Nasal Polyps (Allergic, Non-Allergic, Antrochoanal, Tumor)
In its most basic definition, nasal polyps are grape-like growths that occur in the nose and sinus cavities. The VAST majority of nasal polyps are benign growths although there are some forms that may mimic nasal polyps, but are actually aggressive tumors and in some rare instances, even cancer. Below are two pictures of the nasal cavity taken by nasal endoscopy which is the quickest way to a diagnosis. One is normal and the other containing extensive nasal polyps. At the end of this webpage are CT scans.
Normal appearing nasal cavity. Arrow is pointing at the inferior turbinate.
Extensive nasal polyps denoted by the black arrows. The white arrow is pointing at the middle turbinate and the red arrow at the septum (both normal). This image was taken from knol.com.
Sometimes, the nasal polyp can get so large, you can see it in the nostril.
Although experts may bicker over classification and definition, the simplest way of approaching nasal polyps is by dividing them into 4 categories. It is important to divide the nasal polyps in this manner as the treatment is somewhat different in each case. But, keep in mind that the initial approach may be very similar:
- Allergic Nasal Polyps: This type is by far the most common and is exemplified by the picture above. Allergies is the main trigger for these nasal polyps to grow. Sampter's triad consisting of aspirin sensivity, asthma, and nasal polyps is a particularly nasty sub-class of this type. Churg Strauss Syndrome is another more severe cause of nasal polyps and often requires immunological treatment.
- Non-allergic Nasal Polyps: These polyps are like allergic nasal polyps EXCEPT, allergy testing comes back negative. On exam, they are indistinguishable from allergic nasal polyps.
- Antrochoanal Nasal Polyp: Cause is not exactly known, but generally is a SINGLE large nasal polyp emanating out of one sinus cavity which is different from the other types which are found in numerous sinus cavities and occur in bunches.
- Tumor/Cancer: These fortunately are quite rare and can only be determined by pathology after surgical removal. The most common aggressive tumor is inverting papilloma. Unfortunately, these often cannot be distinguished from the other types of nasal polyps above. However, if bone erosion is seen on CT scan, there is increased risk for such nefarious growths.
There are a multitude of symptoms associated with nasal polyps and may include a number of the following:
- Nasal obstruction
- Nasal congestion
- Loss of smell
- Loss of taste
- Pain/pressure over the face
- Chronic sinusitis
These symptoms may slowly grow worse over a period of months to years. Antibiotics, if given, provide only mild (if any) relief with symptoms immediately recurring. Decongestants and other allergy and sinus medications do little to help. Oral steroids like prednsione often help, but provide only transient relief.
At the initial visit, the workup and treatment is the same regardless of the type of nasal polyp.
To provide immediate relief, oral prednisone steroid medication with antibiotics are often provided. The steroid is probably the one and only medication that often is able to shrink the polyps significantly providing symptom relief quickly. Antibiotics are also given as there is always some baseline infection present, and since steroids are known to cause some degree of immunosuppression, provides some protection from infection initiation or exacerbation. Antibiotics without any oral steroids does pretty much nothing.
If allergic nasal polyps are suspected, the patient is immediately started on nasonex (a steroid nasal spray) and singulair. These medications are to be continued for years and potentially for life. Why? These two medications appear to help prevent the polyps from becoming larger if present, or from coming back after surgical removal. Without these medications, the polyps often come back or grow in size. It should probably be mentioned that nasonex is the ONLY steroid nasal spray that has an FDA indication for nasal polyps. No other steroid nasal spray has this indication. [Link]
Allergy testing and immunotherapy also is highly encouraged in the case of allergic nasal polyps. It is felt that such polyps are due to an underlying immune dysfunction related to allergies. As long as there is underlying allergies present, the polyps will have a tendency to come back.
If a patient also has high blood pressure, the drug verapamil has been found helpful in reducing not only high blood pressure but also the symptoms associated with nasal polyps. Verapamil belongs to a class of calcium-channel blockers used to treat high blood pressure. More info on this here.
If Sampter's Triad is present or Churg-Strauss Syndrome is of concern, getting an immunologist involved is important as more aggressive immunological internvention is typically required for long-term nasal polyp control.
For patients with severe asthma, eosinophilia (high eosinophil count in the blood), and bad allergies, monoclonal antibody treatment (ie, dupilumab and nucala) may be helpful as well.
