Nasal polyp

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Nasal polyps
Polype nasal.jpg
A nasal polyp
Specialty Otorhinolaryngology
Symptoms Trouble breathing through the nose, loss of smell, decreased taste, post nasal drip, runny nose [1]
Complications Sinusitis, broadening of the nose [2] [3]
CausesUnclear [1]
Risk factors Allergies, cystic fibrosis, aspirin sensitivity, certain infections [1]
Diagnostic method Looking up the nose, CT scan [1]
Treatment Steroid nasal spray, surgery, antihistamines [1]
Frequency~4% [1]

Nasal polyps (NP) are noncancerous growths within the nose or sinuses. [1] Symptoms include trouble breathing through the nose, loss of smell, decreased taste, post nasal drip, and a runny nose. [1] The growths are sac-like, movable, and nontender, though face pain may occasionally occur. [1] They typically occur in both nostrils in those who are affected. [1] Complications may include sinusitis and broadening of the nose. [2]

Contents

The exact cause is unclear. [1] They may be related to chronic inflammation of the lining of the sinuses. [1] They occur more commonly among people who have allergies, cystic fibrosis, aspirin sensitivity, or certain infections. [1] The polyp itself represents an overgrowth of the mucous membranes. [1] Diagnosis may be accomplished by looking up the nose. [1] A CT scan may be used to determine the number of polyps and help plan surgery. [1]

Treatment is typically with steroids, often in the form of a nasal spray. [1] If this is not effective, surgery may be considered. [1] The condition often recurs following surgery; thus, continued use of a steroid nasal spray is often recommended. [1] Antihistamines may help with symptoms but do not change the underlying disease. [1] Antibiotics are not required for treatment unless an infection occurs. [1]

About 4% of people currently have nasal polyps while up to 40% of people develop them at some point in their life. [1] They most often occur after the age of 20 and are more frequent in males than females. [1] Nasal polyps have been described since the time of the Ancient Egyptians. [4]

Signs and symptoms

Symptoms of polyps include nasal congestion, sinusitis, loss of smell, thick nasal discharge, facial pressure, nasal speech, and mouth breathing. [5] Recurrent sinusitis can result from polyps. [2] Long-term, nasal polyps can cause destruction of the nasal bones and broadening of the nose. [2]

As polyps grow larger, they eventually prolapse into the nasal cavity, resulting in symptoms. [6] The most prominent symptoms of nasal polyps is blockage of the nasal passage. [7] People with nasal polyps due to aspirin intolerance often have a disease known as aspirin-exacerbated respiratory disease, which consists of asthma and chronic nasal polyps along with a hypersensitivity reaction to aspirin. [5]

Causes

Paranasal sinuses: 1. frontal sinuses, 2. ethmoid sinuses (ethmoidal air cells), 3. sphenoid sinuses, 4. maxillary sinuses Paranasal sinuses numbers.svg
Paranasal sinuses: 1. frontal sinuses, 2. ethmoid sinuses (ethmoidal air cells), 3. sphenoid sinuses, 4. maxillary sinuses

The exact cause of nasal polyps is unclear. [1] They are, however, commonly associated with conditions that cause long term inflammation of the sinuses. [8] This includes chronic rhinosinusitis, asthma, aspirin sensitivity, and cystic fibrosis. [8]

Various additional diseases associated with polyp formation include: [9]

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. [8]

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. [7] [10] Half of people with CF will experience extensive polyps leading to nasal obstruction and requiring aggressive management. [7]

Pathophysiology

The true cause of nasal polyps is unknown, but they are thought to be due to recurrent infection or inflammation. [2] 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. [11]

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. [12]

Diagnosis

Nasal polyp appearing in the middle meatus. Middle meatus polyp.jpg
Nasal polyp appearing in the middle meatus.

