BASICS
- Chronic inflammatory lesion of nasal mucosa
- Appearance of edematous pedunculated mass in the nasal cavity or within the paranasal sinus
- Often causes symptoms of blockage, discharge, or loss of smell
- Most commonly bilateral; suspect tumor, such as inverted papilloma, if unilateral
- Estimated to be ¢ ˆ ¼1 " “4% in adults
- Much rarer in children: ¢ ˆ ¼0.1%
- Increases with age
- Predominant sex: female > male (2:1)
- Asthma is present in 65% of patients, 25% of patients have undiagnosed asthma.
- No clearly delineated pathway; research has demonstrated separate TH1- and TH2-driven pathways (1,2)[B].
- Development of condition remains unclear; multiple inflammatory and infectious pathways resulting from chronic rhinosinusitis is most common (1,3)[B].
- Chronic sinusitis
- Allergic fungal sinusitis
- Aspirin sensitivity
- Cystic fibrosis
- Primary ciliary dyskinesia (Kartagener syndrome)
- Laryngopharyngeal reflux (4)[B]
GENERAL PREVENTION
Use of intranasal corticosteroids after polyp removal surgery has shown effectiveness against recurrence. ‚
COMMONLY ASSOCIATED CONDITIONS
- Bronchial asthma
- Aspirin hypersensitivity
- Allergic rhinitis (4)[B]
- Cigarette smoking promotes eosinophilic inflammation.
DIAGNOSIS
- Two or more symptoms, one of which is either nasal blockage/obstruction/congestion OR nasal discharge (5)[A].
- Nasal obstruction/restricted nasal airflow: persistent mouth breathing (5)[A]
- Nasal discharge:
- Anterior discharge " ”rhinorrhea
- Postnasal drip
- Reduction/loss of smell
- Dull headaches
- Facial pain/pressure
- Symptoms of acute, recurrent, or chronic rhinosinusitis (5)[A]
- Anterior rhinoscopy looking for a pale translucent mass of tissue
- Most commonly from lateral wall of middle meatus
- Otoscope with nasal speculum or even otologic speculum is typically used (5)[A].
- Flexible/rigid endoscopy is required to assess the nasal cavity fully (5)[A].
- Endoscopy is the gold standard for diagnosis.
- Topical anesthesia nasal spray should be used prior to the endoscopy if patient is awake.
- Tympanic membrane examination for eustachian tube dysfunction secondary to large posterior nasal polyps (5)[A]
- Examine the posterior pharynx via oral cavity for large posterior polyps (5)[A].
- Antrochoanal polyp
- Benign or malignant tumor:
- Papilloma
- Intranasal glioma
- Encephalocele
- Rhabdomyosarcoma
- Mycetoma
- Allergy testing (3)[B]:
- Skin prick test
- Immunocap testing
- Radioallergosorbent test (RAST)
- Testing for cystic fibrosis in children with multiple benign polyps: sweat test: often requires repeat tests (3)[B]
- CT scanning (3)[B]:
- May be helpful to corroborate history and endoscopic findings
- Unable to differentiate polyp from other soft tissue masses
- MRI (3)[B]:
- May aid in unilateral polyposis if concern for neoplasia, mycetoma, or encephalocele
Histologic exam to exclude malignancy if unilateral polyp ‚
- Diagnosis is made by the combination of rhinoscopy, endoscopy, and CT scanning.
- CT reveals extent of disease and is necessary to formulate a plan for surgical intervention (3)[B].
- Ciliated pseudostratified columnar epithelium: with areas of transitional or squamous epithelium
- Chronic infiltration of inflammatory cells
- Eosinophils are the predominant cells in most patients (4)[B].
TREATMENT
- Intranasal corticosteroid use has been demonstrated to reduce polyp size and recurrence, as well as improvement in nasal congestion based on controlled studies (2,5)[A],(6)[B].
- Treat for a minimum of 12 weeks; minimal systemic absorption, side effects rare " ”minor nose bleeding is most common (2,5)[A].
- Budesonide 256 Ž ¼g/day
- Beclomethasone dipropionate 320 Ž ¼g/day
- Fluticasone propionate 400 Ž ¼g/day
- Mometasone furoate 200 Ž ¼g BID
- For children mometasone furoate is preferred:
- 100 Ž ¼g BID ages 6 to 12
- 200 Ž ¼g BID for ages 12 to 17 (7)[A]
- Oral systemic corticosteroids: less definitive benefit; more systemic adverse effects; use with caution in patients with diabetes mellitus, hypertension, or peptic ulcer disease (2,5)[A]
- Prednisolone
- Weight-based dosing burst with taper
- Perioperative use oral prednisone 30 mg daily 5 to 7 days prior to surgery (2)[A]
- Decrease nasal mucosa inflammation
- Improves surgical field
- Shorter surgical time
- Improves postop results
- Weight-based dosing burst with taper
ISSUES FOR REFERRAL
Patients with severe obstruction symptoms should be referred for surgery (5)[A]. ‚
ADDITIONAL THERAPIES
Antileukotrienes: clinical improvement without aspirin hypersensitivity (2,5)[A],(3)[B]: ‚
- Aspirin desensitization may have a role in reducing recurrence of nasal polyposis.
- Anti-interleukin-5 immunomodulators: may benefit those with TH2 eosinophilic disease process
- Oral antibiotics: doxycycline for 3 to 4 weeks or oral macrolide for 12 weeks is an option for disease unresponsive to steroids alone with mixed results of therapy (8)[C]
- Indicated for patients with four or more episodes in 1 year of acute rhinosinusitis refractory to medical therapy (5)[A]
- Disease must be documented endoscopically or on CT during symptomatic period prior to surgical intervention.
