Nasal polyps (NP)

What is nasal polyps?

Nasal polyps are benign inflammatory and hyperplastic sinonasal mucosal outgrowths. The most prevalent incidence is in people with chronic rhinosinusitis (CRS). As a result, when describing nasal polyps, the phrase chronic rhinosinusitis with nasal polyposis is commonly applied. 

Polyposis is a late-stage sign of uncontrolled allergies, and treating existing polyposis is merely the beginning of the process. Furthermore, the respiratory physician must be aware of features of NP therapy that can have a major influence on chronic obstructive pulmonary illness, particularly asthma.

Epidemiology

The frequency of NP in the general population is estimated to be approximately 4%. This frequency has been demonstrated in cadaveric investigations to be as high as 40%. They mostly affect adults and are more common in people over the age of 20.

They are rare in children under the age of ten and maybe the first sign of cystic fibrosis. There is at least a 2:1 male to female ratio. Asthma affects up to one-third of NP patients, although polyps are diagnosed in just 7% of asthmatics.

Males are more likely than females to suffer chronic rhinosinusitis with nasal polyposis, according to one study, which found a 38% prevalence in girls and a 62% prevalence in males. Females, on the other hand, are more likely to develop severe illnesses.

Causes for nasal polyps

The cause of NP is unclear. According to some views, polyps are caused by diseases that produce persistent inflammation in the nose and nasal sinuses, marked by stromal edema and varying cellular infiltration.

Localized polyps, diffuse polyps, and systemic polyps are the three types of nasal polyps. Localized nasal polyps are often the result of either inflammatory or neoplastic processes. Patients with chronic rhinosinusitis who have nasal polyposis are more likely to have diffuse nasal polyposis (CRSwNP). CRSwNP has several etiologies.

Patients with cystic fibrosis have neutrophil-driven inflammation within their polyps and can frequently have severe nasal polyposis without a clear allergic trigger, despite the clinical examination being quite comparable. Cystic fibrosis should be considered in the differential diagnosis of a young patient with persistent nasal polyposis, especially if the patient is of European origin.

A cystic fibrosis diagnosis must be made as soon as possible since it has systemic and genetic/familial ramifications. A fungi-driven inflammatory mechanism has also been hypothesized, as has a huge inflammatory response induced by exotoxins from Staphylococcus aureus infections. Finally, people with systemic disorders with nasal symptoms are referred to as having systemic nasal polyposis.

Pathophysiology

Nasal polyps have a wide range of pathogenesis. As we age, the human body undergoes a series of anatomical and functional changes that result in thick mucus stasis and hindered removal of irritants and biologic offenders (viruses, bacteria, fungus), making patients more likely to develop polyps.

The reduced ciliary beat frequency with poor mucociliary clearance, sinonasal mucosa atrophy with decreased vasculature, and decreased mucus output are among the alterations. All of these factors have the potential to enhance the permeability of the epithelial basement membrane and disrupt normal osmotic control between cells.

Overall edema and chronic inflammation occur, resulting in a localized increase in cell and tissue size. Hereditary factors have been mentioned as well (cystic fibrosis being but one of the hereditary factors, there are many others).

One study found a 4.1-fold greater risk in first-degree relatives of CRSwNP patients. Finally, individuals with weak innate and adaptive immunity are more susceptible to bacterial colonization.

Patients with Staphylococcus aureus colonization had greater levels of IgE and eosinophils in nasal polyps, according to research. Furthermore, it is thought that hyperimmune reactions in the presence of fungal components have a role in the creation of nasal polyps.

Nasal polyps are classified into two types: ethmoidal and antrochoanal. Ethmoidal polyps grow from the ethmoid sinuses and expand into the nasal cavity through the middle meatus. Antrochoanal polyps, which often form in the maxillary sinus and spread into the nasopharynx, account for just 4–6% of all nasal polyps.

Antrochoanal polyps, on the other hand, are more prevalent in children, accounting for one-third of all polyps in this demographic. Ethmoidal polyps are generally tiny and numerous, but antrochoanal polyps are usually big and solitary.

Nasal polyps symptoms

Patients with growing nasal obstruction, nasal and/or facial congestion, rhinorrhea, and a diminished sense of smell should be suspected of having nasal polyposis (cardinal symptoms of CRS). Patients should be asked about their susceptibility to aspirin or NSAIDs, as well as the existence of asthma (Samter's triad).

The presence of unilateral symptoms, a history of epistaxis, a history of chronic otitis media, recurrent bronchitis, and/or pneumonia should alert the doctor to the possibility of alternative etiologies.

