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Otolaryngology and Facial Plastic Surgery > NASAL AND SINUS DISEASES
Nasal Polyps, Nonsurgical Treatment
Article Last Updated: Nov 29, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Sanford M Archer, MD, FACS, Associate Professor, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Kentucky Medical Center
Sanford M Archer is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Rhinologic Society, American Society for Head and Neck Surgery, Kentucky Medical Association, and North American Skull Base Society
Editors: Eric Moore, MD, Residency Director, Assistant Professor, Department of Otorhinolaryngology/Head and Neck Surgery, Mayo Graduate School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert M Kellman, MD, Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
nasal polyps, nasal polyposis, nasal tumors, tumors of the nasal cavity, environmental allergies, olfaction, nasal obstruction, hyperplasia of the intranasal mucosal membrane
Background
Nasal polyposis is an inflammatory condition of unknown etiology. Nasal polyps are the most common tumors of the nasal cavity. Approximately 30% of patients with nasal polyps test positive for environmental allergies. The prevalence of nasal polyps is increased in children with cystic fibrosis and persons with known aspirin hypersensitivity. Nasal polyposis can impair a person's quality of life more than perennial allergic rhinitis. Olfaction and nasal obstruction are the most important considerations in terms of symptoms.
Pathophysiology
Nasal polyposis results from chronic inflammation of the nasal and sinus mucous membranes. Chronic inflammation causes a reactive hyperplasia of the intranasal mucosal membrane, which results in the formation of polyps. The precise mechanism of polyp formation is incompletely understood. In 1990, Tos reported 10 pathogenic theories of nasal polyp formation:1
- Adenoma and fibroma theories
- Necrosing ethmoiditis theory
- Glandular cyst theory
- Mucosal exudate theory
- Cystic dilatation of the excretory duct and vessel obstruction theory
- Blockade theory
- Periphlebitis and perilymphangitis theory
- Glandular hyperplasia theory
- Gland new formation theory
- Ion transport theory
Multiple chemical mediators have been identified in nasal polyps but their significance has not been completely elucidated. Some of these mediators may be released by the polyps themselves and others by the eosinophils found in certain subsets of polyps. Cysteinyl leukotriene receptors and interleukin-5 (IL-5) appear to be the most well studied.
Frequency
United States
Nasal polyps are present in 5% of nonallergic people and only 1.5% of people with allergic rhinitis. No racial or sexual predilection is reported. The prevalence is increased in patients with cystic fibrosis and aspirin-hypersensitivity triad.
Mortality/Morbidity
Morbidity from polyps is directly related to their location and size.
- Obstruction of the sinus ostia frequently occurs and may lead to acute or chronic sinus conditions. With increased growth, polyps can cause bony destruction because they can exert pressure on bone. Polyps may cause destruction of the nasal bones or other facial bones.
- Nasal obstruction due to polyposis can also lead to hyposmia or even anosmia.
- Nasal polyps are not known to be premalignant. However, they may be confused with papillomas, including inverting papillomas, which are known to be precursors of malignant lesions. In addition, polyps can sometimes arise from inflammation caused by malignant or premalignant nasal lesions. These polyps can obstruct visualization of the more concerning lesions and sometimes cause delay in diagnosis.
History
Patients with massive nasal polyposis typically present with increasing nasal congestion, hyposmia to anosmia, changes in sense of taste, and persistent postnasal drainage. Headaches and facial pain and discomfort are not uncommon and are found in the periorbital and maxillary regions. On occasion, a patient with completely obstructing nasal polyposis presents with symptoms of obstructive sleep apnea.
Patients with solitary polyps frequently present with only symptoms of nasal obstruction, which may change with a shift in position. For example, while lying supine, the polyp may swing posteriorly, opening up the nasal cavity. In an upright position, the polyp has a more obstructive effect.
Whether 1 or more polyps are present, patients may have symptoms of acute, recurrent, or chronic rhinosinusitis if the polyps obstruct the sinus ostia.
Physical
Intranasal examination reveals a fleshy translucent mass or masses in the nasal cavity, usually originating in the superior nasal vault. Polyps can be observed originating in the ethmoid region, from the maxillary sinus ostium (antral choanal polyps), the turbinates, or the septum. Obstructing polyps may make thorough intranasal examination difficult.
Mucopurulent discharge occasionally emanate from the ethmoid region or the superior nasal vault, suggesting an underlying rhinosinusitis. Septal deformities may make the examination more difficult.
