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Bleeding Polypus | Nasal Polyps | Nose | Otorhinolaryngology (Ear Nose Throat / E.N.T) | 4th Year (Fourth Year) | MBBS | Detailed Free Notes

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1. EXAM-READY DEFINITION

  • Bleeding polypus is a benign, highly vascular, non-neoplastic lesion of the nose that arises most commonly from the anterior part of the nasal septum, particularly from Little’s area (Kiesselbach’s plexus).

  • It is characterized by:

    • Recurrent epistaxis

    • A small, reddish, friable polypoidal mass

    • A tendency to bleed profusely on touch

One-Line University Answer

Bleeding polypus is a benign vascular lesion of the nasal septum presenting with recurrent epistaxis.

2. TERMINOLOGY & CLASSIFICATION CONTEXT

2.1 SYNONYMS

  • Bleeding polyp of nasal septum

  • Lobular capillary hemangioma (histological term)

  • Pyogenic granuloma (older term)

Important Clarification

  • Despite the name “pyogenic granuloma”, there is:

    • No pus

    • No granulomatous inflammation

2.2 POSITION IN NASAL MASSES

  • Falls under:

    • Benign vascular lesions of the nose

  • Differs from:

    • Inflammatory polyps (ethmoidal, antrochoanal)

    • Malignant tumors

3. EPIDEMIOLOGY (EXAM-FAVORITE POINTS)

3.1 AGE

  • Common in:

    • Young adults

    • Adolescents

  • Can occur at any age

3.2 SEX

  • More common in:

    • Females

3.3 SPECIAL ASSOCIATION

  • Increased incidence during:

    • Pregnancy

  • Known as:

    • Granuloma gravidarum (when occurring in pregnancy)

Exam Pearl

  • Pregnancy-associated bleeding polypus → due to hormonal vascular proliferation

4. APPLIED ANATOMY (VERY HIGH-YIELD)

4.1 NASAL SEPTUM

  • Divides nasal cavity into two halves

  • Composed of:

    • Septal cartilage (anterior)

    • Vomer

    • Perpendicular plate of ethmoid

4.2 LITTLE’S AREA (KIESSELBACH’S PLEXUS)

  • Located on:

    • Antero-inferior nasal septum

  • Rich vascular network formed by:

    • Anterior ethmoidal artery

    • Septal branch of superior labial artery

    • Greater palatine artery

    • Septal branch of superior ethmoidal artery

Clinical Importance

  • Most common site of:

