What is Nasal Polyps?
Nasal polyps are non-cancerous swellings that grow from the lining of the nose or sinuses. They’re often found in people who have chronic rhinosinusitis, which is long-term inflammation of the nose and sinuses. Because of this, when doctors talk about nasal polyps, they often use the term ‘chronic rhinosinusitis with nasal polyposis’ (CRSwNP). Nasal polyps can also be linked to conditions like aspirin-exacerbated respiratory disease (AERD), certain types of blood vessel inflammation, and cystic fibrosis.
These polyps tend to develop when allergies are not well-controlled. Treating existing polyps is just the first step. After taking care of the polyps, it’s crucial to control the underlying allergy using local and systemic therapies to prevent the polyps from growing back quickly.
The symptoms of nasal polyps can vary. Some people don’t have any symptoms, while others might experience significant nasal blockages, stuffiness in the nose and face, loss of smell, loss of taste, and runny nose. These symptoms can significantly lower the quality of life for those affected.
What Causes Nasal Polyps?
Nasal polyps, or growths in the nose, can be divided into three types: localized, diffuse, and systemic.
Localized nasal polyps are usually a response to inflammation or growths in the body. Diffuse nasal polyps commonly appear in patients with CRSwNP, a chronic sinus and nasal condition. In western countries, nasal polyps commonly occur due to inflammation caused by a specific type of immune cell, the T-helper 2 (Th2) cell, and a protein called immunoglobulin-E (IgE). This often happens when people are exposed to things they’re allergic to in the environment or at specific times of year.
People with cystic fibrosis, a disease that affects the lungs and other parts of the body, often have nasal polyps due to inflammation caused by a type of white blood cell called a neutrophil. These people may have severe nasal polyps even without being exposed to something they’re allergic to, and their symptoms can look very similar to those of other patients with nasal polyps. When young individuals, especially those of European descent, have stubborn nasal polyps, cystic fibrosis might be a possible cause. A speedy diagnosis is important because cystic fibrosis can impact the whole body and often runs in the family.
Other theories suggest nasal polyps might be due to inflammation caused by fungi or a large inflammatory response to toxins from a type of bacteria called Staphylococcus aureus.
Last but not least, systemic nasal polyps are associated with systemic diseases, or diseases that affect the entire body, showing up as nasal symptoms. For example, eosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss syndrome, and cystic fibrosis are categorized in this group.
Risk Factors and Frequency for Nasal Polyps
Chronic rhinosinusitis, or CRS, is a condition that affects a significant portion of the population. In Europe, for example, nearly 11% of people have this condition. In the United States, it’s estimated that about 2.1% of people have two major symptoms of CRS, while another 13% experience one symptom.
- Chronic rhinosinusitis with nasal polyps, or CRSwNP, is a form of CRS that affects 25% to 30% of CRS patients.
- Usually, people between the ages of 40 and 60 are the most affected by CRSwNP in the United States.
- It’s more common in males, who make up 62% of the cases, compared to 38% in females.
- However, when females do get the disease, it tends to be more severe.
Signs and Symptoms of Nasal Polyps
Nasal polyps could be the culprit if you’re experiencing symptoms like a blocked nose, facial congestion, a runny nose, and a reduced sense of smell, which are common signs of a condition called chronic rhinosinusitis (CRS). Doctors might also ask about your reaction to aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) and whether you have asthma. If your symptoms mainly affect one side, or if you have a history of nosebleeds, chronic ear infection, or recurrent lung infections, there might be other causes at play.
Upon visiting the doctor, they may conduct an examination of your nose, during which the presence of polyps or other growths might be detected. Confirmation of nasal polyps typically comes from this nose examination or a nasal endoscopic exam. Sometimes, a CT scan of the sinuses might be needed to understand the severity of the condition and prepare for surgery, if necessary. If you have nasal polyps and two of the main symptoms mentioned earlier, you might be diagnosed with chronic rhinosinusitis with nasal polyps. People with this issue can range from those showing no symptoms to those with a greatly affected quality of life, the latter often requiring surgical treatment from a specialist.
