Nasal Polyps

Approximately 1 in 5 patients with chronic sinusitis have nasal polyps, benign soft fleshy swellings that can grow inside the nose. They typically develop in adulthood, and they are twice as common in men as in women. Nasal polyps are uncommon in children and any child with nasal polyps should also be checked for cystic fibrosis, which can be a risk factor for developing nasal polyps.

Nasal polyps can vary greatly in size, shape, quantity, and location within the nose and sinuses from patient to patient. They tend to be present on both sides of the nose. Unilateral (one-sided) nasal polyps should to be investigated further as they could be a different type of sinonasal tumor such as inverting papilloma (another benign growth) or a malignant tumor.

Causes of nasal polyps and associated conditions

The exact cause of nasal polyps is still unknown despite a vast amount of research. We do know that there is a close association between chronic sinus/nasal inflammation and polyp formation. In some patients, this can be due to environmental allergies, while in other patients, chronic sinus infections may play a role. A subgroup of patients with asthma and nasal polyps develop an allergic reaction and worsening symptoms when taking aspirin or other non-steroidal anti-inflammatory medications. This condition was historically termed Samter’s Triad and is now referred to as aspirin exacerbated respiratory disease (AERD). Allergic fungal rhinosinusitis (AFRS) is a condition that involves an allergic response to inhaled fungi leading to severe inflammation, polyp formation, and thick sticky rubber cement-like mucous that can be extremely difficult to clear from the sinuses.

Symptoms of nasal polyps

The most common symptoms of nasal polyps include:

  • nasal congestion/blockage
  • decreased sense of smell
  • nasal drainage
  • post-nasal drip
  • facial pressure or pain/headaches

The most bothersome symptoms tend to be the nasal congestion (which can also affect a patient’s voice and quality of sleep), and decreased sense of smell (which can also result in loss of taste).

Diagnosis of nasal polyps

Although symptoms can be very helpful in establishing a diagnosis of nasal polyps, all the symptoms listed above can also be experienced by patients with chronic sinusitis without nasal polyps. Thus, a physical exam, including a nasal endocopy is crucial. During this in-office procedure a small endoscope attached to a camera is used to examine the inside of the nose and sinuses to search for any polyps that may exist to confirm the diagnosis. A CAT scan of the sinuses can also be helpful in certain cases to provide more information about the extent of the polyps and which of the sinuses they may extend to on either side of the nose. Biopsies of the polyps may also be taken to confirm the diagnosis in certain cases; this can often be done in the office setting.

Treatment of nasal polyps

Nasal polyps can be treated with medications and/or surgery. Typically, medical treatments are attempted first, prior to considering surgical treatments.

Medical treatment of nasal polyps includes both topical and oral steroids. Nasal steroid sprays can help reduce polyp size by coating the lining of the nose and surface of the polyps, and thus reducing inflammation in these regions. This treatment can sometimes take several weeks to take effect. Similarly, short courses of oral steroids (pills taken by mouth) can also reduce inflammation and help shrink nasal polyps, thus improving symptoms. Oral treatment typically works quicker, however, unlike topical medication, oral steroids have numerous side effects, especially when used over long periods of time.

When medical therapies don’t work or fail to result in long term control of symptoms, sinus surgery may be considered. During sinus surgery, nasal polyps are removed from the nasal cavity and each sinus that may be affected using endoscopes, high definition cameras, and highly specialized instruments and powered devices. Unfortunately, polyps can often recur after some time despite surgery. However, there are numerous preventative options that can be used to help lower the risk of recurrence, including the following:

  • Proper allergy control when indicated
  • Long-term treatment of inflammation with topical steroids – this can be accomplished with specialized nasal sprays or with large volume sinus irrigation whereby liquid steroid is added to a saline filled sinus rinse squeeze bottle
  • Steroid eluting stents delivering topical steroids which can be inserted into the sinuses by surgeons – these implants have been shown to reduce polyp recurrence in a number of studies
  • Dupilumab, a biologic medication that targets a source of underlying inflammation that plays a major role in chronic rhinosinusitis with nasal polyps – this medication is given as an injection every other week and has been shown to reduce the need for surgery and treatment with oral steroids