Nasal Polyps Update
Nasal polyps (i.e., nasal polyposis) are soft, benign growths that develop from the lining of the sinuses and nasal cavity. Approximately 4-5% of the general population has nasal polyps. They look like glistening moist grapes and are typically in the shape of teardrops. These new growths result from chronic inflammation of the tissues inside the nasal and sinus cavities. When the nasal polyps grow large enough, they may obstruct the nasal passages which will block the flow of air through the nose. The mechanical obstruction may also block the passage of secretions from the sinuses into the nose which may result in the predisposition of individuals to develop recurrent or chronic sinus infections.
CAUSES:
Any condition which ends in chronic inflammation inside the sinuses and nose may lead to the formation of nasal polyps. Some of these conditions may include:
1. Allergic sensitivity to indoor or outdoor environmental allergens [allergic rhinitis (i.e., hay fever)] mediated by an the IgE antibody and elevated levels of interleukin 5 (IL-5) cytokine.
2. Chronic sinus infections from bacteria such as Staphylococci as seen in chronic rhinosinusitis with nasal polyposis (CRSwNP).
3. Allergic response to fungal organisms in the inhaled air which is called allergic fungal rhinosinusitis (AFRS).
4. Systemic inflammatory disorders such as aspirin exacerbated respiratory disease (AERD) and cystic fibrosis (CF). Aspirin exacerbated respiratory disease is also called Samter’s triad because it consists of 3 features: asthma, nasal polys that re-occur, and an intolerance to aspirin and NSAID’s (nonsteroidal anti-inflammatory drugs). Between 6% and 48% of individuals with cystic fibrosis develop nasal polyps, so cystic fibrosis should be entertained in anyone who presents with nasal polyps.
5. Eosinophil (i.e., a type of white blood cell) disorders such as eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome.
6. Chronic irritation from smoke, strong odors, and pollutants in the air.
7. Immunodeficiencies such as common variable immunodeficiency, selective IgA deficiency, and primary ciliary dyskinesia
SYMPTOMS:
The symptoms of nasal polyps usually include nasal congestion and a runny nose in the early stages. As time goes on, nasal congestion resulting in a difficulty in breathing through the nostril(s) may occur. The nasal congestion usually worsens as the size of the polyp increases. Other symptoms of nasal polyps may include post-nasal drip, facial pain, headache, decreased or loss of taste (i.e., ageusia) and/or smell (i.e., anosmia), and snoring.
DIAGNOSIS:
The diagnosis of nasal polyps is generally made by examining the nasal cavity with a light source. The presence of nasal polyps will be revealed by shiny, mobile, smooth, gray, and semi-translucent masses. These Inflammatory polyps are usually present in both nostrils. It is important to note that some neoplastic polyps may only be present on one side (i.e., in one nostril). Rhinoscopy is often utilized to visualize the nasal cavity. Imaging of the sinuses with a CT scan may be needed in order to estimate the extent of the polyposis and to plan for surgical removal, if indicated. Allergy testing (e.g., skin testing, blood testing) is often performed to check for environmental allergies. A sweat chloride test may also be performed particularly in children in order to rule out cystic fibrosis.
COMPLICATIONS:
Some complications may arise from having nasal polyps. The problems may include nose bloods (i.e., epistaxis), recurrent or chronic sinusitis, asthma exacerbations, obstructive sleep apnea/snoring, and rarely double vision (i.e., diplopia).
TREATMENT:
1. Intranasal corticosteroid sprays [e.g., Flonase (fluticasone), Nasonex (mometasone), Nasacort (i.e., triamcinolone), Rhinocort (i.e., budesonide), Nasarel (i.e., flunisolide), Xhance (fluticasone)] on a daily basis.
2. Short courses of oral corticosteroids can shrink nasal polyps.
3. Saline irrigation: High-volume, low-pressure nasal saline irrigations are safe and non-expensive. Irrigation increases the clearance of antigens, biofilms, and inflammatory mediators.
4. Topical antihistamine nasal sprays [e.g. olopatadine (Patanase), azelastine (Astelin)]
5. Irrigation or nebulization with anti-inflammatory agents such as budesonide or mometasone in cases of CRSwNP.
6. Allergy testing and allergy immunotherapy (i.e., allergy shots, allergy desensitization, allergy hyposensitization) with relevant inhaled environmental allergens is effective in the treatment of allergic rhinitis, allergic conjunctivitis (i.e., eye allergies), and asthma in 80-85% of the patients that take them.
7. Deposition of corticosteroid medications higher into the nasal cavity by exhalation devices such as Xhance (i.e., fluticasone).
8. Biologic medications such as dupilumab (i.e., Dupixent) given by injections under the skin every 2 weeks, omalizumab (i.e., Xolair) given under the skin every 4 weeks, or mepolizumab (i.e., Nucala) given under the skin every 4 weeks.
9. Aspirin desensitization for AERD.
10. Functional endoscopic sinus surgery (FESS) and excision of the nasal polyps, restoring the patency of the nasal cavity.
11. Polyps have a tendency to recur after surgery and/or aggressive allergy treatments and intranasal corticosteroids can delay or prevent the recurrence.
12. Placing tiny, corticosteroid-coated implants (e.g., Sinuva) in the sinuses.
PREVENTION:
The aggressive management of predisposing conditions such as allergic rhinitis, controlling one’s environment [i.e., reducing one’s exposure to offending allergens such as dust mites, molds, pollens, cats, dogs, and cockroaches, allergy medications, and allergy immunotherapy (i.e., allergy shots, allergy injections, allergy immunotherapy, allergy hyposensitization) may all work together to inhibit polyp formation. In addition, avoiding exposure to strong odors, chemicals, and smoke is important in order to diminish nasal irritation and excessive tissue growth.
Individuals with established chronic sinusitis may require antibiotics, nasal or sinus irrigations, and/or sinus surgery. Patients with a history of aspirin sensitivity should do better after desensitization to aspirin in terms of improved asthma control, as well as a reduction in the recurrence of nasal polyps.
The board certified allergists at Black & Kletz Allergy have been diagnosing and treating both children and adults in the Washington, DC, nNorthern VA, and Maryland metropolitan area for over 50 years. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. There is on-site parking at all of the offices. The Washington, DC and McLean, VA office locations are Metro accessible and there is a free shuttle that runs between our McLean office and the Spring Hill metro station on the silver line. The allergy doctors at Black & Kletz Allergy specialize in all types of allergic conditions including nasal polyps, hay fever, asthma, sinus disease, hives (i.e., urticaria), eczema (i.e., atopic dermatitis, swelling problems (i.e., angioedema), food and medication allergies, and immunological disorders. If you would like to schedule an appointment, please call us or alternatively you can click Request an Appointment and we will respond back to you within 24 hours on the next business day. We look forward to providing you with comprehensive state-of the-art allergy care in a friendly and professional environment.