Testing for Nasal Polyps
It is very important for a doctor to thoroughly review a patient’s medical history and perform a detailed physical examination. If a person shows signs of Chronic Rhinosinusitis (CRS), a condition involving long-term inflammation in your sinuses and nasal passages, they should always receive an endoscopic exam. An endoscope is a thin, flexible tube with a tiny camera on the end that allows the doctor to examine the inside of your nasal passages.
If you have nasal polyps, the endoscopy test will show either one or two, movable, smooth, gray, and semi-transparent masses. These masses tend to originate from the middle meatus or sphenoethmoid recess, which are areas inside the nose. If you have a nasal polyp on one side only, this might hint at a different health issue. Inflammatory polyps, a type of benign(gentle or not harmful) growth, generally occur on both sides. Although benign conditions such as an antrochoanal polyp could cause a single-sided polyp, a high level of suspicion for cancer should be there and a referral to an otolaryngologist, a doctor specializing in ear, nose, and throat disorders, is suggested for performing a biopsy, a test where a small sample of tissue is removed for examination.
Usually, at this stage, the diagnosis of CRS with nasal polyps (CRSwNP) is confirmed. The patient should then be guided towards appropriate medical treatment. If a patient’s symptoms do not get better with medication, they would require further evaluation through a PNS CT scan. Additionally, patients showing symptoms or findings only on one side should immediately undergo imaging tests. Surgery may be considered as an option for patients diagnosed with CRSwNP, especially if they do not respond to medical treatment.
Treatment Options for Nasal Polyps
Nasal polyps are small, noncancerous growths in the nose, often caused by inflammation due to allergies. The type of nasal polyps a person has can influence the treatment they receive. If a patient has long-term sinus inflammation with nasal polyps, doctors normally begin treatment with nasal steroid sprays and nasal saline washes for about 2 to 3 months. Saline washes are safe, low-cost, and help clear away substances that can cause inflammation. Nasal steroids can reduce nasal congestion and shrink the size of the polyps.
If these treatments are not effective, a surgical procedure called functional endoscopic sinus surgery (FESS) might be recommended. However, there’s ongoing discussion among medical professionals about the best timing for this surgery. Once the surgery is complete, it’s important to continue with nasal steroids and possibly antihistamine sprays. Despite what the surgery achieves in removing physical blockages and restoring normal mucosal drainage, it’s also crucial to address any underlying allergy issues. Allergy testing and targeted immunotherapy can also be part of the treatment plan.
A more specialized approach might involve placing biodegradable stents that release steroids into the sinuses during surgery. These stents keep the sinuses open and release steroids for 30 days or longer to reduce inflammation and the chance of the polyps coming back. This method can lead to fewer follow-up procedures and a decrease in the use of oral steroids. Continuing with nasal saline washes and nasal steroids after surgery can improve long-term results.
If symptoms persist despite these treatments, oral steroids may be used, but with caution to avoid potential side effects. If a patient has nasal polyps, asthma, and aspirin sensitivity – a condition known as AERD – a treatment regime of gradual aspirin intake might be beneficial. Antibiotics are commonly used if there is evidence of a bacterial infection. The use of antifungal medications in the treatment of nasal polyps is still a matter of debate.
Biologic drugs, which are lab-produced antibodies that stop certain chemical reactions in the body, can be used in resistant cases. To be a candidate for biologic drugs, a person must have bilateral nasal polyps and three of the following criteria: severe loss of smell, a significant impact on quality of life, a diagnosed asthma, a need for systemic steroids or a contraindication to these, or evidence of type II inflammation.
Patients with systemic illnesses involving nasal polyps, such as EGPA or CF, should receive treatment for their underlying condition. For instance, patients with CF may be treated with a drug called ivacaftor, which helps to improve life quality in patients with rhinologic diseases.
What else can Nasal Polyps be?
When determining the cause of nasal growths, a wide range of possible conditions must be considered. This means it’s usually necessary to examine the cells of the growth under a microscope to confirm the diagnosis. Doctors need to consider various conditions that lead to nasal growths as:
- Antrochoanal polyps
- Inverted papillomas
- Schneiderian papillomas
- Squamous cell carcinoma (SCC)
- Non-Hodgkin lymphoma
- Melanoma
- Esthesioneuroblastoma
- Hemangiopericytoma
- Nasal duct cysts
- Nasal gliomas
- Encephaloceles
- Juvenile nasopharyngeal angiofibroma
- Rhabdomyosarcomas
- Hemangiomas
- Chordomas
All these conditions mentioned above can be ruled out through small tissue samples taken and tested during surgery, especially if it occurs on one side, as this might be a concern for tumors. This is why it is necessary to do a histopathology test on removed polyps during a sinus surgery for chronic sinus infection. Prior to surgery, doctors need to carefully study any available scans or images.
