Nasal Polyps

Overview

A nasal polyp is a grape-like non-cancerous growth of the mucus membrane of the nose. It occurs mainly in patients of chronic sinusitis and allergy. Polyps can occur in either nasal cavity at the region where the sinuses open into the nose. Small polyps do not cause much obstruction but large and multiple ones do. Medications often shrink and eliminate them. But in a lot of sufferers, surgery may be needed. Quite often, even after complete removal, they recur.

Causes and Risk Factors

Polyps occur when there is an irritation of the nasal membrane. The mucous lining of the nose is continuous with that of the sinuses. The lining comes in close contact with each other in the small clefts and crevices inside our nose. Even a small irritation can make them swollen and inflamed. As a result, there is an increased fluid secretion. Over time, with repeated insults, the mucosa grows into tear-drop shaped polyps.

The development of a nasal polyp is regarded as a malfunction of the body’s immune system. Polyps are closely related to allergies and hypersensitivities. The risk factors attributed are

1. Allergic Rhinitis and Asthma – these are hypersensitive reactions of the airway to commonly found airborne substances.
2. Aspirin Sensitivity – A section of people with polyps is sensitive to anti-inflammatory drugs like aspirin, naproxen, and ibuprofen.
3. Churg Strauss Syndrome – A condition where there is inflammation of blood vessels and increased eosinophils in the blood.
4. Cystic Fibrosis – A congenital deficiency in chloride transport across the cells causing abnormal transport of fluids across cell membranes
5. Deficiency of Vitamins – Vitamin D is very important for the proper functioning of our immune system.

Symptoms

Although painless and soft, a nasal polyp causes symptoms like nose block, difficulty in breathing, runny nose, reduced sense of smell, and snoring. Polyps obstruct the outflow tract of sinuses into the nose. This causes mucus accumulation and bacterial infection. Thereafter, the symptoms of infection like fever, pain, and thick pus compound the pre-existing troubles.

Polyps also produce a constant post nasal drip which alters the taste. Next, the nose block makes the head feel heavy and stuffy. People very often complain of a dull headache behind their brows. Last, some patients complain of dental pain and mouth breathing.

When should I see a doctor?

Book an appointment with your ENT surgeon if you suffer from the above symptoms for more than a week. The symptoms of polyps are quite similar to those of a common cold. Only an ENT specialist will be able to differentiate between the two. Above all, the symptoms of polyps and sinusitis occur chronically.

You may need to contact your ENT on an emergency basis if you experience

1. Sudden worsening of the symptoms
2. Swelling around the eye
3. Decreased or double vision
4. Stiff neck
5. Confusion or altered sensorium

Because the above conditions indicate that the disease is producing complications. So, do not delay in seeking immediate attention.

Complications

When you ignore the symptoms, the nasal polyp may silently grow to gigantic proportions. It may push the nasal septum to the opposite side. Finally, it may extend backward and show up in the back of the throat adjacent to the tonsils. Polyps can worsen sleep apnea.

In addition to the above, long-standing polyps thin out the adjacent bones. This may become very serious as only a thin bone separates the eyes and brain from the nasal cavities. Erosion of this bone can lead to disastrous consequences. Therefore, don’t delay in getting treated. Contact us if you need any support.

How is a nasal polyp diagnosed?

The diagnosis of polyps is done primarily by an ENT surgeon. First of all, the specialist does a clinical examination of the nasal cavities with headlight. This reveals big and multiple polyps. Second, putting an endoscope into the nose reveals many small and hidden polyps. In our set-up, we do this examination after a decongestant and anesthetic nasal spray in the office itself. Third, we ask for basic blood counts.

When polyps are detected, the next thing the specialist would want to know is the condition of the sinuses. Because the sinuses and their drainage pathways are not visible using an endoscope, we need a CT. The scan provides details on the bony separation between the nose and the eyes, and, between the nose and the brain. Last, when there is an extension of the disease into the brain or eyes, we order an MRI for additional details.

Allergies and Polyps

As allergies and polyps are very closely related, it is prudent to rule out allergies in polyp patients. One of our directors, Dr. Shyam Kalyan N, did a study in which he checked for the presence of aero-allergens in patients of sinusitis. He found a significant association of mold and house dust mite allergies with sinusitis patients. The association was even stronger in sinusitis patients having nasal polyps.

To check for allergies in our patients we do a skin prick test or blood immunoCAP. For more details on these tests refer to our post on Allergic Rhinitis (Hay Fever).

Treatment

Medicines

Steroids are the mainstay of the medical treatment of polyps. Steroid nasal sprays, which don’t get absorbed into the bloodstream, are prescribed regularly. In addition to shrinking the size of the nasal polyp, they help in reducing allergies also. In cases of extensive polyps, we give steroids in the form of tablets. These, in turn, are stronger than nasal steroids. Finally, in certain recalcitrant and surgical cases, we give steroids intravenously also.

Second, we use antihistamines to reduce the concentration of histamines at the site of polyps. Histamines produce increased secretions and stuffiness. If the polyps are infected, an appropriate antibiotic is added to remove the bacteria causing it.

Third, nasal rinses with saline and bicarb solution remove pent up secretions from the sinus cavities. They replenish the mucosa with moisture and improve its functions.

Last, in the recurrent cases, we use Dupilumab. It is a monoclonal antibody acting at the molecular level to inhibit harmful immune responses. The drug is very costly but has been found very helpful in recurrent nasal polyps, asthma, and atopic dermatitis.

Surgery

Many patients ultimately require surgical clearance of the disease. The surgery is called Functional Endoscopic Sinus Surgery. It is done under general anesthesia and uses rigid endoscopes. In our set-up, we use powered instruments to aid in precision and accuracy. As a result, we minimize the trauma to normal tissues and achieve better clearance.

Follow-up and Recurrence

Even after complete removal, polyps can still recur. This is because it is an immune system disorder with a genetic component. However, if the patients follow up regularly with the surgeon, recurrences can be detected at an early stage. Thereafter, a simple course of steroids can obviate the need for revision surgery. If you have been advised of revision surgery and need to get a second opinion, do not hesitate to call us.

Prevention

Knowing your risk factors and keeping external irritants to a minimum can immensely help in the prevention of polyps. The following strategies help in reducing your chance of developing a nasal polyp (or the chance of recurrence)

1. Good hygiene – follow impeccable hygiene to prevent germs from getting in. Wash hands regularly. Follow social distancing in times of an epidemic.
2. Allergies and asthma – keep your allergies under control. Avoid triggers. Talk to us if your symptoms are not getting controlled
3. Avoid nasal irritants – stay away from smoke, dust, and pollution. Wear a mask while in crowded or polluted areas. Stay far from chemical fumes and fine dust too.
4. Room humidification – use a humidifier at home and prevent inhaling dry air. Keep yourself hydrated and do not lie down directly under the air conditioner.
5. Nasal rinses – Saline nasal rinses help remove dust from the nasal cavities and stop mild inflammation from developing into a full-blown nasal polyp.
6. Seek prompt professional attention – if your symptoms are not getting better, seek our support. Timely diagnosis and prompt steroids can prevent surgery in you.

For more details on strategies to prevent sinus infections, please read our post on home remedies for sionusitis. Please tell us your comments and feedback at feedback@worldentcare.com.

References

1. Dupixent – Dupilumab
2. Vitamin D and the nasal polyp – NCBI shelves
3. Supplementation of Vitamin D in Chronic Rhinosinusitis patients with nasal polyps – the US National Library of Medicine, an interventional (clinical) trial