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Nasal Polyps

BASICS

Description

  • Painless benign inflammatory and hyperplastic lesions of sinonasal mucosa
  • Usually arise near the ethmoid sinus; rarely from maxillary sinus mucosa
  • Strongly associated with chronic rhinosinusitis (CRS)
  • Edematous, pedunculated mass in nasal cavity or paranasal sinus
  • Most are bilateral; unilateral → evaluate for malignancy
  • May cause blockage, discharge, or loss of smell

EPIDEMIOLOGY

  • Incidence:
  • Most diagnosed age 40–60; peak in sixth decade
  • Men more often affected, but women have more severe disease
  • Prevalence:
  • 1–4% general population
  • 0.1% in children (often with cystic fibrosis)
  • Asthma present in up to 65% of patients

ETIOLOGY & PATHOPHYSIOLOGY

  • Immunopathology:
  • T helper 2-driven eosinophilia (IgE, IL-5, allergic triggers)
  • Separate Th1/Th2 pathways
  • Genetics:
  • First-degree relatives at higher risk
  • Environmental/Occupational:
  • Textile workers (dust), smoke, nasal allergens

RISK FACTORS

  • Age >40
  • Occupational dust, irritants
  • Chronic rhinosinusitis, asthma, allergic rhinitis
  • Cystic fibrosis (especially in children)
  • Aspirin hypersensitivity, bronchiectasis, primary ciliary dyskinesia

GENERAL PREVENTION

  • Intranasal corticosteroids after polyp removal to reduce recurrence
  • Humidifiers to keep nasal passages moist

COMMONLY ASSOCIATED CONDITIONS

  • Asthma
  • Bronchiectasis
  • Aspirin hypersensitivity
  • Allergic rhinitis
  • Chronic sinusitis
  • Allergic fungal sinusitis
  • Cystic fibrosis (children)
  • Primary ciliary dyskinesia (Kartagener syndrome)
  • Laryngopharyngeal reflux

DIAGNOSIS

History

  • Symptoms >3 months:
  • Rhinorrhea, nasal congestion, postnasal drainage
  • Hyposmia/anosmia, inability to breathe through nose
  • Dull headache, facial pain/pressure, sleep disturbance
  • May be asymptomatic

Physical Exam

  • Edematous, pale/translucent mass, usually lateral wall of middle meatus
  • Sinus tenderness, rhinorrhea
  • If unilateral, always consider biopsy

Differential Diagnosis

  • CRS without polyps, rhinitis, structural anomalies, neurologic hyposmia
  • Benign/malignant tumors (fibroma, hemangioma, osteoma, chondroma, SCC, melanoma)
  • Encephalocele, meningocele, nasal foreign body

Diagnostic Tests

  • Rhinoscopy: pale, pedunculated mass (lateral wall of middle meatus)
  • Endoscopy: gold standard
  • CT scan:
  • Defines extent; aids surgical planning
  • Cannot reliably distinguish polyp vs other soft tissue
  • MRI:
  • Consider if neoplasia/mycetoma/encephalocele suspected
  • Children: test for cystic fibrosis if polyps present
  • Biopsy:
  • Unilateral or atypical appearance
  • Other:
  • Assess tympanic membrane for eustachian tube dysfunction if large posterior polyps

TREATMENT

General Measures

  • Goal: reduce or eliminate polyps to relieve obstruction, restore smell, and improve drainage
  • Symptom severity: SNOT-22 or Visual Analog Scale

First Line:

  • Daily intranasal corticosteroids + saline irrigation
  • Budesonide: 256 µg/day (64 µg/nostril BID)
  • Beclomethasone: 168–320 µg/day (1–2 sprays/nostril BID)
  • Fluticasone: 400–744 µg/day (1–2 sprays/nostril BID)
  • Mometasone: 400 µg/day (2 sprays/nostril BID; preferred in children)
  • Duration: 1–3 months

Second Line:

  • Short course of oral corticosteroids (14–21 days)
  • Prednisone: 30–50 mg daily (taper as indicated)
  • Prednisolone: 20–60 mg daily (taper as indicated)
  • Risks: hyperglycemia, cataracts, glaucoma, osteoporosis, fractures, heart problems
  • Doxycycline (100 mg daily × 21 days, after 200 mg loading)—not in pregnancy or breastfeeding
  • Severe/untolerated cases: consider both

Other Therapies:

  • Injectable steroids directly into polyps (less systemic side effects, rare vision loss)
  • Systemic antihistamines, leukotriene antagonists (for associated symptoms)
  • Allergy immunotherapy (if concurrent allergic rhinitis)
  • Aspirin desensitization (in aspirin-exacerbated respiratory disease)
  • Biologics:
  • Dupilumab: reduces size, improves symptoms, well tolerated
  • Omalizumab, mepolizumab: also effective in severe/refractory cases

Surgery/Procedures:

  • Endonasal functional endoscopic sinus surgery (FESS) for obstruction or failed medical therapy
  • External Caldwell-Luc approach for complex cases (higher risk)
  • Steroid-releasing stents post-op to prevent recurrence
  • Post-op intranasal corticosteroids: reduce recurrence

ONGOING CARE

  • Recurrence rate: up to 40%
  • Asthma: recurrence twice as likely
  • Intranasal corticosteroids reduce recurrence
  • Allergy testing: may help guide management

PROGNOSIS

  • Symptom improvement common with surgery, but high recurrence rate
  • Aggressive medical/surgical treatment improves asthma control

ICD-10 CODES

  • J33.9 Nasal polyp, unspecified
  • J33.0 Polyp of nasal cavity
  • J33.8 Other polyp of sinus

Clinical Pearls

  • Intranasal corticosteroids reduce polyp size, recurrence, and congestion
  • Short-course oral corticosteroids for persistent symptoms
  • Asthma often coexists—often undiagnosed; aggressive management improves both conditions
  • Unilateral polyps: always refer for biopsy to exclude malignancy