Causes
- Allergy2
- Chronic sinusitis
- Chronic inflammation of indeterminate etiology
Allergic Rhinitis
Juvenile Nasopharyngeal Angiofibroma
Malignant Tumors of the Nasal Cavity
Turbinate Dysfunction
Other Problems to be Considered
Inverting papilloma
Lab Studies
- Allergy testing in patients who have polyps and are not clinically allergic is controversial.
- Many clinicians think that the expense is not justified.
- On the contrary, a thorough allergy evaluation should be considered in patients with a history of environmental allergies or a strong family history of allergies.
- Children who present with nasal polyposis should be tested for cystic fibrosis with either a sweat chloride test or with hematologic genetic testing.
Imaging Studies
- Coronal sinus CT is the imaging study of choice in the evaluation of patients with nasal polyposis.
- Coronal CT of the paranasal sinuses is best for delineating the underlying pathology, the extent of disease, and possible bony destruction.
- Nonenhanced CT with 2- to 3-mm sections helps to delineate the location and origin of the visible polyps, evaluate the underlying condition of all of the sinuses, and assess the anatomy of the paranasal sinuses in the event of surgical intervention.
- MRI is not an appropriate imaging modality for nasal polyposis unless intracranial extension is suspected. Bony details of the paranasal sinus anatomy are poorly visualized on MRI.
- Radiography with Waters views may show opacification of the sinuses.
Procedures
Nasal endoscopy in an office setting can sometimes be helpful in the diagnosis and evaluation of nasal polyps. This technique helps illuminate and improves visualization of the dark recesses of the nasal cavity. Endoscopy may allow the examiner to see beyond an obstructing nasal septal deviation, an enlarged turbinate, or an obstructing polyp.
Histologic Findings
Biopsy is not always required for the diagnosis of nasal polyps. Nasal masses that do not have the classic appearance of bilateral nasal polyps or that do not respond to conservative treatment should be examined with careful biopsy for diagnosis. The histologic appearance of nasal polyps varies from edematous tissue with a few glands to an increase in glandular elements. Eosinophils may be present, indicating an allergic component.
Many factors play a role in the formation of nasal polyp. Epithelial damage has been implicated in the pathogenesis of polyps. Epithelial cells can undergo activation in response to allergens, pollutants, and infectious agents. The cells release various factors that play a role in the inflammatory response and subsequent repair. The epithelium of nasal polyps shows goblet cell hyperplasia and mucous hypersecretion that may play a role in nasal obstruction and rhinorrhea.
Mucin synthesis and goblet cell hyperplasia are thought to be under control of epidermal growth factors (EGF). Inhibitors may block mucous production and goblet cell hyperplasia. Free radicals are highly reactive molecules with an unpaired electron in the outer orbit and may also play a role in polyp formation. The body produces endogenous oxidants as a result of the leakage of electrons from electron transport chains, phagocytic cells and endogenous enzyme systems (MAO, P450, etc).
Exogenous factors include radiation, air pollutants, tobacco smoke, sun exposure, ozone, and others. A certain physiologic level of reactive oxygen species is necessary for proper regulation of cell functions. Exposure to oxidants can initiate free radical-mediated reactions and lead to oxidative stress. Free radicals can result in cellular damage or death and subsequent tissue damage.
Several inflammatory factors have been isolated and are proven to be expressed by nasal polyps. These factors include endothelial vascular cell adhesion molecule (VCAM)-1, nitric oxide synthase, granulocyte-macrophage colony–stimulating factor (GM-CSF), eosinophil survival enhancing activity (ESEA), cys-leukotrienes (Cys-LT) and many other cytokines.
Medical Care
The management of nasal polyps should be based on the causative factors. Unfortunately, most cases of nasal polyps have an unclear etiology. Even if the patient is allergic, no clinical evidence shows that the management of allergies reduces or eliminates polyps. Because the underlying etiology in most cases is inflammatory, medical management is aimed at nonspecific treatment of this inflammatory disorder. Oral corticosteroids are the most effective medication for the short-term treatment of nasal polyps, and oral corticosteroids have the best effectiveness in shrinking inflammatory polyps. Intranasal steroid sprays may reduce or retard the growth of small nasal polyps, but they are relatively ineffective in massive nasal polyposis. Antifungal agents have no role in the management of nasal polyposis, but these agents may be useful in cases of allergic fungal sinusitis with polyposis.