    • Epistaxis

    • Bleeding polypus

4.3 WHY BLEEDING POLYPUS OCCURS HERE

  • High vascularity

  • Repeated trauma

  • Drying and crusting

  • Hormonal influence

5. ETIOLOGY (STEP-WISE, EXAM-ORIENTED)

5.1 LOCAL TRAUMA (MOST COMMON CAUSE)

  • Nose picking

  • Digital trauma

  • Nasal instrumentation

5.2 HORMONAL FACTORS

  • Pregnancy

  • Oral contraceptive use

5.3 INFLAMMATORY IRRITATION

  • Chronic rhinitis

  • Crusting

  • Recurrent epistaxis

5.4 OTHER PREDISPOSING FACTORS

  • Dry climate

  • Poor nasal hygiene

  • Upper respiratory infections

Key Point

  • Bleeding polypus is reactive, not neoplastic

6. PATHOGENESIS (VERY IMPORTANT)

6.1 BASIC MECHANISM

  • Repeated trauma or irritation →

  • Local inflammatory response →

  • Proliferation of capillaries →

  • Formation of vascular granulation tissue →

  • Polypoidal mass with thin epithelium →

  • Easy bleeding

6.2 STEP-BY-STEP PATHOGENESIS

  1. Minor trauma to septal mucosa

  2. Inflammation of subepithelial tissue

  3. Capillary proliferation

  4. Formation of lobulated vascular mass

  5. Thin epithelial covering

  6. Lesion bleeds on minimal touch

6.3 WHY BLEEDING IS PROFUSE

  • Dense capillary network

  • Fragile surface epithelium

  • Absence of muscular layer in vessels

7. GROSS MORPHOLOGY

  • Small polypoidal mass

  • Red or purple in color

  • Soft and friable

  • Pedunculated or sessile

  • Commonly attached to anterior septum

  • Bleeds easily on touch

8. HISTOPATHOLOGY (SCORING SECTION)

8.1 SURFACE EPITHELIUM

  • Thinned stratified squamous epithelium

  • Often ulcerated

8.2 STROMA

  • Lobular arrangement of capillaries

  • Edematous connective tissue

8.3 INFLAMMATORY CELLS

  • Lymphocytes

  • Plasma cells

Histological Diagnosis

  • Lobular capillary hemangioma

9. CLINICAL FEATURES — SYMPTOMS (WITH LOGIC)

9.1 EPISTAXIS (MOST COMMON)

  • Recurrent

  • Profuse

  • Spontaneous or on minor touch

9.2 NASAL OBSTRUCTION

  • Mild

  • Usually unilateral

9.3 NASAL DISCHARGE

  • Blood-stained

9.4 PAIN

  • Usually absent

10. SIGNS ON EXAMINATION

10.1 ANTERIOR RHINOSCOPY

  • Small red polypoidal mass

  • Arising from anterior septum

  • Bleeds on touch

  • Friable surface

10.2 PROBING

  • Soft

  • Profuse bleeding on contact

Examiner Warning

  • Never probe aggressively

11. DIFFERENTIATING FEATURES (EARLY HINTS)

  • Red, vascular lesion

  • Anterior septal location

  • Recurrent epistaxis

  • Unlike inflammatory polyps → bleeds easily

12. INVESTIGATIONS — INTRODUCTORY OVERVIEW

  • Usually clinical diagnosis

  • Biopsy avoided due to bleeding risk

  • Histopathology after excision

(Full investigations & management in Part 2)

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Year / Professional) Otorhinolaryngology (ENT) Free Material

13. DIFFERENTIAL DIAGNOSIS (VERY HIGH-YIELD, EXAM TABLES)

13.1 DIFFERENTIAL DIAGNOSIS OF A BLEEDING NASAL MASS

Feature Bleeding Polypus Ethmoidal Polyp Antrochoanal Polyp Juvenile Nasopharyngeal Angiofibroma Malignancy (SCC)
Color Bright red Pale grey Pale Reddish Irregular
Bleeding Profuse, on touch No No Severe, spontaneous Common
Site Anterior septum Middle meatus Choana Nasopharynx Any
Number Single Multiple Single Single Single
Age Young adults Adults Children Adolescent males Elderly
CT Local septal lesion Ethmoid opacity Maxillary opacity Vascular mass Bone destruction

Examiner Trap

  • Red nasal mass + bleeding ≠ always malignancy

  • Anterior septal origin strongly suggests bleeding polypus

14. INVESTIGATIONS (STEP-WISE, EXAM-ORIENTED)

14.1 CLINICAL DIAGNOSIS

  • Diagnosis is mainly clinical

  • Based on:

    • History of recurrent epistaxis

    • Anterior rhinoscopy findings

14.2 ENDOSCOPIC EXAMINATION

  • Helps:

    • Confirm site of origin

    • Assess extent

  • Done gently to avoid bleeding

14.3 IMAGING

  • Usually not required

  • CT scan indicated only if:

    • Diagnosis is doubtful

    • Suspicion of deeper extension or malignancy

14.4 BIOPSY

  • Not done pre-operatively

  • Risk of severe bleeding

  • Histopathology done after excision

Exam Line

Biopsy of bleeding polypus is contraindicated before excision.

15. MEDICAL MANAGEMENT (LIMITED ROLE)

15.1 WHY MEDICAL TREATMENT IS INEFFECTIVE

  • Lesion is:

    • Structural

    • Highly vascular

  • Does not regress with drugs

15.2 TEMPORARY MEASURES

  • Used only to control bleeding:

    • Nasal packing

    • Topical vasoconstrictors

Important

  • Medical therapy is never definitive

16. SURGICAL MANAGEMENT (CORE EXAM CONTENT)

16.1 TREATMENT OF CHOICE

  • Complete surgical excision with cauterization of base

16.2 PRINCIPLES OF SURGERY

  • Remove entire lesion

  • Destroy feeding vessels

  • Prevent recurrence

16.3 METHODS OF EXCISION

A. ENDOSCOPIC EXCISION (PREFERRED)

  • Performed under:

    • Local anesthesia (small lesions)

    • General anesthesia (large lesions)

  • Steps:

    1. Visualization with nasal endoscope

    2. Grasping polyp

    3. Excision at base

    4. Cauterization of attachment

B. EXCISION WITH ELECTROCAUTERY / LASER

  • Used for:

