Nasal polyps

chronic polypoid rhinosinusitis

BMJ Best Practice

Patient UK
BSACI guidelines for the management of rhinosinusitis and nasal polyposis 2008
EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012

Introduction
Definition
Lesions arising from the nasal mucosa, occurring at any site in the nasal cavity or paranasal sinuses
(esp. clefts of the middle meatus)
Subgroup of chronic rhinosinusitis
Made up of loose connective tissue, oedema, inflammatory cells (eosinophils), glandular cells and
capillaries; usually covered with respiratory pseudostratified epithelium with ciliated cells and goblet
cells
Pale appearance due to poor blood supply; squamous metaplasia fleshy, reddened (benign and
malignant nasal tumours can mimic or co-exist with nasal polyps)
Aetiology
Exact pathogenesis is unknown
Linked with chronic inflammation (chronic rhinosinusitis, vasculitis), superantigens produced
by Staphylococcus aureus
Nasal polyps can be classified as eosinophil-rich (the most common type in the UK), infective, or due
to other causes
Epidemiology
2-4% prevalence (difficult to estimate)
Male:female = 2:1
No racial bias

Associations & DDx

Associations
Asthma
Aspirin sensitivity
CF (esp. children)
Allergic fungal sinusitis (rare in the UK but more common in warmer areas)
Churg-Strauss syndrome
Not associated with allergy
DDx
Unilateral: nasal tumours, encephalocele (children)
Foreign body - unilateral, blood-tinged discharge in young children
Chronic rhinosinusitis without polyps
Sinusitis
Allergic fungal rhinosinusitis
Tumours e.g. nasopharyngeal carcinoma, dermoid tumours

Signs and symptoms

Size-dependent
Nasal congestion, blockage, nasal discharge (watery
anterior rhinorrhoea, sneezing, postnasal drainage),
PND, decreased sense of smell
Hx of recurring acute/chronic sinusitis
Unilateral, blood-tinged secretion suggests a tumour,
foreign body, nose picking, or misapplication of nasal
spray
Dull headaches
Stertor and obstructive sleep sx
Hyposmia/anosmia and reduced taste

Examination
Nasal speculum: anterior edge of the middle
turbinate (single/clusters of grape-like structures)
Very large polyps may grow down into the oropharynx (visualised
with a tongue depressor)
The nasal bridge may be widened in patients with nasal polyps; it
may be depressed in patients with Wegener's granulomatosis
Decongestants and local anaesthesia may help
Lund and Mackays
Grade Description of polyps
Nasal Polyps Grading System: 0
None visible
1

Confined to middle meatus

Beyond middle meatus, but not

completely obstructing the nasal cavity

Complete obstruction of nasal cavity

Investigations
Rigid/flexible nasendoscopy
CT scans reserved for patients failing medical therapy or
atypical/severe disease
CT & biopsy for unilateral polyps
Patients with severe or recurrent polypoid rhinosinusitis: aspirin
sensitivity, allergic fungal rhinosinusitis or Churg-Strauss syndrome
Diagnostic criteria
>12 weeks
2 sx, 1 of which should be either nasal
blockage/obstruction/congestion or nasal discharge (ant/post nasal
drip) facial pain/pressure reduction or loss of smell
Visual analogue scale (VAS): mild (0-3), mod (4-7), severe (8-10)

Management (1)
General principles
Referral to ENT
Children: CF testing
Review for associated/underlying disease (covert asthma and aspirin sensitivity)
Based on sx, VAS [mild (0-3), mod (4-7), severe (8-10)], nasendoscopy
Patients education recurrence
Referral for admission
Associated with severe systemic illness
Orbital involvement peri-orbital oedema/cellulitis, displaced globe, double vision,
ophthalmoplegia or visual acuity
Intracranial involvement severe frontal headache, swelling over the frontal bone, SS of
meningitis or focal neurological signs
Referral for ENT review
Frequent recurrent episodes of acute sinusitis which are troublesome (>3 episodes/year requiring
Abx)
Unremitting or progressive facial pain (refer urgently if suspecting a tumour)
Significant nasal obstruction
Ineffective trial of intranasal corticosteroids for 3 months

Management (2)
Medical
1st topical corticosteroids (betamethasone 2/52); nasal drops > sprays ['head upside
down' position]; also helps prevent recurrence post-op; monitoring in glaucoma,
children
Medical polypectomy = using steroid regimen to treat large polyps
Oral prednisolone (0.5 mg/kg) for 5-10 days + betamethasone nasal drops 2
drops/nostril TDS for 5 days, then BD until the bottle runs out; maintenance
therapy involves fluticasone (drops, spray) or mometasone (spray) BD until the
bottle runs out
Antihistamine (if allergic rhinitis)
Nasal douche (saline) may be of moderate benefit (esp. with steroids, Abx) but not
post-op
Systemic corticosteroids
Insufficient evidence: Abx, azelastine, anti-IgE Ab
Not supported by current guidelines: leukotriene receptor antagonists
Surgical
Functional endoscopic sinus surgery (FESS)

Complications & prognosis

Complications
Acute bacterial sinusitis cx of intracranial infections (meningitis),
cavernous sinus thrombosis, orbital complications
(periorbital/orbital cellulitis, orbital abscess) and subperiosteal
abscess
Sleep disruption
Asthma sx
Rare, extremely large polyps: craniofacial structural abnormalities,
e.g. proptosis, hypertelorism, diplopia
Severe cx are uncommon
Prognosis
No single curative treatment
Recurrence is common even after surgery