Nasal polyps can be seen on physical examination inside of the nose and are often detected during the evaluation of symptoms. On examination, a polyp will appear as a visible mass in the nostril. [5] Some polyps may be seen with anterior rhinoscopy (looking in the nose with a nasal speculum and a light), but frequently, they are farther back in the nose and must be seen by nasal endoscopy. [12] Nasal endoscopy involves passing a small, rigid camera with a light source into the nose. An image is projected onto a screen in the office so the doctor can examine the nasal passages and sinuses in greater detail. The procedure is not generally painful, but the person can be given a spray decongestant and local anesthetic to minimize discomfort. [13]

Attempts have been made to develop scoring systems to determine the severity of nasal polyps. Proposed staging systems take into account the extent of polyps seen on endoscopic exam and the number of sinuses affected on CT imaging. This staging system is only partially validated, but in the future, may be useful for communicating the severity of disease, assessing treatment response, and planning treatment. [6]

Types

There are two primary types of nasal polyps: ethmoidal and antrochoanal. 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. [7]

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. [7]

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. [7] 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. [14]

Histology

Histology of nasal polyp, magnification 25x (H&E stain) Nasal polyp 25x H+E (1).tif
Histology of nasal polyp, magnification 25x (H&E stain)

On histologic examination, nasal polyps consist of hyperplastic edematous (excess fluid) connective tissue with some seromucous glands and cells representing inflammation (mostly neutrophils and eosinophils). Polyps have virtually no neurons. Therefore, the tissue that makes up the polyp does not have any tissue sensation and the polyp itself will not be painful. [6] In early stages, the surface of the nasal polyp is covered by normal respiratory epithelium, but later it undergoes metaplastic change to squamous type epithelium with the constant irritation and inflammation. The submucosa shows large intercellular spaces filled with serous fluid. [15]

Differential diagnosis

Other disorders can mimic the appearance of nasal polyps and should be considered if a mass is seen on exam. Examples include encephalocele, glioma, inverted papilloma, and cancer. [10] Early biopsy is recommended for unilateral nasal polyps to rule out more serious conditions such as cancer, inverted papilloma, or fungal sinusitis. [5]

Treatment

The first line of treatment for nasal polyps is topical steroids. [12] Steroids decrease the inflammation of the sinus mucosa to decrease the size of the polyps and improve symptoms. [12] Topical preparations are preferred in the form of a nasal spray but are often ineffective for people with many polyps. Steroids by mouth often provide drastic symptom relief, but should not be taken for long periods of time due to their side effects. Because steroids only shrink the size and swelling of the polyp, people often have recurrence of symptoms once the steroids are stopped. [12] Decongestants do not shrink the polyps, but can decrease swelling and provide some relief. [7] Antibiotics are only recommended if the person has a co-occurring bacterial infection. [6]

In people with nasal polyps caused by aspirin or NSAIDs, avoidance of these medications will help with symptoms. Aspirin desensitization has also been shown to be beneficial. [12]

Surgery

Professor Heinz Stammberger, known as the father of endoscopic sinus surgery, teaching the technique at Tarabichi Stammberger Ear and Sinus Institute. TSESI.jpg
Professor Heinz Stammberger, known as the father of endoscopic sinus surgery, teaching the technique at Tarabichi Stammberger Ear and Sinus Institute.
CT scan images after application of radioactive laced nasal steroids using long nozzle. Note the reach of the medication into the area where nasal polyps originate Effect of Long Nozzle.jpg
CT scan images after application of radioactive laced nasal steroids using long nozzle. Note the reach of the medication into the area where nasal polyps originate

Endoscopic sinus surgery, advocated and popularized by Professor Stammberger, is often very effective for most people, providing rapid symptom relief. Endoscopic sinus surgery is minimally-invasive and is done entirely through the nostril with the help of a camera. Surgery should be considered for those with complete nasal obstruction, uncontrolled runny nose, nasal deformity caused by polyps or continued symptoms despite medical management. [7] Surgery serves to remove the polyps as well as the surrounding inflamed mucosa, open obstructed nasal passages, and clear the sinuses. This not only removes the obstruction caused by the polyps themselves, but allows medications such as saline irrigations and topical steroids to become more effective. [18] It has been suggested that one of the main objectives in sinus surgery for polyps is to allow delivery of the steroids into those areas of the sinuses where polyps develop, namely, the ethmoid sinuses. Specially designed long nozzles had been developed to use postoperatively to deliver steroids into those areas after sinus surgery for polyps. [19]