Finally, if there are a lot of nasal polyps present, surgical removal by endoscopic sinus surgery is encouraged. This really is the only way to fully get rid of the polyps to allow the medications provided to work as good as possible. Remember, medications generally help prevent polyp regrowth or enlargement... they do NOT get rid of polyps that are already there. At time of surgery, the polyps that are removed are sent to pathology to ensure that there is no cancer or tumors present.
SO, to summarize, a typical patient who comes to see us will have the following happen:
- Initial Visit #1:
- Diagnosis of nasal polyps made by nasal endoscopy.
- Start patient on steroid nasal spray and singulair, generally for life.
- Prescribe antibiotic and steroids for immediate symptom relief with warning that patient will feel much better, but it is only TEMPORARY relief without further treatment.
- Order CT sinus BrainLAB protocol to determine exact extent of the nasal polyps as generally speaking, what one sees in the nose by nasal endoscopy is just the tip of the iceberg.
- Obtain allergy testing.
- IF a patient has known aspirin sensitivity, consider aspirin desensitization by an allergist.
- IF severe asthma and eosinophilia present, consider mAb treatment (generally managed by a pulmonologist or immunologist)
- Follow-up Visit #2:
- Sinus Surgery
- I often prescribe a medrol dose pack to be started ONE week prior to surgery and again after surgery. This protocol has significantly decreased the risk of severe nosebleeds and reduced the need for nasal packing after surgery. Nasal packing after sinus surgery occurs only in about 10% of cases.
- Post-Operative Visit #1-3:
- Ensure adequate healing and debridement of sinus cavities. Aggressive saline flushes is recommended during the recovery period.
- In this time period, the patient invariably notices a VAST improvement in all symptoms.
- Review pathology which generally takes about 1 week after sinus surgery.
- Follow-Up Visits:
- If the final pathology after sinus surgery reveals no cancer:
- Continue with allergy shots if allergy testing positive
- Continue with nasonex and singulair. If no allergies and only a single polyp present, these medications do NOT need to be continued.
- Follow-up visits scheduled every 6 to 12 months only in cases of allergic nasal polyps.
- If antochoanal nasal polyp, no further follow-up needed after surgery. No need to be on medications. Surgery alone is considered curative.
- If the final pathology after sinus surgery reveals cancer or aggressive tumor (ie, inverting papilloma)
- Referral is generally made to a tertiary care center for definitive treatment
- If the final pathology after sinus surgery reveals no cancer:
That's the overall approach and management for patients with nasal polyps!!!
With this treatment protocol, allergic nasal polyps generally recur over a period of 5-10 years (if they even come back at all). HOWEVER, after surgical removal of allergic nasal polyps, if a patient decides to stop prescribed medications and allergy shots, the nasal polyps generally come back within 1-3 years.
In patients where the nasal polyps do not seem to respond to the above protocol (or if patient is refusing surgery), the addition of a very strong drug called Zyflo (zileuton) may be of benefit. This drug can cause liver damage (in <10% of patients) and as such, liver function bloodwork (AST/ALT) is required every month for 3 months and yearly thereafter. As long as the AST/ALT numbers do not exceed 150 (yes, it is higher than what is considered normal), it is generally considered safe to continue with this drug (though would check bloodwork weekly if that happens to ensure stability). Getting an immunologist involved in the care of such patients would also be beneficial, especially for those patients where the nasal polyps are particularly resistant to standard treatment.
Please contact our office for an appointment if you suspect you have nasal polyps!
There are three basic reasons for needing a CT scan in patients with nasal polyps. The first reason is to delineate the exact extent of involvement of the sino-nasal cavities with polyps. Often, what one sees in the nose on nasal endoscopy is just the tip of the iceberg. The second reason for the CT sinus is that it provides a roadmap to perform endoscopic sinus surgery safely. The third and final reason is to look for bone erosion that may suggest an underlying non-benign growth.
|Normal CT Sinus: Note the air within the sinus cavities denoted by black (just like the black surrounding the head). White is bone. Grey is soft tissue.||
|Abnormal CT Sinus: Note the grey coloration within the sinus cavity, especially the right side. This person has right greater than left maxillary sinusitis along with severe bilateral ethmoid sinusitis. Entirely possible that nasal polyps are present in these same locations as well. This person also has a deviated septum.|
|Abnormal CT Sinus: This patient has severe nasal polyps involving all sinus cavities that spills out into the nasal cavity. There is absolutely no air in any sinus cavities.|
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