    • Better hemostasis

    • Reduced recurrence

  • CO₂ laser may be used

16.4 IMPORTANCE OF CAUTERIZATION

  • Prevents:

    • Recurrence

    • Post-operative bleeding

Exam Pearl

  • Failure to cauterize base → recurrence

17. MANAGEMENT IN PREGNANCY (VERY IMPORTANT)

17.1 BLEEDING POLYPUS IN PREGNANCY

  • Known as:

    • Granuloma gravidarum

  • Due to:

    • Estrogen-induced vascular proliferation

17.2 MANAGEMENT STRATEGY

  • Conservative if:

    • Mild bleeding

  • Surgical excision if:

    • Recurrent or severe epistaxis

  • Lesion may regress:

    • After delivery

18. POST-OPERATIVE CARE

  • Nasal packing (if required)

  • Antibiotic ointment

  • Avoid nose picking

  • Humidification

  • Follow-up for recurrence

19. COMPLICATIONS

19.1 IF UNTREATED

  • Recurrent epistaxis

  • Anemia (rare but possible)

  • Anxiety and reduced quality of life

19.2 POST-SURGICAL COMPLICATIONS

  • Bleeding

  • Infection (rare)

  • Recurrence (if base not cauterized)

20. PROGNOSIS

  • Excellent with:

    • Complete excision

    • Adequate cauterization

  • No malignant transformation

21. OSCE / PRACTICAL STATIONS

21.1 SPOT DIAGNOSIS

  • Small red friable nasal mass on septum

Diagnosis: Bleeding polypus

21.2 MANAGEMENT STATION

  • Treatment: Endoscopic excision + cauterization

21.3 COUNSELLING STATION

  • Benign condition

  • No cancer risk

  • Simple surgical cure

22. LONG CASE (UNIVERSITY STYLE)

History

  • 25-year-old female

  • Recurrent unilateral epistaxis

Examination

  • Red polypoidal mass on anterior septum

Diagnosis

  • Bleeding polypus

Management

  • Endoscopic excision + cautery

23. MCQs (EXAM-FOCUSED)

1. Most common site of bleeding polypus:
A. Middle turbinate
B. Nasopharynx
C. Anterior nasal septum
D. Inferior meatus
Correct Answer: C

2. Best treatment:
A. Steroids
B. Antibiotics
C. Excision with cauterization
D. Radiotherapy
Correct Answer: C

24. VIVA QUESTIONS

  • Define bleeding polypus

  • Why does it bleed easily?

  • Common site

  • Management in pregnancy

  • Why biopsy is avoided?

25. EXAMINER TRAPS

  • Biopsying before excision

  • Treating with medicines only

  • Missing pregnancy association

  • Not cauterizing base

26. CLINICAL PEARLS (MUST-REMEMBER)

  • Benign, vascular, reactive lesion

  • Arises from Little’s area

  • Presents with recurrent epistaxis

  • Biopsy contraindicated

  • Excision with cautery is curative

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Year / Professional) Otorhinolaryngology (ENT) Free Material

27. RADIOLOGY–PATHOLOGY–CLINICAL CORRELATION (EXAM-SCORING SECTION)

27.1 WHY THIS CORRELATION MATTERS

  • Bleeding polypus is primarily a clinical diagnosis, but examiners expect you to:

    • Justify why imaging is usually unnecessary

    • Explain why biopsy is avoided

    • Correlate histology with bleeding tendency

27.2 IMAGING FINDINGS AND THEIR SIGNIFICANCE

Aspect Finding Interpretation
Plain X-ray Usually normal Lesion is superficial
CT Scan Small localized septal mass Done only if malignancy suspected
Bone changes Absent Confirms benign nature

Exam Line

Imaging is not routinely required in bleeding polypus because the lesion is superficial and clinically evident.

27.3 HISTOPATHOLOGY–CLINICAL LINK

Histological Feature Clinical Correlation
Lobular capillary proliferation Profuse bleeding
Thin epithelial covering Bleeds on touch
Lack of muscular layer Poor vasoconstriction
Inflammatory infiltrate Reactive lesion

28. SPECIAL SITUATIONS (VERY HIGH-YIELD)

28.1 BLEEDING POLYPUS IN PREGNANCY

  • Term used: Granuloma gravidarum

  • Occurs due to:

    • Estrogen-induced capillary proliferation

  • Common site:

    • Anterior nasal septum

Clinical Behavior

  • Rapid growth

  • Recurrent epistaxis

  • May regress after delivery

Management in Pregnancy

  • Conservative if bleeding is mild

  • Surgical excision if:

