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
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
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
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:
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.
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 😊
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