Surgery lasts approximately 45 to 60 minutes and can be done under general or local anesthesia. [18] Most people tolerate the surgery without much pain, though this can vary from person to person. The person should expect some discomfort, congestion, and drainage from the nose in the first few days after surgery, but this should be mild. [20] Complications from endoscopic sinus surgery are rare, but can include bleeding and damage to other structures in the area including the eye or brain. [20]

Many physicians recommend a course of oral steroids prior to surgery to reduce mucosal inflammation, decrease bleeding during surgery, and help with visualization of the polyps. [12] Nasal steroid sprays should be used preventatively after surgery to delay or prevent recurrence. [7] People often have recurrence of polyps even following surgery. Therefore, continued follow up with a combination of medical and surgical management is preferred for the treatment of nasal polyps. [12]

Epidemiology

Nasal polyps resulting from chronic rhinosinusitis affect approximately 4.3% of the population. [6] Nasal polyps occur more frequently in men than women and are more common as people get older, increasing drastically after the age of 40. [6]

Of people with chronic rhinosinusitis, 10% to 54% also have allergies. An estimated 40% to 80% of people with sensitivity to aspirin will develop nasal polyposis. [6] In people with cystic fibrosis, nasal polyps are noted in 37% to 48%. [6]

Related Research Articles

<span class="mw-page-title-main">Sinusitis</span> Inflammation of the mucous membrane that lines the sinuses resulting in symptoms

Sinusitis, also known as rhinosinusitis, is inflammation of the mucous membranes that line the sinuses resulting in symptoms that may include thick nasal mucus, a plugged nose, and facial pain. Other signs and symptoms may include fever, headaches, a poor sense of smell, sore throat, a feeling that phlegm is oozing out from the back of the nose to the throat along with a necessity to clear the throat frequently and frequent attacks of cough.

<span class="mw-page-title-main">Anosmia</span> Inability to smell

Anosmia, also known as smell blindness, is the loss of the ability to detect one or more smells. Anosmia may be temporary or permanent. It differs from hyposmia, which is a decreased sensitivity to some or all smells.

<span class="mw-page-title-main">Rhinitis</span> Irritation and inflammation of the mucous membrane inside the nose

Rhinitis, also known as coryza, is irritation and inflammation of the mucous membrane inside the nose. Common symptoms are a stuffy nose, runny nose, sneezing, and post-nasal drip.

<span class="mw-page-title-main">Aspirin-exacerbated respiratory disease</span> Chronic inflammatory disease affecting the sinuses and lungs

Aspirin-exacerbated respiratory disease (AERD), also called NSAID-exacerbated respiratory disease (N-ERD) or historically aspirin-induced asthma and Samter's Triad, is a chronic respiratory disease defined by the simultaneous presence of three factors: asthma, chronic rhinosinusitis with nasal polyps, and intolerance of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs). In general, the nasal polyps are more recalcitrant and the asthma more severe than that of aspirin-tolerant patients. Reduction or loss of the ability to smell is extremely common, occurring in greater than 90% of AERD patients. AERD most commonly begins in early- to mid-adulthood and has no known cure. While NSAID intolerance is a defining feature of AERD, avoidance of NSAIDs does not prevent the onset, development or perennial nature of the disease.

<span class="mw-page-title-main">Nasal irrigation</span> Personal hygiene practice for rinsing out nasal passages

Nasal irrigation is a personal hygiene practice in which the nasal cavity is washed to flush out mucus and debris from the nose and sinuses, in order to enhance nasal breathing. Nasal irrigation can also refer to the use of saline nasal spray or nebulizers to moisten the mucous membranes.

Nasal congestion is the partial or complete blockage of nasal passages, leading to impaired nasal breathing, usually due to membranes lining the nose becoming swollen from inflammation of blood vessels.

<span class="mw-page-title-main">Post-nasal drip</span> Medical condition

Post-nasal drip (PND), also known as upper airway cough syndrome (UACS), occurs when excessive mucus is produced by the nasal mucosa. The excess mucus accumulates in the back of the nose, and eventually in the throat once it drips down the back of the throat. It can be caused by rhinitis, sinusitis, gastroesophageal reflux disease (GERD), or by a disorder of swallowing. Other causes can be allergy, cold, flu, and side effects from medications.

