Doctor123.org

Nasal Polyps

BASICS

- 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].

- 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

- 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

  • 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 " ”rhinorrheaPostnasal 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 tissueMost commonly from lateral wall of middle meatusOtoscope 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:PapillomaIntranasal gliomaEncephaloceleRhabdomyosarcomaMycetoma
  • Allergy testing (3)[B]:Skin prick testImmunocap testingRadioallergosorbent 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 findingsUnable 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/dayBeclomethasone dipropionate 320 Ž ¼g/dayFluticasone propionate 400 Ž ¼g/dayMometasone furoate 200 Ž ¼g BIDFor children mometasone furoate is preferred:100 Ž ¼g BID ages 6 to 12200 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]
  • PrednisoloneWeight-based dosing burst with taper
  • Perioperative use oral prednisone 30 mg daily 5 to 7 days prior to surgery (2)[A]Decrease nasal mucosa inflammationImproves surgical fieldShorter surgical timeImproves postop resultsWeight-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 diseaseTwice 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).