An anterior rhinoscopy, which can reveal polyps and other neoplasms, should be performed as part of the physical examination. An anterior rhinoscopy or a nasal endoscopic examination is used to make the clinical diagnosis of nasal polyposis. Imaging investigations, such as computed tomography of the paranasal sinuses (PNS CT scan), are occasionally required to determine the severity of the disease and, if warranted, might help in surgery planning.

Although some persons with tiny nasal polyps have no symptoms, the following are common:

• Runny nose – may be chronic, with the sufferer constantly feeling as though they have a cold
• Persistent stuffy or blocked nose – In other situations, the patient may struggle to breathe via the nose, producing sleeping difficulties.
• Postnasal drip – a constant sensation of mucus trickling down the back of the throat
• No sense of smell or poor sense of smell – may not improve after polyps are treated
• Poor sense of taste 
• Pain in the face
• Headache
• Snoring
• Itchiness around the eyes
• Obstructive sleep apnea (in severe cases) – This is a potentially fatal condition in which the patient stops breathing while sleeping.
• Double vision (in severe cases) – If the patient has allergic fungal sinusitis or cystic fibrosis, this is more likely to happen.

Diagnosis

A thorough medical history and physical examination are essential. Patients who fit the CRS criteria should always have an endoscopic evaluation in the clinic. The endoscopic examination will reveal unilateral or bilateral, movable, smooth, grey, and semi-translucent masses emanating from the middle meatus or sphenoethmoid recess if nasal polyps are present.

The presence of unilateral "nasal polyps" should always raise the possibility of a different diagnosis. Inflammatory polyps are nearly always bilateral. While there are benign unilateral polyp etiologies, such as an antrochoanal polyp, the suspicion for cancer should be high, and a biopsy should be performed by an otolaryngologist.

At this point, the diagnosis of chronic rhinosinusitis with nasal polyposis is usually established, and the patient should be sent to appropriate medical therapy. Patients whose symptoms do not improve despite proper medical treatment may need to be evaluated further with a PNS CT scan.

Furthermore, individuals with unilateral symptoms or findings should be investigated as soon as feasible using imaging investigations. Surgery is considered an option for individuals with a confirmed diagnosis of chronic rhinosinusitis with nasal polyposis who have failed to respond to conventional treatment.

Treatment nasal polyps

Depending on the specific instance, NP therapy may include a combination of observation, medicinal, and surgical therapies. In general, patients are treated medically in primary care before an otolaryngologist considers surgical options. The goals of therapy are to eradicate or greatly reduce the size of the NP, resulting in nasal obstruction reduction, sinus drainage improvement, and olfaction and taste restoration.

Medical treatment 

The diverse endotypes and phenotypes of nasal polyps will impact how they are treated in the future. For individuals with chronic rhinosinusitis with nasal polyposis, intranasal corticosteroids and nasal saline irrigations should be tried for roughly 2-3 months. 

High-volume, low-pressure nasal saline irrigations are safe and inexpensive, and they enhance antigen, biofilm, and inflammatory mediator clearance. Intranasal corticosteroids relieve nasal congestion and reduce the growth of polyps.

The use of topically applied corticosteroids has helped the management of upper (NP and rhinitis) and lower (asthma, chronic obstructive pulmonary disease) airway disorders. Their therapeutic effectiveness is accomplished by a combination of anti-inflammatory actions as well as the capacity to diminish airway eosinophilic infiltration by limiting enhanced viability and activation.

Both topical and systemic glucocorticoids can alter eosinophil function by either directly reducing eosinophil viability and function or indirectly decreasing chemotactic cytokine release by nasal mucosa and polyp epithelial cells.

Corticosteroids are the cornerstone of conservative therapy in NP, serving as both primary treatment and a preventative measure. In the absence of additional warning symptoms such as discomfort, bleeding, or unilateral polyps, treatment can be mostly done in primary care. In 'at-risk categories,' such as those with diabetes, uncontrolled hypertension, and peptic ulcer disease, corticosteroids should be administered with caution.

Nasal polyps surgery

When medication therapy for chronic rhinosinusitis with nasal polyposis (CRSwNP) fails, functional endoscopic sinus surgery (FESS) is planned; however, otolaryngologists disagree on when surgery should be performed. Topical intranasal steroids are an important aspect of CRSwNP therapy after surgery.