<span class="mw-page-title-main">Rhinorrhea</span> Filling of the nasal cavity with fluid mucus

Rhinorrhea, rhinorrhoea, or informally runny nose is the free discharge of a thin mucus fluid from the nose; it is a common condition. It is a common symptom of allergies or certain viral infections, such as the common cold or COVID-19. It can be a side effect of crying, exposure to cold temperatures, cocaine abuse, or drug withdrawal, such as from methadone or other opioids. Treatment for rhinorrhea may be aimed at reducing symptoms or treating underlying causes. Rhinorrhea usually resolves without intervention, but may require treatment by a doctor if symptoms last more than 10 days or if symptoms are the result of foreign bodies in the nose.

Balloon sinuplasty is a procedure that ear, nose and throat surgeons may use for the treatment of blocked sinuses. Patients diagnosed with sinusitis but not responding to medications may be candidates for sinus surgery. Balloon technology was initially cleared by the U.S. Food and Drug Administration in 2005 and is an endoscopic, catheter-based system for chronic sinusitis. It uses a balloon over a wire catheter to dilate sinus passageways. The balloon is inflated with the goal of dilating the sinus openings, widening the walls of the sinus passageway and restoring normal drainage.

Chronic atrophic rhinitis, or simply atrophic rhinitis, is a chronic inflammation of the nose characterised by atrophy of nasal mucosa, including the glands, turbinate bones and the nerve elements supplying the nose. Chronic atrophic rhinitis may be primary and secondary. Special forms of chronic atrophic rhinitis are rhinitis sicca anterior and ozaena. It can also be described as the empty nose syndrome.

<span class="mw-page-title-main">Functional endoscopic sinus surgery</span> Surgery to enlarge the paranasal sinus drainage pathways

Functional endoscopic sinus surgery (FESS) is a procedure that is used to treat sinusitis and other conditions that affect the sinuses. Sinusitis is an inflammation of the sinuses that can cause symptoms such as congestion, headaches, and difficulty breathing through the nose.

Rhinosinusitis is a simultaneous infection of the nasal mucosa (rhinitis) and an infection of the mucosa of the paranasal sinuses (sinusitis). A distinction is made between acute rhinosinusitis and chronic rhinosinusitis.

A sinus is a sac or cavity in any organ or tissue, or an abnormal cavity or passage caused by the destruction of tissue. In common usage, "sinus" usually refers to the paranasal sinuses, which are air cavities in the cranial bones, especially those near the nose and connecting to it. Most individuals have four paired cavities located in the cranial bone or skull.

<span class="mw-page-title-main">Adenoiditis</span> Medical condition

Adenoiditis is the inflammation of the adenoid tissue usually caused by an infection. Adenoiditis is treated using medication or surgical intervention.

Dupilumab, sold under the brand name Dupixent, is a monoclonal antibody blocking interleukin 4 and interleukin 13, used for allergic diseases such as eczema, asthma and nasal polyps which result in chronic sinusitis. It is also used for the treatment of eosinophilic esophagitis and prurigo nodularis.

Antral lavage is a largely obsolete surgical procedure in which a cannula is inserted into the maxillary sinus via the inferior meatus to allow irrigation and drainage of the sinus. It is also called proof puncture, as the presence of an infection can be proven during the procedure. Upon presence of infection, it can be considered as therapeutic puncture. Often, multiple repeated lavages are subsequently required to allow for full washout of infection.

Caldwell-Luc surgery, Caldwell-Luc operation, also known as Caldwell-Luc antrostomy, and Radical antrostomy, is an operation to remove irreversibly damaged mucosa of the maxillary sinus. It is done when maxillary sinusitis is not cured by medication or other non-invasive technique. The approach is mainly from the anterior wall of the maxilla bone. It was introduced by George Caldwell (1893)and Henry Luc (1897). The maxillary sinus is entered from two separate openings, one in the canine fossa to gain access to the antrum and other in the naso antral wall for drainage.