- Most surgeries are approached endonasally.
- Endoscopic sinus surgery has become the mainstay of treatment.
- The external (Caldwell-Luc) approach is used for more difficult cases but carries higher risk of complications.
- Functional endonasal sinus surgery has slightly lower revision rate than intranasal polypectomy. Both modalities provide effective symptom relief.
- Postoperative use of nasal corticosteroids delay the recurrence of nasal polyps and hence the timing of revision surgery (2)[A],(6)[B].
- Postoperative use of steroid releasing stents to prevent polyp recurrence by decreasing mucosal inflammation (2)[A],(6)[B].
- Intrapolyp steroid injection may be considered in cases refractory to other interventions but has risk of visual loss.
ONGOING CARE
- Acute/chronic sinus infection
- Heterotropic bone formation within the sinus cavity
- Recurrence:
- Of patients, 5 " “10% with severe disease
- Twice as likely in those with asthma (4)[B]
REFERENCES
11 Tomassen ‚ P, Van Zele ‚ T, Zhang ‚ N, et al. Pathophysiology of chronic rhinosinusitis. Proc Am Thorac Soc. 2011;8(1):115 " “120.22 Poetker ‚ DM, Jakubowski ‚ LA, Lal ‚ D, et al. Oral corticosteroids in the management of adult chronic rhinosinusitis with and without nasal polyps: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 2013;3(2):104 " “120.33 DeMarcantonio ‚ MA, Han ‚ JK. Nasal polyps: pathogenesis and treatment implications. Otolaryngol Clin North Am. 2011;44(3):685 " “695, ix.44 Kariyawasam ‚ H, Rotiroti ‚ G. Allergic rhinitis, chronic rhinosinusitis and asthma: unravelling a complex relationship. Curr Opin Otolaryngol Head Neck Surg. 2013;21(1):79 " “86.55 Fokkens ‚ WJ, Lund ‚ VJ, Mullol ‚ J, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology. 2012;50(1):1 " “12.66 Rudmik ‚ L, Schlosser ‚ RJ, Smith ‚ TL, et al. Impact of topical nasal steroid therapy on symptoms of nasal polyposis: a meta-analysis. Laryngoscope. 2012;122(7):1431 " “1437.77 Chur ‚ V, Small ‚ CB, Stryszak ‚ P, et al. Safety of mometasone furoate nasal spray in the treatment of nasal polyps in children. Pediatr Allergy Immunol. 2013;24(1):33 " “38.88 Schlosser ‚ RJ, Soler ‚ ZM. Evidence-based treatment of chronic rhinosinusitis with nasal polpys. Am J Rhinol Allergy. 2013;27(6):461 " “466.
ADDITIONAL READING
- Aouad ‚ RK, Chiu ‚ AG. State of the art treatment of nasal polyposis. Am J Rhinol Allergy. 2011;25(5):291 " “298.
- Bachert ‚ C. Evidence-based management of nasal polyposis by intranasal corticosteroids: from the cause to the clinic. Int Arch Allergy Immunol. 2011;155(4):309 " “321.
- H ƒ ¥kansson ‚ K, Thomsen ‚ SF, Konge ‚ L, et al. A comparative and descriptive study os asthma in chronic rhinosinusitis with nasal polyps. Am J Rhinol Allergy. 2014;28:383 " “387.
- Hopkins ‚ C, Slack ‚ R, Lund ‚ V, et al. Long-term outcomes from the English national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis. Laryngoscope. 2009;119(12):2459 " “2465.
- Lee ‚ KI, Kim ‚ DW, Kim ‚ EH, et al. Cigarette smoke promotes eosinophilic inflammation, airway remodeling, and nasal polyps in a murine polyp model. Am J Rhinol Allergy. 2014;28(3):208 " “214.
- Rimmer ‚ J, Fokkens ‚ W, Chong ‚ LY, et al. Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps. Cochrane Database Syst Rev. 2014;(12):CD006991.
- Sharma ‚ R, Lakhani ‚ R, Rimmer ‚ J, et al. Surgical interventions for chronic rhinosinusitis with nasal polyps. Cochrane Database Syst Rev. 2014;(11):CD006990.
CODES
ICD10
- J33.9 Nasal polyp, unspecified
- J33.0 Polyp of nasal cavity
- J33.8 Other polyp of sinus
- J33.1 Polypoid sinus degeneration
ICD9
- 471.9 Unspecified nasal polyp
- 471.0 Polyp of nasal cavity
- 471.8 Other polyp of sinus
- 471.1 Polypoid sinus degeneration
SNOMED
- 52756005 Nasal polyp (disorder)
- 373605001 Nasal polyp - posterior (disorder)
- 32307003 Polyp of nasal sinus
- 26808007 Polypoid sinus degeneration (disorder)
CLINICAL PEARLS
- Intranasal corticosteroid use has been demonstrated to reduce polyp size and recurrence, as well as improvement in nasal congestion.
- Asthma is a common concominant diagnosis and is often previously undiagnosed.
- Aggressive medical and surgical treatment improves asthma outcomes.
- Treat for a minimum of 12 weeks
- Allergy testing can be helpful.
- Nasal polyposis associated with asthma and aspirin hypersensitivity known as Samter triad or aspirin exacerbated respiratory disease (AERD) (1,3)[B]
- Patients with severe obstruction should be referred for surgery.
- Unilateral nasal polyp needs malignancy workup (MRI).