Nasal Polyps – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

Chronic inflammatory lesion of nasal mucosaAppearance of edematous pedunculated mass in the nasal cavity or paranasal sinusOften causes symptoms of blockage, discharge, or loss of smellOften bilateral; suspect tumor such as inverted papilloma if unilateral

Epidemiology

Incidence

Estimated to be ~1–4% in adultsMuch rarer in children: ~0.1%Increases with age

Prevalence

Estimated to be ~2–4% in general populationPredominant sex: Female > Male (2:1)

Risk Factors

Chronic sinusitisAllergic fungal sinusitisCystic fibrosisChurg-Strauss syndromePrimary ciliary dyskinesia (Kartagener syndrome)

General Prevention

The effectiveness of prophylactic intranasal corticosteroid after polyp removal surgery is being evaluated (1).

Pathophysiology

Largely unknown

Etiology

Largely unknown

Commonly Associated Conditions

Bronchial asthma: CommonAspirin hypersensitivity: CommonPrimary ciliary dyskinesia

Diagnosis

History

Nasal obstruction/restricted nasal airflow: Persistent mouth breathingNasal discharge: Reduction/loss of smellDull headachesFacial pain/discomfortSymptoms of acute, recurrent, or chronic rhinosinusitis

Physical Exam

Anterior rhinoscopy looking for a pale translucent mass of tissue: Most commonly from lateral wall of middle meatusOtoscope with nasal speculum or even otologic speculum is typically used.Flexible or rigid endoscopy is required to fully assess the nasal cavity. Topical anesthesia nasal spray should be used prior to the endoscopy if patient is awake.Middle ear examination for eustachian tube dysfunction secondary to large posterior nasal polypsExamination of posterior pharynx via oral cavity for large posterior polyps

Diagnostic Tests & Interpretation

Lab

Initial lab tests

Allergy test: Skin prick testRadioallergosorbent testTesting for cystic fibrosis in children with multiple benign polyps: Sweat test: Often requires repeat tests

Imaging

Initial approach

Computed tomography (CT) scanning may be helpful occasionally: Corroborates history and endoscopic findings

Diagnostic Procedures/Surgery

Diagnosis is made by the combination of rhinoscopy, endoscopy, and CT scanning.

Pathological Findings

Ciliated pseudostratified columnar epithelium: With areas of transitional or squamous epitheliumChronic infiltration of inflammatory cellsEosinophils are the predominant cells in most patients.Lower density of goblet cells than in normal epithelium

Differential Diagnosis

Antrochoanal polypBenign or malignant tumor: PapillomaIntranasal gliomaEncephaloceleRhabdomyosarcoma

Treatment

Medication

First Line

Intranasal corticosteroids:

400 µg/d in either spray or powder form: Budesonide (1,2)[A]Beclomethasone dipropionate (3)[B]Fluticasone dipropionate (4,5)[A]200 µg b.i.d.: Mometasone furoate (6,7)[A]Treatment generally should continue for at least 12 weeks.Minor nose bleeding is the most common side effect.Side effects from systemic absorption are rare (8).

Second Line

Oral systemic corticosteroids: Prednisolone 50 mg × 2 weeks (9)[B]

Additional Treatment

Additional Therapies

Aspirin desensitization may have a role in reducing recurrence of nasal polyposis (10)[C].

Surgery/Other Procedures

Most surgeries are approached endonasally. External (Caldwell-Luc) approach carries higher risk of complications (11)[C].Functional endonasal sinus surgery has slightly lower recurrence rate than intranasal polypectomy (12)[C]. Both modalities are equally effective in symptom relief.Up to 20% of patients will require revision surgery regardless of the initial modality of surgery (13)[C].Postoperative use of nasal corticosteroid may delay the recurrence of nasal polyps and hence timing of revision surgery (14)[B].

Ongoing Care

Complications

Acute or chronic sinus infectionObstructive sleep apnea

References

1. Lildholdt T, Rundcrantz H, Lindqvist N. Efficacy of topical corticosteroid powder for nasal polyps: a double-blind, placebo-controlled study of budesonide. Clin Otolaryngol Allied Sci. 1995;20:26–30.

2. Tos M, Svendstrup F, Arndal H, et al. Efficacy of an aqueous and a powder formulation of nasal budesonide compared in patients with nasal polyps. Am J Rhinol. 1998;12:183–9.

3. Holmberg K, Juliusson S, Balder B, et al. Fluticasone propionate aqueous nasal spray in the treatment of nasal polyposis. Ann Allergy Asthma Immunol. 1997;78:270–6.

4. Penttilä M, Poulsen P, Hollingworth K, et al. Dose-related efficacy and tolerability of fluticasone propionate nasal drops 400 microg once daily and twice daily in the treatment of bilateral nasal polyposis: a placebo-controlled randomized study in adult patients. Clin Exp Allergy. 2000;30:94–102.

5. Aukema AA, Mulder PG, Fokkens WJ. Treatment of nasal polyposis and chronic rhinosinusitis with fluticasone propionate nasal drops reduces need for sinus surgery. J Allergy Clin Immunol. 2005;115:1017–23.

6. Small CB, Hernandez J, Reyes A, et al. Efficacy and safety of mometasone furoate nasal spray in nasal polyposis. J Allergy Clin Immunol. 2005;116:1275–81.

7. Stjärne P, Mösges R, Jorissen M, et al. A randomized controlled trial of mometasone furoate nasal spray for the treatment of nasal polyposis. Arch Otolaryngol Head Neck Surg. 2006;132:179–85.

8. Bateman ND, Fahy C, Woolford TJ. Nasal polyps: still more questions than answers. J Laryngol Otol. 2003;117:1–9.

9. Hissaria P, Smith W, Wormald PJ, et al. Short course of systemic corticosteroids in sinonasal polyposis: a double-blind, randomized, placebo-controlled trial with evaluation of outcome measures. J Allergy Clin Immunol. 2006;118:128–33.

10. Stevenson DD, Hankammer MA, Mathison DA, et al. Aspirin desensitization treatment of aspirin-sensitive patients with rhinosinusitis-asthma: long-term outcomes. J Allergy Clin Immunol. 1996;98:751–8.

11. DeFreitas J, Lucente FE. The Caldwell-Luc procedure: institutional review of 670 cases: 1975–1985. Laryngoscope. 1988;98:1297–300.

12. Hopkins C, Browne JP, Slack R, et al. The national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis. Clin Otolaryngol. 2006;31:390–8.

13. Hopkins C, Slack R, Lund V, Brown P, Copley L, Browne J et al. Long-term outcomes from the English national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis. Laryngoscope.2009;119:2459–65.

14. Stjärne P, Olsson P, Alenius M. Use of mometasone furoate to prevent polyp relapse after endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg. 2009;135:296–302.

Codes

ICD9

471.9 Unspecified nasal polyp

Snomed

52756005 nasal polyp (disorder)

Clinical Pearls

Appearance of edematous pedunculated mass in the nasal cavity or paranasal sinus