- Oral corticosteroids: The time-tested medical treatment for obstructing nasal polyps is oral corticosteroids. The nonspecific anti-inflammatory agent quickly and substantially reduces the size of the inflammatory polyps and improves symptoms. Patients whose polyps respond to oral corticosteroids may be re-treated safely 3-4 times a year, especially if they are not candidates for surgery. The mechanism of action of corticosteroids is unclear. One study showed that corticosteroids induce apoptosis in inflammatory cells in human nasal polyps in vitro.
- Topical steroids: Intranasal corticosteroid sprays reduce the growth of small intranasal polyps are most effective in the postoperative period to prevent or retard regrowth of the polyps.
- Intrapolyp steroid injections: Intrapolyp steroid injections have been shown to reduce polyp growth and nasal symptom scores compared with intranasal medical therapy and appear to be a safe alternative to surgery in select patients. More studies are necessary.3
- Leukotriene inhibitors: Leukotrienes are formed during the breakdown of arachidonic acid by the enzyme 5-lipoxygenase. They are inflammatory mediators and have been implicated in the pathogenesis of asthma, allergic rhinitis, and nasal polyposis. As a result, they have become targets for therapeutic modulation. Early studies of leukotrienes synthesis inhibitors have shown improvements in nasal airflow and reduction in nasal polyps on endoscopy and imaging studies. Benefits appear to be greatest in patients with concomitant allergic rhinitis and eosinophilic infiltration of the nasal polyps on histology.
- Other agents: Other agents with a possible role in management of nasal polyposis are macrolides antibiotics, topical diuretic therapy, and intranasal lysine–acetylsalicylic acid.
Surgical Care
See Nasal Polyps, Surgical Treatment.
Consultations
- Consultation with an allergist is beneficial for patients with a history of environmental allergies.
- Allergy pharmacotherapy or immunotherapy is beneficial for patients with allergy symptoms.
- Consultation with a pulmonologist is helpful for patients with lower airway allergy, asthma, or cystic fibrosis.
Diet
Dietary modifications should be considered in patients with food allergy and nasal polyposis. Controlling allergy in these patients is important, and recording a food diary or undergoing tests for food allergy may help control symptoms and slow polyp growth.
The only medications effective in shrinking polyps are corticosteroids. Available both orally and topically, they provide a nonspecific anti-inflammatory response that reduces the size of the polyps and improves symptoms related to nasal obstruction. Other medications currently undergoing evaluation affect the nasal inflammatory pathway in different ways and specificity, but they have not shown great promise.
Drug Category: Oral corticosteroids
The time-tested medical treatment for obstructing nasal polyps is oral corticosteroids. This nonspecific anti-inflammatory agent significantly reduces the size of the inflammatory polyps and improves symptoms quickly. Unfortunately, the effects are short lasting, and polyps frequently regrow and cause similar symptoms within weeks to months.
| Drug Name | Prednisone (Deltasone, Orasone) |
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| Description | Immunosuppressant to treat autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Potent anti-inflammatory, generically available, and cost effective. |
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| Adult Dose | 5-60 mg/d PO; taper over 2-3 wk
Example: 20 mg PO tid for 4 d, then 20 mg PO bid for 4 d, 10 mg PO tid for 4 d, 10 mg PO bid for 4 d, 10 mg PO qd for 4 days, 5 mg PO qd for 4 d, then discontinue |
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| Pediatric Dose | 0.05-2 mg/kg PO divided bid/qid; taper over 2-3 wk |
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| Contraindications | Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease |
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| Interactions | Coadministration with estrogens may decrease clearance; concurrent digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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| Precautions | Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteoporosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use; caution in CHF, seizure disorders, and cirrhosis |
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Drug Category: Topical nasal corticosteroids
These induce a nonspecific anti-inflammatory response that should theoretically reduce the size of polyps and prevent regrowth when used continuously. Available nasal steroid sprays appear to be similarly effective and relatively safe for both short- and long-term use.