The physical blockage is removed after surgery, restoring more normal mucosal drainage, but the underlying allergic etiology must be treated. Topical nasal steroids and antihistamines are standard treatments, along with rigorous allergy testing and, if available, tailored immunotherapy.

Biodegradable steroid-eluting stents can be inserted during surgery on a more specialized level. These stents maintain the sinuses open while delivering steroids over the next 30 days or more, reducing inflammation and recurrence. As a result, post-operative treatments and oral steroid use are decreasing.

Even after surgery, nasal saline irrigations and intranasal corticosteroids must be continued to enhance the probability of long-term success. The purpose of surgery is to reduce the disease's inflammatory load and to improve the effects of local drugs in the post-surgical sinus cavities.

To prevent crusting and adhesions, it is critical to frequently douche the nasal cavity with saline after surgery. To prevent a recurrence, topical intranasal steroids are also used as part of post-surgery therapy.

If a patient's symptoms persist despite the aforementioned treatments, oral corticosteroids are occasionally employed. To minimize undesired side effects, systemic steroids should be used with caution.

Another therapy that may be effective for AERD patients is aspirin desensitization (nasal polyps, asthma, and aspirin sensitivity). If there is evidence of an acute bacterial exacerbation, antibiotics are often administered. The use of antifungals in the treatment of CRSwNP is debatable.

The procedure takes 45 minutes to an hour and can be performed under general or local anesthetic. Most individuals tolerate the procedure well, however, this varies from person to person. In the first few days following surgery, the patient should expect some pain, congestion, and nasal discharge, but this should be minimal. Endoscopic sinus surgery complications are uncommon, although they might include bleeding and harm to other tissues in the region, such as the eye or brain.

Many doctors advocate using oral steroids before surgery to minimize mucosal inflammation, reduce bleeding after surgery, and aid in the visibility of polyps. After surgery, nasal steroid sprays should be taken as a prophylactic measure to postpone or prevent a recurrence. Even after surgery, polyps frequently return. As a result, for the treatment of nasal polyps, ongoing follow-up with a combination of medicinal and surgical treatments is suggested.

Treatment Planning

Polyp size has been demonstrated to be reduced by intranasal corticosteroids such as budesonide, fluticasone propionate, and mometasone furoate. These should be used twice daily for many weeks before the full benefits may be realized. Oral corticosteroids, on the other hand, can be administered in pulses and in a tapering manner for more severe illnesses. There is no apparent agreement among otolaryngologists on the maximum daily dose of systemic steroids, as well as the tapering strategy.

While antibiotics can be used to treat acute infections, their significance in nasal polyps is debatable. There have been occasional reports of success with macrolides in individuals with nasal polyps, low IgE, and neutrophilic illnesses. Current trials are being conducted to investigate the effectiveness of this family of antibiotics.

However, macrolides should be taken with caution because they are connected with cardiovascular hazards. Doxycycline has been demonstrated to be effective in a slight reduction in polyp size, post-nasal drip, and inflammatory markers. 

Natural remedies

If the symptoms of a nasal polyp appear to be connected to an allergic reaction, avoiding the allergen that causes the reaction would most likely assist.

Although tea tree oil and other therapies have been presented, there appears to be little evidence to support their efficacy.

A steam bath might help relieve congestion symptoms.

Vitamin D may help alleviate symptoms, but only at high therapeutic doses. It is unknown how this works, how it should be supplied, and how successful it may be. 

Is nasal polyps cancerous?

Nasal polyps are abnormal growths that form within the nasal cavity or paranasal sinuses. The majority of nasal polyps are benign (not cancerous) and are caused by persistent inflammation in the nose. Doctors can typically distinguish benign polyps from malignancy using examinations and testing.

Differential Diagnosis

Nasal polyps have a wide range of differential diagnoses. As a result, histopathological confirmation of nasal growths is usually required. Among the possible diagnoses are:

• Antrochoanal polyps
• Inverted papillomas
• Schneiderian papillomas
• Squamous cell carcinoma (SCC)
• Non-Hodgkin lymphoma
• Melanoma
• Esthesioneuroblastoma
• Hemangiopericytoma
• Nasal duct cysts
• Nasal gliomas
• Encephaloceles
• Juvenile nasopharyngeal angiofibroma
• Rhabdomyosarcomas
• Hemangiomas
• Chordomas

All of the foregoing differentials can be checked out with biopsies in the operating room (OR), especially if unilateral, which enhances the possibility of neoplasia. Polyps removed during endoscopic sinus surgery for chronic sinusitis require histopathologic confirmation for the same reason.

