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Nasal Polyps Types, Symptoms, Diagnosis, Treatment

Nasal Polyps Types/Nasal polyp growths are round, soft, semi-translucent, pale or yellow glistening structures that originate from any part of the nasal mucosa or paranasal sinuses (although most commonly from the ethmoid or middle meatus regions). Polyp development has been linked to chronic inflammation, allergy, autonomic nervous system dysfunction and genetic predisposition.

Nasal polyps (NP) are one of the most common inflammatory mass lesions of the nose, affecting up to 4% of the population. They present with nasal obstruction, anosmia, rhinorrhoea, post nasal drip, and less commonly facial pain. Their etiology remains unclear, but they are known to have associations with allergy, asthma, infection, fungus, cystic fibrosis, and aspirin sensitivity. However, the underlying mechanisms interlinking these pathologic conditions to NP formation remain unclear.

Pathophysiology

The true cause of nasal polyps is unknown, but they are thought to be due to recurrent infection or inflammation.^[rx] Polyps arise from the lining of the sinuses. Nasal mucosa, particularly in the region of middle meatus becomes swollen due to collection of extracellular fluid. This extracellular fluid collection causes polyp formation and protrusion into the nasal cavity or sinuses. Polyps which are sessile in the beginning become pedunculated due to gravity.^[rx]In people with nasal polyps due to aspirin or NSAID sensitivity, the underlying mechanism is due to disorders in the metabolism of arachidonic acid. Exposure to cycloxygenase inhibitors such as aspirin and NSAIDs leads to shunting of products through the lipoxygenase pathway leading to an increased production of products that cause inflammation. In the airway, these inflammatory products lead to symptoms of asthma such as wheezing as well as nasal polyp formation.^[rx]

Nasal Polyps Types

There are two primary types of nasal polyps

Ethmoidal – Ethmoidal polyps arise from the ethmoid sinuses and extend through the middle meatus into the nasal cavity. Antrochoanal polyps usually arise in the maxillary sinus and extend into the nasopharynx and represent only 4–6% of all nasal polyps.^[rx]
Antrochoanal – However, antrochoanal polyps are more common in children comprising one-third of all polyps in this population. Ethmoidal polyps are usually smaller and multiple while antrochoanal polyps are usually single and larger.^[rx]

Causes of Nasal Polyps

The exact cause of nasal polyps is unclear.^[rx] They are, however, commonly associated with conditions that cause long term inflammation of the sinuses.^[rx] This includes chronic rhinosinusitis, asthma, aspirin sensitivity, and cystic fibrosis.^[rx]Various additional diseases associated with polyp formation include

Allergic fungal sinusitis
Kartagener’s syndrome
Young’s syndrome
Eosinophilic granulomatosis with polyangiitis
Nasal mastocytosis
Asthma – a disease that causes overall airway inflammation and constriction
Aspirin sensitivity – may cause some people to be more likely to develop nasal polyps
Allergic fungal sinusitis – an allergy to airborne fungis
Churg-Strauss syndrome – a rare disease that causes the inflammation of blood vessels
Chronic rhinosinusitis – is a common medical condition characterized by symptoms of sinus inflammation lasting at least 12 weeks. The cause is unknown and the role of microorganisms remains unclear. It can be classified as either with or without nasal polyposis.^[rx]
Cystic fibrosis (CF) – is the most common cause of nasal polyps in children. Therefore, any child under 12 to 20 years old with nasal polyps should be tested for CF.^[rx]^[rx] Half of people with CF will experience extensive polyps leading to nasal obstruction and requiring aggressive management.^[rx]

Symptoms of Nasal Polyps

Symptoms of polyps include nasal congestion, sinusitis, loss of smell, thick nasal discharge, facial pressure, nasal speech, and mouth breathing.^[rx] Recurrent sinusitis can result from polyps.^[rx] Long-term, nasal polyps can cause destruction of the nasal bones and widening of the nose.^[rx]

Stuffy or blocked nose
Sneezing
Postnasal drip
Runny nose
Facial pain
Trouble with sense of smell
Loss of taste
Itching around the eyes
Infections
A sensation in the nose that it is blocked
Reduced sense of smell
Nasal stuffiness
Postnasal drip –excess mucus running down the path to the back of your throat
Nasal congestion
Snoring
Sleep apnea
Feeling of pressure in the jaw and head
a sensation that your nose is blocked
postnasal drip, which is when excess mucus runs down the back of your throat
breathing through your mouth
a feeling of pressure in your forehead or face