| Drug Name | Fluticasone (Flonase) |
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| Description | Potent vasoconstrictive and anti-inflammatory activity; weak inhibitory potency on HPA when applied topically. Advise patients to administer spray toward lateral nasal wall, avoiding irritation to septum or having drug run down back of pharynx. |
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| Adult Dose | 2 sprays each nostril once daily |
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| Pediatric Dose | <4 years: Not established
>4 years: 1 spray each nostril once daily |
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| Contraindications | Documented hypersensitivity; viral, fungal, and bacterial skin infections |
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| Interactions | None reported |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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| Precautions | Caution in recent nasal surgery or trauma, nasal septal perforation, atrophic rhinitis, and acute sinusitis; prolonged use may increase systemic absorption of corticosteroids causing Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria |
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| Drug Name | Mometasone (Nasonex) |
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| Description | Nasal spray; elicits anti-inflammatory activity. Indicated for nasal polyposis treatment. Demonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic activity in preclinical trials. Decreases rhinovirus-induced up-regulation in respiratory epithelial cells and modulates pretranscriptional mechanisms. Reduces intraepithelial eosinophilia and inflammatory cell infiltration (eg, eosinophils, lymphocytes, monocytes, neutrophils, plasma cells). Before initial use, prime pump by actuating 10 times or until a fine spray appears; if stored unused for > 1 wk, reprime. Advise patients to administer spray toward lateral nasal wall, avoiding irritation to septum or having drug run down back of pharynx. |
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| Adult Dose | 2 sprays (50 mcg/spray) each nostril once daily |
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| Pediatric Dose | <18 years: Not established
>18 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; nasal septal perforation; nasal surgery; nasal trauma |
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| Interactions | None reported |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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| Precautions | Use with caution in patients with active or quiescent tuberculosis of the respiratory tract; untreated fungal, bacterial, systemic viral infections; or ocular herpes; rare instances of decreased growth velocity in pediatric patients have been reported; also, rare instances of nasal septum perforation and increased IOP have been reported; nasal and inhaled corticosteroids have been associated with development of glaucoma and/or cataracts; prolonged use may increase systemic absorption of corticosteroids, causing Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria |
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| Drug Name | Budesonide (Rhinocort, Rhinocort Aqua) |
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| Description | Potent vasoconstrictive and anti-inflammatory activity. Budesonide is indicated for nasal polyposis management. Advise patients to administer spray toward lateral nasal wall, avoiding irritation to septum or having drug run down back of pharynx. |
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| Adult Dose | 2 sprays in each nostril once daily |
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| Pediatric Dose | <6 years: Not established
>6 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; viral, fungal, and bacterial skin infections |
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| Interactions | None reported |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | Caution in recent nasal surgery or trauma, nasal septal perforation, atrophic rhinitis, and acute sinusitis; prolonged use may increase systemic absorption of corticosteroids causing Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria |
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Drug Category: Leukotriene receptor antagonists
These agents prevent or reverse some of the pathologic features associated with the inflammatory process mediated by leukotrienes.
| Drug Name | Montelukast (Singulair) |
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| Description | Potent and selective antagonist of leukotriene D4 (LTD4) at the cysteinyl leukotriene receptor, CysLT1. Prevents or reverses some of the pathologic features associated with the inflammatory process mediated by leukotrienes C4, D4, and E4. |
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| Adult Dose | 10 mg PO qd |
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| Pediatric Dose | <2 years: Not established
2-5 years: 4 mg PO qd
6-14 years: 5 mg PO qd
>14 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Phenobarbital and rifampin may reduce AUC of montelukast |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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| Precautions | Not indicated for immediate relief of acute asthma symptoms, use appropriate short-acting inhaled beta2-agonist inhaler for exacerbations; not for use as monotherapy in management of exercise-induced bronchospasm; if already taking montelukast daily (eg, chronic asthma, allergic rhinitis), do not take an additional dose to prevent EIB; administration for chronic asthma has not been established to prevent acute EIB; chewable tab contains phenylalanine, caution with phenylketonuria |
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Further Outpatient Care
- Patients with nasal polyposis can easily be monitored as outpatients, and they should be examined by an otolaryngologist.
- Patients with limited symptoms may be monitored once or twice a year.
- Patients with severe obstructive symptoms may need closer follow-up, especially if they are receiving high-dose oral corticosteroids or using nasal steroid sprays long term.
- Consider surgical intervention for nasal polyps after appropriate medical therapy is unsuccessful and for patients with recurrent sinus infections that need treatment with multiple antibiotics.
Complications
- Intranasal
- Recurrent sinusitis
- Chronic sinusitis
- Acquired nasal deformity
- Orbital
- Intracranial
Prognosis
- Medical therapy for nasal polyposis is usually reserved for patients who are not surgical candidates or who require temporization of symptom relief.
- Rarely do the polyps resolve, but they occasionally shrink enough to provide symptomatic relief.
Patient Education
Special Concerns
- Closely monitor the use of corticosteroids in children to avoid potential growth suppression.
- Studies show that certain intranasal steroid sprays are safe, but the U.S. Food and Drug Administration (FDA) mandates close monitoring of growth patterns of children using these sprays.
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Nasal Polyps, Nonsurgical Treatment excerpt Article Last Updated: Nov 29, 2007
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