Practice Essentials
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. Coronal sinus computed tomography (CT) scanning is the imaging study of choice in the evaluation of patients with nasal polyposis. Oral corticosteroids are the most effective short-term medical treatment for nasal polyps. [1, 2, 3]
Signs and symptoms of nasal polyposis
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.
Workup of nasal polyposis
Coronal sinus CT scanning is the imaging study of choice in the evaluation of patients with nasal polyposis. Endoscopy in an office setting can sometimes be helpful in the diagnosis and evaluation of nasal polyps.
Nasal masses that do not have the classic appearance of nasal polyps (translucent to gray, fleshy and pedunculated) or that do not respond to conservative medical treatment should be biopsied for confirmatory diagnosis.
Management
Oral corticosteroids are the most effective short-term medical treatment for nasal polyps. [1, 2, 3] These nonspecific anti-inflammatory agents quickly and substantially reduce the size of inflammatory polyps and improve 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.
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: [4]
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Adenoma and fibroma theories
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Necrosing ethmoiditis theory
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Glandular cyst theory
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Mucosal exudate theory
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Cystic dilatation of the excretory duct and vessel obstruction theory
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Blockade theory
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Periphlebitis and perilymphangitis theory
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Glandular hyperplasia theory
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Gland new formation theory
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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.
Epidemiology
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.
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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.
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Nasal obstruction due to polyposis can also lead to hyposmia or even anosmia.
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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.
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Nasal polyposis, right nasal passage.
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Nasal polyposis, right nasal passage.