    • Recurrent

    • Severe bleeding

  • Prefer local anesthesia

Examiner Trap

  • Waiting indefinitely despite severe bleeding → wrong

28.2 RECURRENT BLEEDING POLYPUS

Causes

  • Incomplete excision

  • Failure to cauterize base

  • Persistent local trauma

Prevention

  • Wide excision

  • Adequate cauterization

  • Patient education

29. COMPLICATIONS (COMPLETE LIST)

29.1 LOCAL COMPLICATIONS

  • Recurrent epistaxis

  • Secondary infection (rare)

  • Anxiety and distress

29.2 SYSTEMIC COMPLICATIONS

  • Iron deficiency anemia (rare, chronic cases)

29.3 POST-SURGICAL COMPLICATIONS

  • Bleeding

  • Crusting

  • Recurrence

30. PROGNOSIS

  • Excellent prognosis

  • No malignant transformation

  • Complete cure with proper excision

  • Recurrence rare if base is cauterized

31. PREVENTION STRATEGIES

  • Avoid nose picking

  • Maintain nasal humidity

  • Treat underlying rhinitis

  • Early treatment of recurrent epistaxis

32. OSCE / PRACTICAL EXAMINATION (FULL SET)

32.1 SPOT DIAGNOSIS

  • Small red friable mass on anterior septum

Answer: Bleeding polypus

32.2 HISTORY STATION

  • Recurrent unilateral epistaxis

  • No nasal obstruction

  • No weight loss

32.3 EXAMINATION STATION

  • Anterior rhinoscopy:

    • Red pedunculated lesion

    • Bleeds on touch

32.4 MANAGEMENT STATION

  • Treatment:

    • Endoscopic excision with cauterization

32.5 COUNSELLING STATION

  • Benign condition

  • No cancer risk

  • Simple surgical cure

33. LONG CASE (UNIVERSITY STYLE)

33.1 HISTORY

  • 30-year-old female

  • Recurrent unilateral epistaxis

  • No nasal obstruction

33.2 EXAMINATION

  • Red friable polyp on anterior septum

  • Profuse bleeding on touch

33.3 DIAGNOSIS

  • Bleeding polypus of nasal septum

33.4 MANAGEMENT

  • Endoscopic excision

  • Cauterization of base

  • Post-operative nasal care

34. SHORT CASES / VIVA FAVORITES

  • Bleeding nasal mass

  • Recurrent epistaxis in pregnancy

  • Septal lesion with profuse bleeding

35. MCQs (FINAL SET)

1. Histological diagnosis of bleeding polypus is:
A. Fibroma
B. Papilloma
C. Lobular capillary hemangioma
D. Angiofibroma
Correct Answer: C

2. Biopsy of bleeding polypus is avoided because:
A. It is painful
B. It causes infection
C. It causes profuse bleeding
D. It delays healing
Correct Answer: C

3. Most common etiological factor:
A. Allergy
B. Trauma
C. Infection
D. Malignancy
Correct Answer: B

36. VIVA QUESTIONS (RAPID-FIRE)

  • Define bleeding polypus

  • Why does it bleed easily?

  • Most common site

  • Management in pregnancy

  • Why biopsy is contraindicated?

37. EXAMINER TRAPS (MUST AVOID)

  • Biopsy before excision

  • Treating with steroids alone

  • Ignoring pregnancy association

  • Incomplete excision

  • No cauterization of base

38. FINAL CLINICAL PEARLS (EXAM GOLD)

  • Benign, reactive vascular lesion

  • Arises from Little’s area

  • Presents with recurrent epistaxis

  • Biopsy contraindicated

  • Excision + cauterization is curative

  • Pregnancy increases risk

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Year / Professional) Otorhinolaryngology (ENT) Free Material

Hunain Zia

Hunain Zia has previously achieved considerable success in the high-school educational stream, gaining a massive 154 Total A Grades and 7 Major Distinctions, a process in which he broke/ set 11 different world records, including the most A grades ever achieved, most subjects ever appeared in, most distinctions, gaining distinctions across two separate boards (Pearson Edexcel and CAIE) within the same year/ ever, and even 19 hours of constant examination. All records stand intact today. Hunain pursued his Honors Accounting Degree from the prestigious Bentley University, and then completed an LLB (in Honors) from University of London. Currently, he manages multiple social and commercial projects, has founded digital streams and works tirelessly in the education sector.

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