Nasal Polyps

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Nasal Polyps: A full understanding of current treatment strategies

Healthylife Pharmacy16 June 2014|3 min read

The moist inner lining of the nose is called its mucosa. Facial bones surrounding the nose have air-filled spaces that open into the nasal cavity. These are called the paranasal sinuses, also called nasal sinuses or simply sinuses. These sinuses too are lined with mucosa and their secretions drain into the nose. When the mucosa of the nose and sinuses swells up, projects and protrudes, nasal polyps are formed. On examination they appear as teardrops or grape-like structures inside the nasal cavity.

Are they cancerous?

While you may have heard of polyps in other areas of the body like the colon (large intestine) or bladder that may turn malignant, nasal polyps are different as they are almost always benign, that is to say, they seldom become cancerous. In that sense and of themselves, they are harmless.

What makes them troublesome?

Firstly, they obstruct the nose and sinuses giving rise to multiple problems.

Secondly, the disease process that initially aided in their formation persists with its own symptoms.

If left unattended and neglected, nasal polyps can produce some fearsome complications over the long run.

There are two main types of nasal polyps:

  • Ethmoidal polyps: These are usually multiple and bilateral (occur on both sides of the nose). They give the classic “bunch of grapes” appearance. As their name suggests, they arise from the ethmoid sinuses.
     
  • Antrochoanal polyps: These are usually single and unilateral (occur on one side of the nose). They arise from the opening of the maxillary sinus and project into the nose.

Since around 95% of people with nasal polyps have ethmoidal polyps; the term nasal polyps usually means ethmoidal polyps. Whenever you read about nasal polyps, they will actually be telling you about ethmoidal polyps. If antrochoanal polyps are being discussed, that is clearly specified. The rest of our discussion pertains to ethmoidal nasal polyps.

Who do they effect?

Though nasal polyps can occur at any age, the tendency to acquire them increases with age. So people presenting with polyps tend to be older. If a child presents with nasal polyps; suspect a strong underlying predisposing condition such as cystic fibrosis. Nasal polyps are three times as common in men than in women.

What causes nasal polyps?

This is still an open question. While there are many conditions that predispose to polyp formation, polyps may emerge without any associated risk factor. A classic example is asthma. While there is an increased association of nasal polyps with asthma; not all asthmatics develop nasal polyps, nor will all people with nasal polyps have asthma. The same can be said about allergic rhinitis, which is another condition strongly linked to nasal polyp formation. The following are considered as risk factors for the development of nasal polyps:

  • Asthma
  • Allergic rhinitis
  • Aspirin sensitivity
  • Cystic fibrosis
  • Churg-Strauss syndrome
  • Family history

The underlying mechanism for most of these risk factors is inflammation of the nasal mucosa, causing it to swell up. Factors such as sneezing and gravity act upon these local mucosal swellings to convert them into pedunculated growths (growing from a stalk or narrow attachment).

What symptoms do nasal polyps cause?

Many of the symptoms are due to the nasal obstruction and stuffiness caused by the polyps. They also block openings of the various sinuses, which predisposes to infection. Any underlying disease process causing polyp formation contributes to the symptoms.

Signs and Symptoms

  • Nasal stuffiness, sneezing, nasal obstruction and runny nose
  • Sinus infections
  • Snoring and sleep apnea
  • Headache, earache, sense of ear fullness, and hearing loss
  • Loss of smell and taste sensation
  • Mouth breathing dry throat
  • Fatigue, daytime sleepiness and irritability

This long list indicates that while nasal polyps are benign growths and under normal circumstances have no associated mortality, they can seriously affect a person’s quality of life and productivity.

What are the complications of nasal polyps?

Nasal polyps are slow growing masses causing many symptoms and in an increasingly health-focused population, it would be difficult for them to go unnoticed and untreated for a long time. However if they remain unattended for months and years, nasal polyps can give rise to dreaded complications. These result from an ability of the polyps to erode bone. Hence they will make their way into the orbit or the cranial cavity. In the orbit they can push the eyeball out, impede eye movement leading to double vision and squint or cause blindness. In the cranial cavity they can lead to various pressure symptoms or infections such as meningitis or brain abscess.

