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Nasal Polyps: types, causes, ddx, symptoms, investigations, treatment

Definition: Pedunculated edematous nasal and/or sinus mucosa, they are soft, noncancerous, painless growths on the lining of nasal passages or sinuses which hang down like grapes or teardrops. 
Nasal Polyps result from chronic inflammation due to asthma, recurring infection, allergies, drug sensitivity or certain immune disorders.

Nasal polyps may be asymptomatic if they are small, but they can cause symptoms like nose blockage, breathing difficulty, repeated infections and loss of smell.
nasal-polyps

What are the types of nasal polyps?

  1. Chronic rhinosinusitis with polyps
  2. Extensive sinonasal polyps
  3. Antrochoanal polyp
  4. Allergic fungal sinusitis
  5. Nasal polyps with systemic diseases

Differential diagnosis:

  • Benign neoplasm especially inverted papilloma: unilateral, firm papillary polyps.
  • Malignant neoplasm: unilateral, bad odor, soft, bleeding on touch mass.
  • Meningocele and encephalocele: soft, pulsating, greyish polyp with superior attachment to skull base.
  • Granuloma of the nose and sinuses: nodules adherent to nasal septum and/or turbinates.

Causes:

Definite cause of nasal polyps is yet not known, Scientists still don't understand why chronic nose or sinus inflammation triggers polyp formation in some people and does not in others.

Studies show that those who develop polyps have different chemical markers and a different immune system response in their mucous membranes than do those who don't develop polyps.

Risk factors: 

Diseases or disorders that result in chronic inflammation increase the possibility of developing nasal polyps. The following disorders are usually associated with nasal polyps.

  • Salicylate (Aspirin) sensitivity.
  • Bronchial asthma: as it causes inflammation in the whole respiratory passages.
  • Allergic fungal sinusitis.
  • Cystic fibrosis.

What are the symptoms of Nasal Polyps?

As mentioned above, small nasal polyps are usually asymptomatic as polyps are soft and lack sensation, So symptoms appear when polyps become large enough to block nasal passages as follows.

  • Nose blockage.
  • Snoring.
  • Hyposmia (decreased smell) or anosmia (loss of smell).
  • Symptoms of chronic sinusitis like headache, facial pain, pain in the upper teeth. 
  • Positive family history.

Investigations:

  1. Systematic nasal endoscopy
  2. Computed tomography and magnetic resonance imaging help to achieve proper diagnosis.

N.B. Neoplasm may be associated with polyps due to blockage of sinus ostia and sinusitis or contact mucosa and polyps.

Detailed review of types of nasal polyps

1. Chronic rhinosinusitis with polyps

Origin: Mainly ethmoid sinuses.
Etiology: chronic sinusitis, most common causative organisms are Streptococcus Pneumonia, Moraxella Catarrhalis, and Hemophilus Influenza.
Age: adults
Sex: equal
Incidence: common.

Clinical picture:
Refer to chromic sinusitis (the same clinical picture).
Recurrence: uncommon.

2. Extensive sinonasal polyps

Origin: Mainly ethmoid sinuses.
Etiology:
  • Allergic. 
  • Non-allergic.
Age: adults.
Sex: equal.
Incidence: common.
Symptoms:
  • Nasal obstruction: bilateral, of gradual onset and progressive course. It is partial at the beginning and complete when the polyps fill the nose.
  • Anterior nasal discharge: bilateral, profuse and watery but may become purulent in case of associated sinusitis.
  • Sneezing.
  • Itching.
  • Smell affection.
Signs:
  • Polyps: bilateral multiple, pale, glistening, gray, soft [grapes like], arising mainly from the middle meatus. They may protrude from the nostril associated with infection and metaplastic thick covering.
  • Bilateral profuse watery nasal discharge.
  • Bilateral generalized edematous and pale nasal mucosa.
Investigations:
  • Nasal endoscopy: Bilateral multiple polyps, watery discharge and generalized mucosal edema.
  • Computed tomography: bilateral extensive opacity affecting the nose and most the paranasal sinuses.
  • Allergy skin test (may be positive).
  • Biopsy: polyps with eosinophilia (for allergic polyps).
Treatment:
  1. Allergy management: If the patient is atopic.
  2. Medical: Systemic and local steroids
  3. Surgical: ESS This includes:
         a. Polypectomy
         b. Anterior and posterior ethmoidectomy
         c. Middle meatal antrostomy.
         d. Sphenoidotomy.
         e. And/or frontal recess clearance.

Aim of surgery:
  • Removal of all polyps and their routes
  • Ensure patency of the ostia of all the sinuses.

N.B. Avulsion of polyps by nasal snare and/or Luc’s forceps was done under local anesthesia in primary cases and external ethmoidectomy in recurrent cases. These are not done anymore after the introduction of FESS (functional endoscopic sinus surgery).

Recurrence: common

3. Antrochoanal Polyp (Killian polyp)

Origin: from the maxillary sinus, passing through widening of the natural ostium or through an accessory ostium into the nose and then backwards through the nasal choana, to the nasopharynx. It has a dumbbell shape with a constriction at its exit from the maxillary sinus. Its maxillary part is usually cystic and nasal part firm and fibrous.

Etiology: unknown but maybe:
  • Retention cyst. 
  • Inflammatory.
Age: young adults
Sex: equal.
Incidence: uncommon.

Symptoms:
  • Nasal obstruction: unilateral, of gradual onset and progressive course. It may become bilateral when the polyp fills the nasopharynx.
  • Unilateral anterior nasal discharge.
Signs:
  • Unilateral single nasal polyp, firm, pink and glistening, arising from the middle meatus. It may become big enough to appear in the oropharynx behind the soft palate.
  • Unilateral retained mucoid nasal discharge.

N.B. Posterior nasal mirror was used to visualize the polyp in the nasopharynx before the introduction of the diagnostic nasal endoscopy.

Investigations:
  1. Nasal endoscopy: Unilateral polyp arising from the maxillary sinus. It may be seen in the nasopharynx from the other nasal cavity. .
  2. Computed tomography (CT): Unilateral opacity affecting the whole cavity of the maxillary sinus extending to the nose and the nasopharynx. Wide maxillary sinus ostium may be also observed.

Treatment: 
Transnasal endoscopic removal of the nasal, nasopharyngeal and sinus parts through a wide middle meatal antrostomy.

N.B. Transnasal avulsion of the polyp was done in primary cases and radical antrum operation, through a sublabial incision, in case of recurrence. They were performed before the introduction of the transnasal endoscopic sinus techniques.

Recurrence: uncommon.

4. Allergic fungal sinusitis
Refer to fungal sinusitis.

5- Nasal polyps with systemic diseases:

a. Aspirin exacerbated respiratory disease (AERD or Samter’s triad): Triad of extensive nasal polyps, aspirin sensitivity and bronchial asthma. It is resistant to medical treatment and usually needs repeated endoscopic operations.

b. Cystic fibrosis: defective muco-ciliary clearance causing extensive nasal polyps in children leading to broadening of the nasal bridge due to distention before fusion of the nasal bones. There is very thick and tenacious nasal discharge [Mucoviscidosis]. Positive sweat test [elevated sodium level] is diagnostic. It has very high rate of recurrence after endoscopic shaving.

Key points

Sinonasal polyps are not the same. They have different types and accordingly managed differently. -Allergy may play a role in the pathogenesis of polyps but not the sole or main cause. -Steroids are the main stay in management of sinonasal polyps usually local spray. -Surgery is indicated only in case of failure of medical therapy.

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