Nasal Polyps

Allergic rhinitis, acute and chronic infections (especially chronic rhinosinusitis), and cystic fibrosis all predispose to the formation of nasal polyps. Bleeding polyps occur in allergic fungal infections of the nose and paranasal sinuses such as rhinosporidiosis. Nasal polyps may also be observed in patients with eosinophilic granulomatosis with polyangiitis and primary ciliary dyskinesia. Unilateral polyps occasionally occur in association with or represent benign or malignant tumors of the nose or paranasal sinuses. They can also occur in response to a foreign body. Nasal polyps are strongly associated with:

• Aspirin allergyAspirin allergy

• Chronic rhinosinusitis

• Asthma

• Allergic rhinitis

Symptoms of nasal polyps include nasal obstruction and postnasal drainage, congestion, sneezing, rhinorrhea, facial pressure, and ocular itching. Anosmia and hyposmia are characteristic features and should immediately raise suspicion for nasal polyps.

Due to nasal obstruction, patients may have difficulty sleeping, leading to reduced quality of life. Snoring may occur due to the obstruction of nasal airflow.

• Primarily history and physical examination (nasal speculum or rhinoscopy)

• Sometimes imaging studies (CT, MRI)

• Sometimes histopathology (biopsy)

Diagnosis of nasal polyps is generally based on direct visualization of suspected polyps on physical examination. Nasal speculum examination is typically the first method used. If deeper polyps are suspected, or if the nasal vestibule is narrow, endoscopy (rhinoscopy) may be performed. Anterior rhinoscopy is considered the gold standard for diagnosing nasal polyps. A developing polyp appears pearly white, translucent, and teardrop-shaped; when mature, it resembles a peeled seedless grape.

Sinusitis With Polyps

Image

DNA Illustrations/SCIENCE PHOTO LIBRARY

Imaging studies (CT, MRI) may be necessary in some cases, especially for evaluating extent of involvement. CT scans are helpful for assessing the severity of a disease, particularly when it does not respond to medical treatment or for surgical planning. Due to high concurrence with chronic sinusitis, CT scans also help evaluate sinus involvement, bony structures in the nose, paranasal sinuses and the skull base. MRI is used, albeit rarely, to distinguish between polyps and other sinonasal masses and to assess the extent of soft tissue involvement.

Anatomy of Nasal Polyps

3D Model

Sometimes internal sinus polyps are only visible on imaging.

Histopathological examination is rarely needed for diagnosis; however, it may be essential for unilateral polyps to exclude the possibility of tumors. The presence of eosinophils in tissue samples (more than 10 cells per high-power field) may indicate an allergic or fungal (eg, aspergillosis) etiology and a higher chance of recurrence.

Nasal Polyp

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Image provided by Bechara Ghorayeb, MD.

• Topical glucocorticoid spray

• Sometimes biologic therapies

• Sometimes surgical removal

The first line of therapy is usually intranasal glucocorticoids (eg, fluticasone, mometasone, beclomethasone, flunisolide aerosols), given as 1 or 2 sprays twice a day in each nasal cavity; these may shrink or even eliminate smaller polyps, as may a 1-week tapered course of oral glucocorticoids (The first line of therapy is usually intranasal glucocorticoids (eg, fluticasone, mometasone, beclomethasone, flunisolide aerosols), given as 1 or 2 sprays twice a day in each nasal cavity; these may shrink or even eliminate smaller polyps, as may a 1-week tapered course of oral glucocorticoids (1). Specialized delivery devices with dual vents in the oral and nasal cavities are available for more efficient delivery of intranasal glucocorticoids (2).

In patients with bilateral polyps or severe chronic rhinosinusitis with nasal polyps, biologics (eg, omalizumab, dupilumab, mepolizumab, benralizumab) have been effective in shrinking the polyps and improving symptoms (In patients with bilateral polyps or severe chronic rhinosinusitis with nasal polyps, biologics (eg, omalizumab, dupilumab, mepolizumab, benralizumab) have been effective in shrinking the polyps and improving symptoms (2, 3, 4). Dupilumab and mepolizumab are also appear to improve quality of life measures (5). In general, these targeted biologic therapies demonstrate favorable safety profiles.

When medical management is ineffective, surgical removal of nasal polyps may be required. Polyps that obstruct the airway or promote sinusitis are removed, as are unilateral polyps that may be obscuring benign or malignant tumors.

Polyps tend to recur unless the underlying allergy, infection, or other inflammatory process is controlled. After removal of nasal polyps, nasal glucocorticoid therapy tends to deter recurrence. In severe recurrent cases, maxillary sinusotomy or ethmoidectomy may be indicated. These procedures are usually performed endoscopically.