TGIF dear friends!
It has certainly been a WET WET start to Friday with multiple flash floods seen in various parts of the island! I do hope you and your family are nice and dry :-) ready for this weeks installation.
Today, we are looking at an interesting topic: NASAL POLYPS and NASAL BLOCKAGE.
Many times, I am referred patients to see or review for nose blockage and polyps for a check naso-endoscopy. Most times, it turns out to be enlarged (hyper-trophied) inferior turbinates that are the culprit, rather than actual nasal polyps per se.
Q: What are nasal polyps?
Nasal polyps: a schematic illustration (from MEDLINE)
Nasal polyps are soft, noncancerous growths arising from the lining of your nose, nasal passage or paranasal sinuses. They often form in groups, rather like grapes on a stem. So if you can imagine, a bunch of white grapes.......that is what they look like.
Q: What symptoms do nasal polyps cause?
Common signs and symptoms of chronic sinusitis with nasal polyps include:
A runny nose
Persistent nasal stuffiness or blockage
Post-nasal drip
Decreased (hyposmia) or absent (anosmia) sense of smell
Loss of sense of taste
Facial pains or headache
Pain around your upper teeth
A sense of pressure over your forehead and face
Snoring 😴 & mouth breathing
Frequent nosebleeds
Q: What causes nasal polyps to form?
We don't yet fully understand what causes nasal polyps, why some people develop long-term inflammation, or why irritation and swelling (inflammation) triggers polyps to form in some people but not in others. The swelling occurs in the fluid-producing lining (mucous membrane) of your nose and sinuses. There is a familial tendency for patients with nasal polyposis.
There's some evidence that people who develop polyps have different immune system responses and different chemical markers in their mucous membranes than do those who don't develop polyps. Oftentimes, nasal polyposis patients also have intolerance to ASPIRIN. This is a clue to the role of immune / metabolic pathways eg the cyclo-oxygenase system have to play in the aetiology of nasal polyposis.
Also, any condition that triggers long-term irritation and swelling (inflammation) in your nose or sinuses, such as infections or allergies, may increase your risk of developing nasal polyps.
Conditions often associated with nasal polyps include:
Asthma, a disease that causes the lower airway to swell (inflame) and narrow
Aspirin sensitivity
Allergic fungal sinusitis, an allergy to airborne fungi.
Cystic fibrosis, a rare genetic disorder that results in abnormally thick, sticky fluids in the body, including thick mucus in the nose and sinuses.
Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis), a rare disease that causes inflammation of blood vessels.
Vitamin D deficiency, which occurs when your body does not have enough vitamin D
Your family history also may play a role. There is some evidence that certain genetic variations associated with immune system function may predispose you to develop nasal polyps.
Here we can see the typical appearance of nasal polyps in the nose cavity: the polyp is the pale, greyish lump in the middle, between the nasal septum and the turbinates. As you can imagine, if the polyps get large enough, they will cause significant nasal blockage to the patient, who may resort to breathe through their mouths. Sometimes, the polyps get so large, that they prolapse out of the nose onto the upper lip area! As my kids would say: so gross!
Also, the patient may lose their sense of smell as the smell receptors are located high up in the nasal passage and the smell molecules will not reach the nerve cell receptors due to the large, obstructing polyps.
Right Nasal Cavity: almost complete obstruction by a nasal polyp is seen.
Left Nasal Cavity: partial obstruction by a nasal polyp. There is still some air space around the polyp to breathe on this side.
Initially, when the polyps are small, they may cause little or no symptoms, but as they enlarge, they tend to block the nasal passages and also the paranasal sinuses, causing repeated acute or chronic infections. So oftentimes you may come across this acronym which we ENT's use quite a lot:
CRSwNP
It stands for: Chronic Rhino Sinusitis with Nasal Polyposis; so this is the stage when most patients present to us for management, as they develop headaches and/ or facial pain etc.
Q: How are nasal polyps detected / diagnosed?
Most commonly, your GP will refer you to see an ENT Specialist. Here in our ENT clinic, we will usually perform and / or arrange a few studies / tests for you, such as:
Naso-endoscopy. A narrow tube with a lighted magnifying lens or tiny camera (naso-endoscope) enables your doctor to perform a detailed examination inside your nose and sinuses.
Imaging studies. Images obtained with computerised tomography (CT scan) can help your doctor pinpoint the size and location of polyps in deeper aspects of your sinuses and evaluate the extent of swelling and irritation (inflammation). These studies may also help your doctor rule out other possible blockages in your nasal cavity, such as structural abnormalities or another type of cancerous growths.