A thorough review of preoperative imaging investigations is required. Encephaloceles, for example, may appear as inflammatory polyps during nasal endoscopy, but their actual nature is revealed by CT imaging. An encephalocele biopsy will result in a cerebrospinal fluid (CSF) fistula.

In patients when cancer is suspected in the preoperative setting, a complete examination using imaging is critical. A CT scan with intravenous (IV) contrast aids in determining the bone outlines, vascularity of the lesions, and soft tissue invasion. Magnetic resonance imaging (MRI) aids in the detection of neoplasms that have progressed to the perineural, orbital, and intracranial spaces.

It is also beneficial in the treatment of complicated sinusitis. Different nasal cavity disorders display differently on imaging. Patients with nasal polyposis, for example, show smooth, convex, enhancing soft tissue masses on CT. Squamous cell carcinomas, on the other hand, may show bone degradation on CT and a hypointense look on T2-weighted MRI with homogeneous enhancement on contrasted MRI.

Toxicity and Side Effect Management

Intranasal corticosteroids are typically safe and have few negative effects when used to treat nasal polyps. Epistaxis and nasal mucosa ulcers have been described as rare side effects. Oral steroids, while more efficacious, have a higher prevalence of systemic adverse effects.

They must be administered with caution to patients with diabetes mellitus and hypertension, since they may cause uncontrolled blood glucose levels and hypertensive crises in sensitive individuals. Gastric ulcers, osteoporosis, and mental problems are all related contraindications. They should also be avoided in individuals who have been diagnosed with TB since they may restart the illness.

Prognosis

The endotype of the disease process influences the prognosis of nasal polyps. Recurrence appears to be greater in individuals with allergic fungal rhinosinusitis (AFRS) than in people with nasal polyps related to asthma or aspirin sensitivity, according to an article by Guo M, et al.

Patients with aspirin sensitivity, on the other hand, had a more widespread illness and a greater recurrence rate when compared to nasal polyps patients. Younger age at presentation, greater Lund-Mackay scores, high global osteitis, and enhanced tissue eosinophilia/neutrophilia are further possible prognostic variables linked with poor outcomes.

Complications

Nasal polyps are frequently a symptom of an underlying illness process; hence, consequences are usually defined by the underlying condition. Patients with nasal polyps have obstructive nasal symptoms, as well as sleep disruption and, to a lesser extent, persistent weariness. Nasal polyps can restrict the drainage routes of the paranasal sinuses, allowing mucoceles to develop.

Mucoceles can cause orbital structures to compress, resulting in exophthalmos, diplopia, and an unattractive look. Some people may have such a severe condition that their quality of life is adversely impacted. Nasal polyps might cause permanent anosmia in this case. Furthermore, nasal polyps have been linked to obstructive sleep apnea (OSA).

Consultations

Patients with nasal polyposis should be assessed by an otolaryngologist to determine the underlying cause and treat their condition. Several consultations should be explored if an underlying etiology has been determined and an endotype has been implicated.

An allergist should be consulted for individuals with AERD, chronic rhinosinusitis with nasal polyposis, and allergic fungal rhinosinusitis; immunotherapy, aspirin desensitization, or both may be necessary.

Conclusion 

Nasal polyps are noncancerous, painless growths that line the nose or sinuses. Nasal polyps can become inflamed and large, obstructing the nasal passages and sinuses. They are more common in persons who have asthma, allergies, recurring infections, or nasal irritation.

In many cases, patients are unaware that they have nasal polyps and do not seek medical attention for their annoying symptoms. Patients with nasal polyps should be evaluated thoroughly after they have been detected. Aside from improved nasal breathing, patients should understand that the etiology of the nasal polyps should be narrowed down and that additional clinical evaluation by a pulmonologist and allergist will aid in disease management as well as the identification and treatment of additional undiagnosed comorbidities such as asthma.

Medical care, like with most disorders, normally comes before surgery. Although surgery for nasal polyps is typically safe and well-tolerated, it may have a number of hazards, including substantial bleeding, epiphora, and, in rare cases, damage to orbital or cerebral structures. As a result, it is critical to begin patients on intranasal corticosteroids and nasal saline irrigations, check compliance, and monitor their progress.

Failure to respond to medical treatment or the presence of really severe symptoms may need surgery. Furthermore, patients should recognize that, while surgery will considerably enhance their quality of life, it may not cure the condition. Patients should continue to be under medical supervision in order to get the best surgical outcomes. Close monitoring is advised to ensure that the patient's quality of life is good.