> Table of Contents > Nasal Polyps
Nasal Polyps
Katherine Holmes, MD
Daniel Young, MD
image 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 ˜1-4% in adults
  • Much rarer in children: ˜0.1%
  • 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.
image 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].
image 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 &mgr;g/day
    • Beclomethasone dipropionate 320 &mgr;g/day
    • Fluticasone propionate 400 &mgr;g/day
    • Mometasone furoate 200 &mgr;g BID
    • For children mometasone furoate is preferred:
      • 100 &mgr;g BID ages 6 to 12
      • 200 &mgr;g 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]
  • P.705

  • 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.
image 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
1. Tomassen P, Van Zele T, Zhang N, et al. Pathophysiology of chronic rhinosinusitis. Proc Am Thorac Soc. 2011;8(1):115-120.
2. 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.
3. DeMarcantonio MA, Han JK. Nasal polyps: pathogenesis and treatment implications. Otolaryngol Clin North Am. 2011;44(3):685-695, ix.
4. 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.
5. 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.
6. 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.
7. 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.
8. Schlosser RJ, Soler ZM. Evidence-based treatment of chronic rhinosinusitis with nasal polpys. Am J Rhinol Allergy. 2013;27(6):461-466.
Additional Reading
&NA;
  • 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.
  • Håkansson K, Thomsen SF, Konge L, et al. A comparative and descriptive study of asthma in chronic rhinosinusitis with nasal polyps. Am J Rhinol Allergy. 2014;28(5):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
&NA;
ICD10
  • J33.9 Nasal polyp, unspecified
  • J33.0 Polyp of nasal cavity
  • J33.8 Other polyp of sinus
Clinical Pearls
&NA;
  • 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).