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. Your doctor or nurse then observes your skin for signs of allergic reactions. If a skin test can't be performed, your doctor may order a blood test that screens for specific antibodies to various allergens.
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. This condition is somewhat rare in Asians. The standard diagnostic test for cystic fibrosis is a noninvasive sweat test, which determines whether your child's perspiration is saltier than what sweat normally is.
Blood test. Your doctor may test your blood for low levels of vitamin D, which are associated with nasal polyps
Q: How to treat nasal polyps?
The treatment goal for nasal polyps is to reduce their size or eliminate them.
Medications are usually the first approach. Surgery may sometimes be needed, but it may not provide a permanent solution because polyps do tend to recur, due to the underlying inflammatory conditions.
Medical Therapy: As a first line, your ENT Specialist will discuss these options with you:
Nasal corticosteroids. Your doctor is likely to prescribe a intra-nasal corticosteroid nose spray to reduce swelling and irritation. This treatment may shrink the polyps or eliminate them completely. Nasal corticosteroids include fluticasone (Avamys GSK or Flixonase Allergy Relief, Flovent HFA, Xhance), budesonide (Rhinocort), mometasone (Nasonex, Asmanex HFA), triamcinolone (Nasacort Allergy 24HR), beclomethasone (Beconase AQ, Qvar Redihaler, Qnasl) amongst others available.
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. In my practice, I use a 2-week tail down prednisone course (based on your body weight) with gastric protection eg PPI medication like omeprazole, as the oral steroid treatment usually increases gastric acid production. Injectable corticosteroids may rarely be used if nasal polyposis is severe.
Other medications. Your doctor may prescribe drugs to treat conditions that contribute to long-term swelling in your sinuses or nasal passages. These may include antihistamines to treat allergies and antibiotics to treat a chronic or recurring infection. Aspirin desensitisation, under the care of an allergy specialist with experience in desensitisation, may benefit some patients with nasal polyps and aspirin sensitivity. The treatment involves gradually increasing the amount of aspirin you take while under a doctor's care in a hospital or clinic to help your body tolerate taking aspirin long term.
Surgical Treatment:
If medical treatment does not effectively shrink or eliminate nasal polyps, you may need endoscopic sinus surgery (ESS) to remove polyps and to correct problems with your sinuses that make them prone to inflammation and the development of polyps.
In endoscopic sinus surgery (ESS), the surgeon inserts a small tube with a lighted magnifying lens or tiny camera (endoscope) into your nostrils and guides it into your sinus cavities. The surgeon uses tiny instruments to remove polyps and other substances that block the flow of fluids from your sinuses.
Your surgeon may also enlarge the openings leading from your sinuses to your nasal passages. Endoscopic sinus surgery (ESS) is usually performed as an outpatient procedure. Many of us now use a Navigational image-guided surgical interface to ensure pin-point accuracy and reduce possible complications.
Schematic illustration from MEDLINE to show the endoscopic clearance of polyps and sinus air cells to improve the ventilation / aeration of the paranasal sinuses and their sinus openings into the nose.
After surgery, you will very likely continue to use a intra nasal corticosteroid nose spray to help prevent recurrence of nasal polyps. Your doctor may also recommend the use of a saltwater (saline) nasal rinse to promote healing after surgery. We will follow up with regular inspections to monitor the nose & sinuses.
So, dear friends, if you or your family member is suffering from nasal polyps, do arrange to see your GP or friendly ENT Specialist for a check up.