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Diagnosis of Nasal Polyps

The main diagnostic tests include

Nasal endoscopy – A narrow tube with a lighted magnifying lens or tiny camera (nasal endoscope) enables your doctor to perform a detailed examination inside your nose and sinuses. He or she inserts the endoscope into a nostril and guides it into your nasal cavity.
Imaging studies – Images obtained with computerized tomography (CT) can help your doctor pinpoint the size and location of polyps in deeper areas of your sinuses and evaluate the extent of inflammation. These studies may also help your doctor rule out the presence of other possible obstructions in your nasal cavity, such as structural abnormalities or another type of cancerous or noncancerous growth.
Allergy tests – Your doctor may suggest skin tests to determine if allergies are contributing to chronic inflammation. With a skin prick test, tiny drops of allergy-causing agents (allergens) are pricked into the skin of your forearm or upper back. The drops are left on your skin for 15 minutes before your doctor or nurse observes your skin for signs of allergic reactions.
Test for cystic fibrosis – If you have a child diagnosed with nasal polyps, your doctor may suggest testing for cystic fibrosis, an inherited condition affecting the glands that produce mucus, tears, sweat, saliva and digestive juices. The standard diagnostic test for cystic fibrosis is a noninvasive sweat test, which determines whether your child’s perspiration is saltier than most people’s sweat is.
CT scan – CT scan can show the full extent of the polyp, which may not be fully appreciated with physical examination alone. Imaging is also required for planning surgical treatment.^[rx] On a CT scan, a nasal polyp generally has an attenuation of 10–18 Hounsfield units, which is similar to that of mucus. Nasal polyps may have calcification.^[rx]

Treatment of Nasal Polyps

Nasal corticosteroids – Corticosteroid nasal sprays are generally prescribed to reduce the inflammation. This treatment may shrink the polyps or eliminate them.
Oral corticosteroids – If a nasal corticosteroid is not effective, oral corticosteroid may be prescribed. Because oral corticosteroids can cause serious side effects, they are generally taken only for a limited period of time.
Antibiotics – Antibiotics may be prescribed in case of chronic and recurring infection of your sinuses. Some antibiotics also have anti-inflammatory properties which may reduce the inflammation of your sinuses as well as the polyps size.
Antihistamines – If you suffer from allergies, antihistamines may be prescribed to help reducing the allergic inflammation of your sinuses and nose.Spraying nasal steroids into the nose can reduce your runny nose and the sensation of blockage by shrinking the polyp. However, if you stop taking them, symptoms may quickly return. Examples of nasal steroids include – fluticasone (Flonase, Veramyst), budesonide (Rhinocort), mometasone
Allergen immunotherapy (AIT) – is also known as desensitisation, and is sometimes used in people with allergic rhinitis (hay fever) as well as nasal polyps. While AIT often helps allergic rhinitis, it is not known if AIT helps shrink nasal polyps.
Biologicals – Biological drugs are promising novel treatments (new molecules) currently being tested to reduce the size of nasal polyps in patients with chronic rhinosinusitis.
Oral and injectable corticosteroids – If a nasal corticosteroid isn’t effective, your doctor may prescribe an oral corticosteroid, such as prednisone, either alone or in combination with a nasal spray. Because oral corticosteroids can cause serious side effects, you usually take them only for a limited period. Injectable corticosteroids may be used if nasal polyps are severe.
Other medications – Your doctor may prescribe drugs to treat conditions that contribute to chronic inflammation in your sinuses or nasal passages. These may include antihistamines to treat allergies and antibiotics to treat a chronic or recurring infection. Aspirin desensitization and treatment may benefit some patients with nasal polyps and aspirin sensitivity.
Antileukotriene Medications – Oral antileukotriene medications, such as Singulair (montelukast), are theoretically beneficial in people with nasal polyps especially those with an aspirin allergy. People with an aspirin allergy are known to have high levels of leukotrienes, so medications that block these chemicals should help to reduce symptoms of chronic sinus disease and polyp formation.
Nasal Saline Irrigation – Nasal saline irrigation can be especially helpful in people with nasal polyps and chronic sinus infections. This is especially true for those who have had sinus surgery, as the saline can rinse out the sinuses and not just the nasal passages.
Allergy Shots – Many allergists may use allergy shots in an attempt to treat or prevent nasal polyps from growing back after surgery. The best data for the use of allergy shots is in those with allergic fungal sinusitis; allergy shots may also prove to be helpful in those with nasal polyps and evidence of significant allergic triggers.

