Nasal Polyps Picture, Surgery and Treatment
What is Nasal Polyps
Nasal polyps have been recognized and treated since ancient times. The "aspirin triad" or occurrence of nasal polyps in association with asthma and aspirin sensitivity was first identified in 1911 . Nasal polyps represent a consequence of chronic mucosal inflammation; this condition also has been referred to as hypertrophic rhinitis. In most cases, nasal polyps arise from the middle meatus and clefts of the ethmoid region. Histologic sections of nasal polyp tissue exhibit infiltration with eosinophils, plasma cells, lymphocytes, and mast cells. Polypoid tissue is rich in ground substance containing acid mucopolysaccharide.
The overall incidence or prevalence of nasal polyposis is unknown. Nasal polyps are diagnosed more frequently in men and during the third and fourth decades of life. Most clinical data indicate that there is no greater prevalence of nasal polyps among atopic compared with normal populations. A population-based study was conducted in Finland to determine the prevalence of asthma, aspirin intolerance, nasal polyposis, and chronic obstructive pulmonary disease in the adult population. The overall prevalence of nasal polyposis was 4.3%. Overall prevalence of aspirin intolerance and aspirin-induced asthma was 5.7% and 1.2%, respectively. In an adult allergy clinic population, 211 (4.2%) had nasal polyps; 71% had asthma. Nasal polyps occur in 7% of patients with asthma . Approximately 14% of polyp patients reported aspirin intolerance. The prevalence could be underestimated in that 8% of nasal polyp patients without histories of salicylate sensitivity exhibit aspirin intolerance when challenged with aspirin. Nasal polyps are much less common in children than in adults. If nasal polyps are recognized in a child, the clinician must exclude cystic fibrosis, a disease in which the occurrence of nasal polyps ranges between 6.7% and 26%. A recent study of 211 adults with cystic fibrosis, who underwent intranasal endoscopy, reported a 37% prevalence of nasal polyps.
Causes of Nasal Polyps
The pathogenesis of nasal polyposis has not been defined. Allergic mechanisms have been investigated, but no consistent association has been established between atopy and nasal polyposis. Mast cells and their mediators could play a role in that mast cells as well as eosinophils are abundantly present in nasal polyp tissue. Bunstead and colleagues detected measurable amounts of histamine, a mast cell and basophil mediator, in nasal polyp fluid. Allergen-induced release of histamine and proinflammatory mediators (e.g., leukotrienes) has been demonstrated after passive sensitization of nasal polyp tissue with allergic serum.
Symptoms of Nasal Polyps
Perennial nasal congestion, rhinorrhea, and anosmia (or hyposmia) are common presenting symptoms. Nasal and osteomeatal obstruction may result in purulent nasal discharge and sinusitis. Enlargement of nasal polyps may lead to broadening of the nasal bridge, and rarely, nasal polyps can encroach into the orbit, causing compression of ocular structures and resulting in unilateral proptosis, which falsely suggests the presence of an orbital malignancy.
A thorough examination with a nasal speculum is necessary for identification of nasal polyps. More complete visualization of nasal polyps can be accomplished by flexible rhinoscopy. Nasal polyps appear as bulbous translucent to opaque growths, and are best visualized extending from the middle and inferior nasal turbinates, causing partial or complete obstruction of the nasal canals. Frontal, ethmoidal, and maxillarytenderness with purulent nasal discharge from the middle meatus indicate concurrent acute or chronic paranasal sinusitis. Sinus radiographic studies are rarely necessary for identification of nasal polyps. Common radiographic changes observed in patients with chronic nasal polyposis include the following: widening of the ethmoid labyrinths; mucoceles or pyoceles within the paranasal sinuses; and generalized loss of translucence in the maxillary, ethmoid, and frontal sinuses.
Treatment and Prevention of Nasal Polyps
The surgical treatment of nasal polyposis often is unsatisfactory. Simple nasal polypectomy results in temporary relief of nasal obstructive symptoms but is often followed by recurrence. Medical treatment with topical intranasal glucocorticoids has been reported to be more effective than surgical polypectomy. Aggressive treatment of nasal polyps with nasal corticosteroids can reduce the requirement for nasal sinus surgery. Intranasal steroids significantly reduce the size of polyps, nasal congestion, and rhinorrhea, and increase nasal airflow.
Among the various mechanisms of action, topical corticosteroids have been reported to reduce secretion of proinflammatory cytokines such as granulocyte-macrophage colony-stimulating factor (GM-CSF) from nasal polyp epithelial cells and reduce tissue eosinophils . Optimal delivery is achieved by positioning of the head in the downward and forward position. There is evidence that higher doses of a potent nasal corticosteroid are more effective; fluticasone propionate administered as 400 µg twice daily was more effective than 400 µg once daily in improving nasal inspiratory flow and reducing polyp size . Unfortunately, intranasal steroids have marginal effects in improving olfactory function. The latter result is best achieved with brief courses of systemic corticosteroids. Intranasal steroids exert little effect on associated sinus disease, as evidenced by lack of improvement in sinus radiographs over a 12-month interval. Leukotriene antagonists are effective antiasthmatic agents and are particularly effective in aspirin-sensitive patients. However, there have been no published controlled clinical trials of antileukotriene agents in the treatment of nasal polyps .
Long-term treatment of Nasal Polyps with daily intranasal glucocorticoids is safe and has not been reported to result in atrophic changes in nasal mucosa . If polyps fail to respond to intranasal glucocorticoids, a brief 5- to 7-day course of oral prednisone (30-35 mg/day) may be effective. The long-term use of oral glucocorticoids should be avoided. Once nasal polyps have been reduced in size with prednisone, maintenance dosages of intranasal glucocorticoids should be resumed to prevent recurrence. Coexistent sinus infection may render individuals refractory to intranasal glucocorticoids and therefore should be treated with an appropriate course of antibiotics.