For example, encephaloceles can look like inflammatory polyps during a nasal inspection, but their true identity can be seen in CT images. If an encephalocele is mistakenly biopsied, it could potentially lead to an annoying leak of cerebrospinal fluid.
In instances where cancerous growth is suspected before operation, a detailed evaluation through scans is vital. A CT scan with intravenous (IV) contrast helps examine the bony contours, the blood supply of the lesions, as well as invasion into soft tissue. MRI helps to identify the spread of tumors into nerves, orbit, and brain. It is likewise beneficial in complex sinus infection cases. Different causes of nasal cavity pathologies have different appearances on imaging. For instance, patients with nasal polyposis have smooth, bulging, enhancing soft tissues on CT. On the other hand, patients with squamous cell carcinomas may exhibit bone erosion on CT and a dim appearance on T2-weighted MRI with homogeneous enhancement after contrast MRI.
What to expect with Nasal Polyps
The outlook for nasal polyps greatly depends on the specific type of the disease. According to research, those afflicted with allergic fungal rhinosinusitis, a specific kind of sinus infection, are likely to experience a higher recurrence of nasal polyps compared to patients with chronic rhinosinusitis with nasal polyps due to asthma or a sensitivity to aspirin.
However, surprisingly, those with a sensitivity to aspirin might have more severe cases of the disease and higher occurrences of nasal polyps compared to others.
Other factors that could potentially worsen the outcomes include being diagnosed at a young age, having high Lund-Mackay scores (measures the severity of sinus disease), and having specific conditions like high global osteitis (a type of bone inflammation) and elevated tissue eosinophilia/neutrophilia (high white blood cell counts).
Possible Complications When Diagnosed with Nasal Polyps
Nasal polyps are typically signs of an underlying health issue, and any complications that arise are generally due to this underlying problem. People with nasal polyps often suffer from obstruction of the nasal passageways, which can lead to sleep difficulties and chronic tiredness to a lesser degree. Nasal polyps can also block the sinus drainage pathways, leading to the formation of things called mucoceles.
Mucoceles can press against the structures in the eye socket, leading to bulging eyes, double vision, and an unattractive appearance. In some cases, the disease can be so severe that it significantly impacts the person’s quality of life. For instance, nasal polyps may lead to an irreversible loss of the sense of smell, a condition known as anosmia. It’s also been noted that nasal polyps can contribute to a condition called obstructive sleep apnea (OSA), where the person’s breathing stops and starts repeatedly while they’re asleep.
Common Issues with Nasal Polyps:
- Obstruction of nasal passages
- Sleep difficulties
- Chronic tiredness
- Formation of mucoceles
- Bulging eyes
- Double vision
- Impairment of physical appearance
- Possible irreversible loss of smell (anosmia)
- Potential contribution to obstructive sleep apnea (OSA)
Preventing Nasal Polyps
Nasal polyps can affect people’s health and everyday life in different ways, because each person is unique. Many people may have nasal polyps and not realize it because they don’t seek medical help for the symptoms that bother them. If nasal polyps are identified, it is recommended that the person receive a full medical check-up. Apart from improving breathing through the nose, it’s important to find out what’s causing the polyps. Additional check-ups with a lung specialist (pulmonologist) and an allergy specialist (allergist) can help manage this condition and identify and treat other possible related conditions, like asthma, which might not have been diagnosed earlier.
One key aspect of managing this condition is consistently following the prescribed treatment. Research shows that when patients regularly use a high-volume, low-pressure nasal salt water rinse and a twice-daily nasal corticosteroid spray, their quality of life improves. However, many people with nasal polyps may experience a return of the condition if they do not use their nasal spray as directed. Therefore, regular follow-up visits and stressing the importance of consistently using the medication as instructed can help achieve the best possible outcome.
