A patient with nasal polypi is usually an adult, who presents with long standing nasal obstruction, which becomes complete from time to time, with or without a nasal discharge. He has grey fleshy masses in both his nasal cavities. When you remove them, they look like skinned grapes. Polypi are common and treatable. Try non-operative treatment first, and if this fails, remove as many as you can surgically. Some polypi of the maxillary antrum are so large that they project through the ostium into his nasopharynx, and have to be removed through his mouth. If a polyp is on one side only, it may be malignant (or, very rarely a meningocele), so treat it as such, until you have proved it is benign.
Fig. 25-8 THE MOFFAT POSITION FOR PUTTING DROPS IN THE NOSE. A, over a table. B, on the floor. If a patient inserts drops in either of these positions, and remains in them for 3 minutes afterwards, the drugs they contain are more likely to remain in contact with his mucosa for long enough to be effective.
NASAL POLYPI NON-OPERATIVE TREATMENT. Ask the patient to place 2 drops of betamethasone (50 [gm]g) into each nostril twice daily for 4 weeks, while he is in the Moffat position in Fig. 25-8, and ask him to remain in this position for three minutes afterwards.
REMOVING POLYPI UNDER LOCAL ANAESTHESIA. Premedicate him thoroughly. Sit opposite him, and ask a nurse to stand behind his head. Spray or douche his nose with lignocaine 2% with adrenalin 1/100,000. Be careful not to exceed the maximum dose (A 5-1). Wait for 5 minutes.
With a good light coming over your right shoulder, open his nostrils with a nasal speculum. Pass a Glegg's polypectomy snare, manoeuvre the loop to catch a polyp round its base, and remove it. If polypi do not come out with the snare, pull them out piecemeal with angled forceps.
Repeat the process, until you have removed as many polypi as you can. If he feels pain, spray more anaesthetic and wait another 5 minutes. If he bleeds excessively at the end of the operation, pack his nose as for epistaxis (25.6).
REMOVING POLYPI UNDER GENERAL ANAESTHESIA enables you to remove them more completely than under local anaesthesia, but there will be more bleeding. Avoid ketamine, because the laryngeal and pharyngeal reflexes are partly preserved, and cause trouble. Give him a general anaesthetic, intubate him, and pack his throat with a large pack. Be sure the throat pack is visible all through the operation, or has a stout thread fixed to it. Have good suction available. Large clots can form in his pharynx, and be aspirated when you remove the tube. So clear his throat first, and remove the pack with care.
When you have removed all the polypi you can, pack his nose with an anterior pack each side (25.6). Send him back to the ward lying on his side.