Well, till next week, do have a safe & dry weekend! TGIF 😊
For more Information on Nasal Polyposis; you can refer to the following references:
References
Albertien AC, Aukema MD, Mulder PDH. Treatment of nasal polyposis and chronic sinusitis with fluticasone propionate nasal drops reduces the need for sinus surgery. J Allergy Clin Immunol. 2005;115:1017–23. [PubMed] [Google Scholar]
Bachert C, Gevaert P, Holappels G, et al. Total and specific IgE in nasal polyps is related to local eosinophilic inflammation. J Allergy Clin Immunol. 2001;107:607–14. [PubMed] [Google Scholar]
Bachert C, Hormann K, Mosges R. An update on the diagnosis and treatment of sinusitis and nasal polyposis. Allergy. 2003;58:176–91. [PubMed] [Google Scholar]
Bachert C, Wagenmann M, Hauser U, et al. IL-5 synthesis is upregulated in human nasal polyp tissue. J Allergy Clin Immunol. 1997;99:837–42. [PubMed] [Google Scholar]
Badia L, Lund V. Topical corticosteroids in nasal polyposis. Drugs. 2001;61:573–8. [PubMed] [Google Scholar]
Bateman ND, Fahy C, Woolford TJ. Nasal polyps: still more questions than answers. J Laryngol Otol. 2003;117:1–9. [PubMed] [Google Scholar]
Baudoin T, Kalogjera L, Hat JI. Capsaicin significantly reduces sinonasal polyps. Acta Otolaryngol. 2000;120:307–11. [PubMed] [Google Scholar]
Bent JP, Kuhn FA. Diagnostic of allergic fungal sinusitis. Otolaryngol Head Neck Surg. 1994;111:580–8. [PubMed] [Google Scholar]
Browne JP, Hopkins C, Slack R, et al. Health related quality of life after polypectomy with and without additional surgery. Laryngoscope. 2006;116:297–302. [PubMed] [Google Scholar]
Browning GG. Management of nasal polyps with steroids; the current literature. Clin Otolaryngol. 2007;32:195. [Google Scholar]
Burgel PR, Cardell LO, Ueki IF, et al. Intranasal steroids decrease eosinophils but not mucous expression in nasal polyps. Eur Resp J. 2004;24:594–600. [PubMed] [Google Scholar]
Dalziel K, Stein K, Round A, et al. Systematic review of endoscopic sinus surgery for nasal polyps. Health Technol Assess. 2003;7:1–159. [PubMed] [Google Scholar]
Dinis PB, Gomes A. Sinusitis and asthma; how do they interrelate in sinus surgery? Am J Rhinol. 1997;11:421–8. [PubMed] [Google Scholar]
Drake-Lee AB. Nasal polyps. In: Kerr AG, Mackay AS, Bull TR, editors. Scott-Brown’s Otolaryngology. 6. Vol. 4. Rhinology, Oxford: Butterworth-Heinneman; 1997. 4/10/1-16. [Google Scholar]
Drake-Lee AB. Nasal polyps. Hospital Med. 2004;65:264–7. [PubMed] [Google Scholar]
Fokkens W, Lund V, Mullol J European Position Paper on Rhinosinusitis and Nasal Polyps Group. EP3OS 2007: European position paper on rhinosinusitis and nasal polyps 2007. A summary for otorhinolaryngologists. Rhinology. 2007;45:97–101. [PubMed] [Google Scholar]
Gaevert P, Bachert C, Novo CP, et al. Enhanced soluble Interleukin-5 receptor alpha expression in nasal polyposis. Allergy. 2003;58:371–9. [PubMed] [Google Scholar]
Haye R, Aaneson JP, Burtin B, et al. The effect of cetirizine on symptoms and signs of nasal polyposis. J Laryngol Otol. 1998;112:1042–6. [PubMed] [Google Scholar]
Hedman J, Kaprio J, Poussa T, et al. Prevalence of asthma, aspirin intolerance, nasal polyposis and chronic obstructive pulmonary disease in a population-based study. Int J Epidemiol. 1999;28:717–22. [PubMed] [Google Scholar]
Hissaria P, Smith W, Wormald PJ, et al. Short course of systemic corticosteroids in sinonasal polyposis: A double-blinded, randomized, placebo-controlled trial with evaluation of outcome measures. J Allergy Clin Immunol. 2006;118:128–33. [PubMed] [Google Scholar]
Hopkins C, Browne JP, Slack R, et al. The national comparative audit of surgery for nasal polyps and chronic rhinosinusitis. Clin Otolaryngol. 2006;31:390. [PubMed] [Google Scholar]
Iinuma T, Hirota Y, Kase Y. Radio-opacity of the paranasal sinuses. Conventional views and CT. Rhinology. 1994;32:134–6. [PubMed] [Google Scholar]
Jacobsen J, Svendstrup F. Functional endoscopic sinus surgery in chronic sinusitis- a series of 237 consecutively operated patients. Acta Otolaryngol. 2000;543:158–61. [PubMed] [Google Scholar]