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Role of Anti IgE Therapy

Based on the concept of S. aureus derived enterotoxins acting as superantigens, massive IgE formation takes place within the airways. Because of the multiclonality, a range of allergens could possibly maintain a constant degranulation of mast cells present in the polyp tissue, which may contribute to disease severity. Omalizumab counteracts these interactions by reducing serum levels of free IgE.
Therapy targeted at IgE also interferes with its binding to the low-affinity receptors inhibiting the amplification of the Th2-type response [rx]. The high costs of treatment with omalizumab, the high frequency of NP, as well as the current lack of data concerning safety in long-term application of omalizumab has to be borne in mind and further studies have to be conducted [rx].

Role of CMC Foam

Recurrence of nasal polyposis after endoscopic sinus surgery can be difficult to manage. Topical steroid sprays and irrigations may not provide adequate treatment and systemic steroid therapy is limited by side effects. Steroid-infused carboxymethylcellulose (CMC) foam as a treatment for recurrence of chronic rhinosinusitis with nasal polyposis after endoscopic sinus surgery has been tried.
Four milliliter of CMC foam hydrated with triamcinolone, 40 mg/ml is placed endoscopically into the ethmoid cavities bilaterally. Statistically significant endoscopic results were obtained regarding improvement in symptoms and endoscopic findings in patients with recurrent sinonasal polyposis after endoscopic sinus surgery [rx].

Tamoxifen

Possible future perspectives in sinonasal polyposis include inhibition of human mast cell proliferation by tamoxifen. A study by Duffy et al. [rx] suggests that tamoxifen might be useful in the treatment of mast cell-mediated diseases. Further studies are needed to prove its efficacy.

Intranasal Furosemide

The best therapeutic approach to relapse of nasal polyposis is to interfere with the early phase of NP development. A key element in this context is the edematous infiltrate. Manipulation of this target may be effective in preventing relapses after surgery. According to this hypothesis, the genesis of nasal polyposis and their relapse is the development of edema secondary to increased plasma and water absorption into the lamina propria of the NP tissue [rx].

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Surgery

An operation may be advised if polyps are large, or if steroid nose drops or tablets have not worked.

Polypectomy involves removing the polyps with a surgical instrument. It can be done through the nostrils, either with local anaesthetic (awake) or under general anaesthetic. The type of anaesthetic might depend on the number and size of the polyps, where they are and how fit you are for an operation.
Endoscopic sinus surgery is done with a general anaesthetic. It might be done where the polyps are very large and numerous, or where they are seriously blocking your sinuses. The endoscope allows the surgeon to see into the sinuses with a camera and to do the operation in a place that is difficult to reach with normal surgical instruments.
More research is needed to show if medical or surgical treatment gives better outcomes than the other. (2)

Prevention

Humidity – if the air in your home is dry, consider using a humidifier.
Hygiene – regular and thorough handwashing reduces the risk of having a bacterial or viral infection, resulting in fewer cases of inflammation of the sinuses and nasal passages.
Manage allergies and asthma – Follow your doctor’s treatment recommendations for managing asthma and allergies. If your symptoms aren’t well-controlled, talk to your doctor about changing your treatment plan.
Avoid nasal irritants – As much as possible, avoid breathing airborne substances that are likely to contribute to inflammation or irritation of your nose and sinuses, such as allergens, tobacco smoke, chemical fumes, and dust and fine debris.
Practice good hygiene – Wash your hands regularly and thoroughly. This is one of the best ways to protect against bacterial and viral infections that can cause inflammation of the nasal passages and sinuses.
Humidify your home – Use a humidifier if the air in your home tends to be dry. This may help moisten your breathing passages, improve the flow of mucus from your sinuses, and help prevent blockage and inflammation.
Use a nasal rinse or nasal lavage – Use a saltwater (saline) spray or nasal lavage to rinse your nasal passages. This may improve mucus flow and remove allergens and other irritants.
Irritants – avoiding irritants, such as some allergens, chemicals, and airborne pollutants (which cause inflammation) may help some people reduce their risk of developing polyps.
Management of asthma and allergies – patients who follow their doctor’s recommendations regarding asthma and/or allergy treatment are less likely to develop nasal polyps.
Nasal lavage or nasal rinse – rinsing the nasal passages with a nasal lavage or saline spray will help improve the flow of mucus and remove irritants and allergens.