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Monday, August 11, 2025

Nasal polyps


Introduction
Nasal polyps are benign, non-cancerous, soft, and painless growths of the nasal or paranasal sinus mucosa, often resulting from chronic inflammation. They typically arise from the mucous membranes of the nose or paranasal sinuses, especially the ethmoid sinuses, and protrude into the nasal cavity. While not life-threatening, nasal polyps can cause significant nasal obstruction, reduced sense of smell, and recurrent sinus infections.

They are commonly associated with chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, aspirin-exacerbated respiratory disease (AERD), allergic rhinitis, and other inflammatory or immune-mediated disorders.

Epidemiology

  • Prevalence: ~1–4% in the general population.

  • More common in adults over 40 years of age.

  • Twice as common in males compared to females.

  • Rare in children; when present in children, cystic fibrosis should be considered.

Etiology and Risk Factors

Underlying Mechanisms

  • Chronic mucosal inflammation leads to oedema, epithelial disruption, and polyp formation.

  • Often associated with Type 2 helper T cell (Th2)-mediated inflammation, eosinophilia, and elevated interleukin-5 (IL-5) levels.

Risk Factors

  • Chronic rhinosinusitis.

  • Aspirin sensitivity and NSAID intolerance (part of Samter’s triad with asthma and polyps).

  • Asthma.

  • Allergic rhinitis or non-allergic rhinitis.

  • Cystic fibrosis.

  • Primary ciliary dyskinesia.

  • Churg–Strauss syndrome (eosinophilic granulomatosis with polyangiitis).

  • Recurrent nasal infections.

Pathophysiology

The mucosal lining undergoes persistent inflammation and oedema, leading to structural changes:

  1. Epithelial cell injury from allergens, irritants, or infections.

  2. Cytokine-driven recruitment of eosinophils and other inflammatory cells.

  3. Formation of a polypoid mass filled with oedematous stroma and inflammatory cells.

Clinical Features

Symptoms

  • Persistent nasal blockage or congestion.

  • Rhinorrhoea (usually clear, watery, or mucoid).

  • Postnasal drip.

  • Reduced or absent sense of smell (hyposmia/anosmia).

  • Facial pressure or pain (more common with coexisting sinusitis).

  • Snoring and sleep disturbance.

Signs

  • Smooth, pale, grey, translucent, grape-like masses in nasal cavity on anterior rhinoscopy or nasal endoscopy.

  • Usually bilateral in CRSwNP; unilateral polyps require evaluation to rule out neoplasm.

Diagnosis

Clinical Examination

  • Nasal endoscopy confirms the presence, size, and location of polyps.

Imaging

  • CT scan of paranasal sinuses: Demonstrates extent of disease, sinus opacification, and guides surgical planning.

Additional Workup

  • Allergy testing if allergic rhinitis suspected.

  • Sweat chloride test or genetic testing in children to evaluate for cystic fibrosis.

  • Consider antineutrophil cytoplasmic antibody (ANCA) testing in suspected vasculitis.

Differential Diagnosis

  • Antrochoanal polyp.

  • Inverted papilloma.

  • Benign or malignant nasal tumors (especially in unilateral presentation).

  • Hypertrophic turbinates.

Management

Management aims to reduce inflammation, shrink or remove polyps, and control underlying disease.

1. Medical Therapy – First-line treatment for most patients

Intranasal Corticosteroids (INCS) – Cornerstone of therapy

  • Fluticasone propionate: 50 mcg per spray, 2 sprays per nostril once daily.

  • Mometasone furoate: 50 mcg per spray, 2 sprays per nostril once daily.

  • Budesonide: 64 mcg per spray, 1 spray per nostril twice daily.

Short Course of Oral Corticosteroids – For severe symptoms or large polyps

  • Prednisolone: 30–50 mg orally once daily for 5–10 days, then taper (not for long-term use due to side effects).

Saline Nasal Irrigation – Improves mucociliary clearance and reduces inflammation

  • Isotonic or hypertonic saline solution, 50–250 mL per nostril once or twice daily.

Leukotriene Receptor Antagonists – Useful in aspirin-sensitive asthma

  • Montelukast: 10 mg orally once daily.

Biologic Therapy – For severe CRSwNP unresponsive to standard therapy

  • Dupilumab: 300 mg subcutaneously every 2 weeks (IL-4/IL-13 inhibitor).

  • Mepolizumab: 100 mg subcutaneously every 4 weeks (IL-5 inhibitor).

  • Omalizumab: 75–600 mg subcutaneously every 2–4 weeks (anti-IgE; dose based on IgE levels and body weight).

2. Surgical Therapy

Indicated for:

  • Persistent symptoms despite optimal medical therapy.

  • Recurrent polyps causing significant obstruction.

  • Suspicion of neoplasm (especially unilateral).

Endoscopic Sinus Surgery (ESS)

  • Removes polyps and restores sinus ventilation and drainage.

  • Postoperative INCS essential to prevent recurrence.

Complications

  • Chronic or recurrent sinusitis.

  • Sleep-disordered breathing.

  • Recurrent polyp formation.

  • Rare: Orbital or intracranial spread of infection in severe sinusitis cases.

Prognosis

  • Chronic condition with a tendency to recur, especially in patients with asthma or aspirin sensitivity.

  • Lifelong management and follow-up often required.




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