NASAL POLYPS

Presentation

The onset of nasal polyps is usually experienced as a rather sudden development of the inability to move air through one or both nostrils. This obstruction tends to be very persistent. Usually this obstruction is accompanied by a loss or a decrease in the ability to smell and taste. Our sense of smell is a major component in enjoying the taste of many foods. This combination of rapid onset of nasal obstruction and decreased ability to smell-taste is almost diagnostic of nasal polyps and any individual who experiences this should have their nose assessed for polyps or other types of obstruction.

What Are Polyps

Nasal polyps develop from the respiratory lining of the side of the nose or of the sinuses. They produce symptoms when they are large enough to impede airflow through the nose or block off air access to the olfactory cells (the cells that give us our ability to smell) which are located at the top of the inside of the nose. If you look into the nose, a polyp looks like a clear small grape that hangs from a small stem (or stalk). Although they can be single, the majority of patients have multiple polyps by the time they experience symptoms. There does appear to be a hereditary component at least in some individuals, where more than one member of a family will develop polyps during their lifetime. They can develop in children, but usually occur in adults. Nasal polyps in children can occur in cystic fibrosis. Nasal polyps do not turn into cancer. The most common complication of chronic nasal polyposis is recurrent or chronic sinusitis (secondary to the blockage of the sinus openings by the polyps). It is very clear that the respiratory lining of the nose and sinuses in these individuals is different than individuals who never develop polyps. Once polyps develop, these individuals have a tendency to continue to produce polyps for the rest of their life. Although it can occur, it is rare for an individual to develop only one or two polyps during their lifetime. It is precisely this characteristic of polyps, to continually reoccur once they start developing, that guides the treatment.

The Triad

Specific mention should be made of a subgroup of individuals who develop nasal polyps. As the name suggests, these individuals have three diagnoses. They have asthma, nasal polyps, and ASA-NSAI sensitivity. Individuals who are ASA-NSAI sensitive develop reactions to this group of medicines which can range from hives (urticaria)-swelling (angioedema), respiratory symptoms (nasal symptoms, difficulty breathing-acute asthma) to cardiac symptoms (low blood pressure, fainting, to complete cardiovascular system collapse (i.e. anaphylaxis). Most of these individuals have had asthma and often allergic rhinosinusitis for a number of years. They then develop the other two components of this Triad over a period of time. The time frame is highly variable and any of these specific diagnoses can develop first followed by the other two. If any individual has two of these three diagnoses, they should always be informed about the possibility of the third developing. In general, patients with the Triad have severe and difficult to treat asthma, often severe recurrent sinus problems, and their polyps tend to be multiple and difficult to treat requiring multiple surgeries over time.

Treatment

Ear, nose, and throat surgeons learned long ago that simply removing the polyps does little to help these individuals long-term. After surgery, the polyps commonly came back. Surgical removal involves placing a snare around the stem or stalk of the polyp which cuts the stalk and the polyp is pulled out the front of the nose. The surgery is not as easy as it sounds because there are often multiple polyps and it can be very difficult to actually see the stock of an individual polyp. The main risk of surgery is profuse bleeding, so the nose is packed for a period of 24-48 hours after surgery to allow clotting to occur. Infection is also a risk after surgery, either at the surgical site or in the sinuses (as the sinuses have been blocked by the nasal packing and /or residual swelling or residual polyps).

Because of the tendency for polyps to regrow-reoccur, the modern treatment of nasal polyps revolves around attempting to reduce the size of the polyps, minimize symptoms, and to maintain polyps in their reduced size long-term. Many topical treatments have been tried over the years. The only topical treatment that has been shown to be effective is topical intranasal corticosteroids. In some individuals, using high dosage topical intranasal steroids (such as Nasonex TM, Flonase TM, Nasacort AQ TM, Rhinocort TM, etc.) for a period of weeks can decrease polyp size, which is then followed by a reduced long-term maintenance dose (usually twice daily) of the topical intranasal steroid. However, a large percentage of individuals do not respond to topical intranasal steroids initially, and often require an initial course of prednisone for 10 to 14 days to induce the initial shrinkage of the polyps. This is followed by regular topical intranasal steroids for an indefinite period to maintain the polyps in their smaller state. If an individual fails to respond to prednisone, or topical intranasal steroids do not maintain a smaller polyp size, surgery is usually required. As soon as possible after surgery, intranasal corticosteroids are started in an attempt to prevent significant regrowth of polyps. It is not unusual to try more than one course of prednisone prior to deciding on surgery. Please go to the Contents Section and read the subsection on Rhinitis and Medications to further understand the risks and benefits of prednisone and topical intranasal corticosteroids.

Because polyps often occur in individuals with significant allergies, virtually every allergic treatment has been tried for nasal polyps. Most standard allergy treatments such as antihistamines and decongestants have been shown to have no effect whatsoever on nasal polyps. In my experience, there are some highly allergic individuals whose polyps do respond to immunotherapy (allergy shots). Allergy shots help standard allergic symptoms (such as runny nose, sneezing, post nasal drip, itchy eyes, allergic asthma, etc.), but there is no guarantee that allergy shots will definitively improve nasal polyps. I have some patients whose polyps have dramatically responded to immunotherapy, and other patients whose polyps appear to have been totally unaffected by immunotherapy. There is no way at this time to tell if immunotherapy will help a specific individual. In individuals with the Triad, ASA desensitization has been shown to be somewhat beneficial, but the long-term risks versus benefits of this form of treatment is unclear.

Summary

Any individual who experiences a rather sudden onset of persistent nasal obstruction associated with decrease or loss of the sense of smell-taste should be assessed for the possibility of nasal polyps. The standard medical treatment of nasal polyps at this time is to initially attempt to decrease the size of the polyps, and if this is successful to maintain the polyps in their smaller state with the use of long-term topical intranasal corticosteroids. Surgery is generally reserved for individuals who fail medical treatment and whose polyps remain significantly symptomatic.

Dr. Bruce Sweet 2006