<span class="mw-page-title-main">Fungal sinusitis</span> Inflammation of the paranasal sinuses due to fungal infection

Fungal sinusitis or fungal rhinosinusitis is the inflammation of the lining mucosa of the paranasal sinuses due to a fungal infection. It occurs in people with reduced immunity. The maxillary sinus is the most commonly involved. Fungi responsible for fungal sinusitis are Aspergillus fumigatus (90%), Aspergillus flavus, and Aspergillus niger. Fungal sinusitis occurs most commonly in middle-aged populations. Diabetes mellitus is the most common risk factor involved.

Nasal surgery is a medical procedure designed to treat various conditions that cause nasal blockages in the upper respiratory tract, for example nasal polyps, inferior turbinate hypertrophy, and chronic rhinosinusitis. It encompasses several types of techniques, including rhinoplasty, septoplasty, sinus surgery, and turbinoplasty, each with its respective postoperative treatments. Furthermore, nasal surgery is also conducted for cosmetic purposes. While there are potential risks and complications associated, the advancement of medical instruments and enhanced surgical skills have helped mitigate them.

Odontogenic sinusitis is a type of sinusitis, specifically caused by dental infections or procedures. Comprising approximately 10-12% of all chronic sinusitis cases, this condition primarily affects the maxillary sinus, which is in close proximity to the upper teeth.

References

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  3. ↑ Frazier, Margaret Schell; Drzymkowski, Jeanette (2014-03-12). Essentials of Human Diseases and Conditions. Elsevier Health Sciences. p. 432. ISBN   9780323292283.
  4. ↑ Önerci, T. Metin; Ferguson, Berrylin J. (2010). Nasal Polyposis: Pathogenesis, Medical and Surgical Treatment. Springer Science & Business Media. p. 1. ISBN   9783642114120.
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  9. ↑ Behrbohm, Hans; Kaschke, Oliver (1 Jan 2011). Ear, Nose, and Throat Diseases: With Head and Neck Surgery. Thieme. ISBN   9783131702135.
  10. 1 2 Insalaco, Louis (2017). Ferri's Clinical Advisor. p. 885.
  11. ↑ Wilkins, Lippincott Williams & (2009). Professional Guide to Diseases . Lippincott Williams & Wilkins. p.  717. ISBN   9780781778992.
  12. 1 2 3 4 5 6 7 8 Courey, Mark (2016). Upper Airway Disorders. Elsevier Saunders. pp. 877–896. ISBN   978-1455733835.
  13. ↑ "Nasal Endoscopy". care.american-rhinologic.org. Archived from the original on 2017-12-14. Retrieved 2017-12-13.
  14. ↑ Richard M. Berger. "Diagnosis: Antral choanal polyp". University of Kansas School of Medicine . Archived from the original on 2017-02-16. Retrieved 2017-02-15.
  15. ↑ Michaels, Leslie (2012-12-06). Ear, Nose and Throat Histopathology. Springer Science & Business Media. p. 168. ISBN   9781447133322.
  16. ↑ Takahara M, Kumai T, Kishibe K, Nagato T, Harabuchi Y (2021). "Extranodal NK/T-Cell Lymphoma, Nasal Type: Genetic, Biologic, and Clinical Aspects with a Central Focus on Epstein-Barr Virus Relation". Microorganisms. 9 (7): 1381. doi: 10.3390/microorganisms9071381 . PMC   8304202 . PMID   34202088.{{cite journal}}: CS1 maint: multiple names: authors list (link)
    - "This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/)."
  17. ↑ Mario L. Marques-Piubelli, M.D., Carlos A. Torres-Cabala, M.D., Roberto N. Miranda, M.D. "Extranodal NK / T cell lymphoma, nasal type". Pathology Outlines.{{cite web}}: CS1 maint: multiple names: authors list (link) Last author update: 5 January 2021. Last staff update: 14 October 2021
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  19. ↑ Kapadia, Mustafa; Grullo, Precious Eunice R.; Tarabichi, Muaaz (2019-05-07). "Comparison of short nozzle and long nozzle spray in sinonasal drug delivery: a cadaveric study". Ear, Nose & Throat Journal. 98 (7): E97–E103. doi: 10.1177/0145561319846830 . ISSN   0145-5613. PMID   31064245.
  20. 1 2 "Endoscopic Nasal & Sinus Surgery". care.american-rhinologic.org. Archived from the original on 2017-12-22. Retrieved 2017-12-13.
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