Diagnostic workup

A thorough history and general physical examination are always helpful. A nasal examination usually reveals the diagnosis. Large polyps are easily visible and do not require any special instruments. A nasal endoscope which is a flexible tube with a tiny camera and a light source can aid in visualizing the nasal cavity and sinus openings. A computerised tomography (CT) scan and/or a magnetic resonance imaging (MRI) scan can reveal the extent of the polyps and any underlying structural abnormalities.

Management of nasal polyps

Treating nasal polyps can be quite a challenge. This is because of their stubborn tendency to recur. Treatment options are:

Treat the underlying cause: It is imperative to treat any underlying disease process.

Associated asthma or allergic rhinitis under good control would mean that the polyps will respond to treatment and regress and in treated cases not recur for longer periods. If the risk factors are not treated or controlled, targeting nasal polyps alone may prove futile.

Saline irrigation: Washing the nose and sinuses with a saline solution (salt water) is usually a good idea. It helps to drain sinus secretions. It is beneficial in alleviating symptoms or after surgery to delay polyp recurrence.

Antihistamines: Antihistamines either topical such as intranasal sprays (azelastine) or oral such as loratadine or fexofenadine are used in nasal polyp management. Their main role being to curb accompanying allergies.

Corticosteroids: This is the only group of drugs that has a direct impact on the polyps. Not only do steroids halt polyp progression, they actually diminish the size and number of polyps and in some cases make them disappear altogether.

Corticosteroids are the mainstay of nasal polyp treatment

  • Topical steroids come in the form of drops and sprays and contain beclomethasone, fluticasone, mometasone etc. They are very safe and therefore can be used for long durations.
  • Systemic steroids such as prednisone and prednisolone can also be used if a quicker effect is required. Corticosteroids are used extensively after surgery as well to prevent recurrence.

Antibiotics: These can be used to treat concomitant sinus infections. Common examples are amoxycillin-clavulanate and clarithromycin.

Surgery: Once nasal polyps have reached a certain size, it is difficult to eradicate them with corticosteroids alone. Surgery becomes necessary. Surgery to remove nasal polyps is called a polypectomy. It is done with the help of a nasal endoscope, and named an endoscopic sinus surgery. The procedure can be performed under local or general anesthesia. It may be done on an outpatient basis, where the patient is able to return home the same day.

Other drugs such as mast cell stabilisers (nedocromil), nasal decongestants (xylometazoline) and leukotriene inhibitors (montelukast) may be advised by the doctor either to alleviate symptoms or to manage underlying risk factors but these drugs do not have a direct effect on the nasal polyps.

Developments and future treatments:

The following may be of interest:

Laser surgery: The underlying principles are the same as for conventional endoscopic surgery. In this case the polyps are burnt with a laser. It is thought that this causes less bleeding and decreases recurrence rates. Results of further comparative studies are awaited.

Alternative medicine: Abundant literature is available about alternative therapies and home remedies to cure nasal polyps. Most of these aim to optimise the body’s immune system, through various diet plans and food supplements, which can then take care of the polyps. Though a balanced and healthy diet is always recommended, a new diet plan or food supplement should only be tried once adequate insight is gained into its pros and cons.

References

  1. Frosini P, Picarella G, De Campora E. Antrochoanal polyp: Analysis of 200 cases. Acta Otorhinolaryngol Ital.2009;29(1):21–6.
  2. Newton Jonathan Ray, Ah-See Kim Wong. A review of nasal polyposis. Ther Clin Risk Manag.2008;4(2):507–12.
  3. Kalish L, Snidvongs K, Sivasubramaniam R, et al. Topical steroids for nasal polyps. Cochrane Database Syst Rev 12:CD006549, 2012.
  4. Benitez P, Alobid I, de Haro J, et al. A short course of oral prednisone followed by intranasal budesonide is an effective treatment of severe nasal polyps. Laryngoscope. 2006;116(5):770–775.
  5. Levine HL. Endonasal laser surgery: an update.Otolaryngol Clin North Am. 2006;39(3):493–501.