby reducing mucus glands, thus providing contributions to enhance epithelial mucus secretion. Nasal polyps contain more eosinophils, neutrophil and plasma cells compared with nasal mucosa. The mechanism that causes the accumulation of eosinophils in nasal polyps is unknown.
8. ManagementManagement of nasal polyps is a combination of observation, Medika mentosa and dissection of the case by case basis. In general, patients initially received medical therapy prior to surgery by ENT specialist. The goal of therapy is to reduce or eliminate the amount of nasal polyps thus eliminating obtruksi expedite the flow of the sinuses, improve function pembauan and taste. Symptoms of rhinitis therapy is also required.
Medical 8.1Giving kortikostroid proven cure topical nasal polyps. This is caused by a combination of anti-inflammatory effect that reduces the infiltration of eosinophils.Oral medications such as prednisone 50 mg / day or dexamethasone for 10 days, then dose reduced slowly - land (tappering off). Intrapolip injection, for example triamsinolon prednisolone acetonide or 0.5 cc, once every 5-7 days, until polipnya missing. Nasal spray containing corticosteroids, a drug for allergic rhinitis, often used together or as advanced oral corticosteroid treatment. Systemic effects of this drug is very small, making it more secure.Giving antibiotics for infections aimed at preventing the growth of polyps and reduce bleeding during surgery. Antibiotics are given must comply with staphylococcal bacteria, streptococcus and anaerobic bacteria that normally exist in chronic snisitis. Pseudomonas aeruginosa is usually found in patients with cystic fibrosis, especially for patients with imunokompromise. Roxitromisin makrolide group reported to inhibit fibrosis and prevent progesivitas of nasal polyps.
8.2 SurgerySurgical treatment is used in case of a failed medical. No single type of surgical therapy proven to provide relief and patients usually get a procedure repeated and long-term medical therapy.Polyp extraction is the simplest action in cleaning nasal polyps. Performed with local anesthesia or general and polyp extraction by forceps or polyp snare Blakesly.In cases of recurrent polyps - again, needs to be done etmoidektomi operation because generally comes from the sinus polyp etmoid. Edmoidektomi aim to lift semnua polyp tissue with all sellulea etmoid, ensuring drainage into the nasal cavity etmoid labyrinth and prevent complications to the orbit and frontal and maxillary sinus.Functional Endoscopic Sinus Surgery (BSEF) is done for cases - cases in which nasal polyps accompanied by acute or chronic sinusitis of polyps - small polyps in the meatus medius. The principle is to open and clean BSEF ostiomeatal complex that no longer hanbatan ventilation and drainage. Endoscopic tool used is a rigid endoscope sinus equipped with angled teloskop 25 and 70 and has a vacuum.
9. EvaluationEvaluation of nasal polyps beginning of anamnesis and supplementary examination symptoms.
Figure 1: Flow evaluation and nasal polyps tatalaksanaanQuoted from: Naclerio RM, Mackay I: Guidelines for the management of nasal polyposis. In Nasal Polyposys: An infalmmantory Disease and its Treatment. Edited by Mygind N, Lildholdt T. Compenhagen: Muksgaard; 1997: 177-180
10. PrognosisNasal polyps often grow back, therefore the treatment also should address the cause. Recurrence occurs in severe cases reach 50-10%.
SummaryPolyps rice is one that provides ENT disease on nasal obstruction complaints are settled and the longer felt heavier.In the anamnesis of patients, obtained nasal complaints obtruksi, anosmia, a history of allergic rhinitis, frontal region headaches or around the eyes, the nasal secretions.On examination the anterior rinoskopi found a soft mass, stemmed, low effort, no tenderness and no decline in the delivery of local vasokontriktor.Treatment for polyps of this rice in a conservative bias as well as operative, which is usually chosen by looking at the size of the polyp itself and complaints from the patients themselves.In patients with a history of allergic rhinitis, polyps rice has a greater chance for recurrence, so the possibility of the patient must undergo polipektomi several times in his life.
REFERENCES1. Mangunkusumo E, Wardani S. Nasal polyps. In: Soepardi EA, Alexander N. Ed. Textbook Ear Nose Throat Health Sciences 6th edition jakarta: FK-UI Balai publisher, 2007.h.123 - 124.2. McClay J Nasal polyps 2008 October 223. Hedman J, Kaprio J, Poussa T, et al. Prevelance of asthma, aspirin intolerasce, nasal polyposis and chronic obstructive pulmonary disease in a population-based study. Int J Epidemiol 1999; 28: 717-22.4. Drake-Lee AB. Nasal Polyps In Mackay IS, Bull Tr, eds. Scott Browns Otolaringology, Vol 4 Rhinology 5th ed. London: Butterwoths, 1987: 142-1535. Tos M, Sasaki Y, Ohnishi M, Larsen P, Drake-Lee AB. Fireside conference 2. Pathogenesis of nasal polyps. Rhinol Suppl 1992; 14: 181-5.6. N. Mygind Nasal polyps In: Philips Norman ed. Essential Alergy. An Illustrated text for student and specialist. Oxford: Blackwell Scientific publication, 1986: 324-328.7. Drake-Lee AB. Nasal polyps Hospital Med 2004; 65: 264-7.8. Linuma T, Hirota Y, Kase Y. Radio-opacity of the paranasal sinuses. Conventional views and CT. Rhinology 1994; 32: 134-6.9. Kim SS, Kim KS, Lee JG, et al.: Levels of intracellular protein and messenger RNA of mucin and lysozyme in normal human nasal and polyp epithelium. Laryngoscope 2000, 110: 276 -280.10. Morinaka S, Nakamura H: inflammatory cells in nasal mucosa and nasal polyps. Auris Nasus larynx, 2000, 27: 59-64.11. N. Mygind Advances medical treatment of nasal polyps. Allergiy 1999; 54: 12-16.12. Burgel PR, Cardell LO, Ueki IF, et al. intranasal steroids Decrease eosinophils but not mucous expression in nasal polyps. Eur Resp J 2004; 24: 549-600.13. Nonaka M, Pawankar R, Tomiyama S, et al. A macrolide antibiotic, roxithromycin, inhibits the growth of nasal polyps fibroblasts. Am J Rhinol 1999, 13: 267-272.14. Fokkens W, Lund V, Mullol J; European Position Paper on Rhinosinusitis and Nasal polyps Group. 2007. EP3OS 2007: European position paper on rhinosinusitis and nasal polyps A summary for otorhinolaryngologists. Rhinology 2007; 45: 97-10.15. Ballantyne, J. Nasal polyposis In: Ballantyne J, Groves J eds Scott Brown's Diseases of the Ear, Nose and Throat 4th ed The Nose and sinuses. London; Butterswoths, 1979: 25-234.16. Montgomery W, Singer M, Hamaker R. Tumors of the nose and paranasal sinuses In: Ballanger JJ, ed. Disease of the Nose, Throat, Ear, Head and Neck 13 ed. Philadelphia: Lea and Febigen; 1995: 282-293.17. Stammberger H. Surgical treatment of nasal polyps: past, present, and future. Allergy 1999; 54: 7-11.18. Naclerio RM, MacKay I: Guidelines for the management of nasal polyposis In Nasal polyposis: An Inflammatory Disease and Its Treatment. Edited by Mygind N, lildholdt T. Copenhagen: Munksgaard, 1997:177 - 180.

Editing By : Nuryaqin_EnongXP