Jamal A, Maran AGD. Atopy and nasal polyposis. J Laryngol Otol. 1987;101:355–8. [Google Scholar]
Kayarker R, Clifton NJ, Woolford TJ. An evaluation of the best head position for instillation of nasal steroid drops. Clin Otolaryngol. 2002;27:18–21. [PubMed] [Google Scholar]
Kennedy DW, Bolger WE, Zinerich SJ. Diseases of the sinuses; diagnosis and endoscopic management. Hamilton and London: Decker; 2001. [Google Scholar]
Kieff DA, Busaba NY. Efficacy of montelukast in the treatment of nasal polyposis. Ann Otol Rhinol Laryngol. 2005;114:941–5. [PubMed] [Google Scholar]
Laren PL, Tos M. Anatomic site of origin of nasal polyps: endoscopic nasal and paranasal sinus surgery as a screening method for nasal polyps in autopsy material. Rhinology. 1994;33:185–8. [PubMed] [Google Scholar]
Larsen K, Tos M. A long-term follow-up study of nasal polyp patients after simple polypectomies. Eur Arch Otorhinolaryngol. 1997;1:85–8. [PubMed] [Google Scholar]
Lund V, Mackay IS. Staging in chronic rhinosinusitis. Rhinology. 1993;31:183–4. [PubMed] [Google Scholar]
Lund VJ, Fllod J, Sykes A, et al. Effect of fluticasone in severe polyposis. Arch Otolaryngol Head Neck Surg. 1998;124:513–18. [PubMed] [Google Scholar]
Luxenburger W, Posch G, Berghold A, et al. HLA patterns in patients with nasal polyposis. Eur Arch Otorhinolaryngol. 2000;257:137–9. [PubMed] [Google Scholar]
Marple BF. Allergic fungal rhinosinusitis: current management and theories. Laryngoscope. 2001;111:1006–17. [PubMed] [Google Scholar]
Messerklinger W. Role of the lateral nasal wall in the pathogenesis, diagnosis and therapy of recurrent and chronic sinusitis. Laryngol Rhinol Otol. 1987;66:293–9. [PubMed] [Google Scholar]
Millar AW, Johnson A, Lamb D. Allergic aspergillosis of the maxillary sinuses. Thorax. 1981;36:710. [Google Scholar]
Mygind N. Advances in medical treatment of nasal polyps. Allergy. 1999;54:12–16. [PubMed] [Google Scholar]
Mygind N, Lildholdt T. Nasal polyps treatment: medical management. Allergy Asthma Proc. 1996;17:275–82. [PubMed] [Google Scholar]
Patiar S, Reece P. The Cochrane Collaboration. John Wiley and Sons, Ltd; 2007. Oral steroids for nasal polyps. Review. [Google Scholar]
Ponikau JU, Sherris DA, Kern EB. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc. 1999;74:877–84. [PubMed] [Google Scholar]
Roca-Ferrer J, Mullol J, Xaubet A. Effect of topical anti-inflammatory drugs on epithelial cell-induced eosinophil survival and GM-CSF secretion. Eur Respir J. 1997;10:1489–95. [PubMed] [Google Scholar]
Rowe Jose JM, Medcalf M, Durham SR, et al. Functional endoscopic sinus surgery: 5 year follow up and results of a prospective randomised double-blind placebo controlled trial of post-operative fluticasone propionate nasal spray. Rhinology. 2005;43:2–10. [PubMed] [Google Scholar]
Safirstein BH. Allergic bronchopulmonary aspergillosis with obstruction of the upper respiratory tract. Chest. 1976;70:788–90. [PubMed] [Google Scholar]
Schubert MS. Medical treatment of allergic fungal sinusitis. Ann Allergy Asthma Immunol. 2000;85:90–7. [PubMed] [Google Scholar]
Settipane GA. Epidemiology of nasal polyps. Allergy Asthma Proc. 1996;17:231–6. [PubMed] [Google Scholar]
Settipane GA, Chafee FH. Nasal polyps in asthma and rhinitis. A review of 6037 patients. J Allergy Clin Immunol. 1977;59:17–21. [PubMed] [Google Scholar]
Simon HU, Yousefi S, Schranz C. Direct demonstration of delayed eosinophilic apoptosis as a mechanism causing tissue eosinophilia. J Immunol. 1997;158:3902–8. [PubMed] [Google Scholar]
Stammberger H. Surgical treatment of nasal polyps: past, present, and future. Allergy. 1999;54:7–11. [PubMed] [Google Scholar]
Stjarne P, Mosges R, Jorissen M, et al. Randomized controlled trial of mometasone furoate nasal spray for the treatment of nasal polyposis. Arch Otolaryngol Head Neck Surg. 2006;132:179–85. [PubMed] [Google Scholar]
Talbot AR, Herr TM, Parsons DS. Mucocilliary clearance and buffered hypertonic saline solution. Laryngoscope. 1997;107:500–3. [PubMed] [Google Scholar]
Van Camp C, Clement PAR. Results of oral steroid treatment in nasal polyposis. Rhinology. 1993;32:3–9. [Google Scholar]
