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Nasal polyps and their management

Nasal polyps are oedematous growths that develop from the nasal mucosa as a result of chronic inflammation. They tend to increase in size and multiply in numbers to take over all the available space in the nasal cavity and paranasal sinuses (maxillary, ethmoid, sphenoid and frontal sinuses). Bilateral nasal polyps are usually benign and do not infiltrate their nearby structures. They exert pressure though which can sometimes widen the nasal space causing external deformity of the nose. The incidence of nasal polyps varies from 0.5 – 4.3% in the adult population and is more common in men than women. The exact aetiology is unknown. Environmental pollutants like organic particles from bacteria, viruses, fungi and inorganic allergens cause overstimulation of the immune system resulting in chronic inflammation and the development of nasal polyps in genetically predisposed patients.

Nasal polyps

The symptoms include nasal obstruction with discharge, reduction in the sense of smell and consequently taste and pressure around the nose. It feels like a heavy cold that does not want to go away. The diagnosis is made by the ENT surgeon after examining the nose with the endoscope, as small polyps can be missed on simple examination. Depending on the findings, further investigations like CT / MRI scans or sometimes biopsies can be arranged. A CT scan is mandatory prior to surgery.

The management of nasal polyps can be medical or surgical. Unilateral polyps generally are removed endoscopically for histological examination to exclude more serious pathology like inverted papilloma, juvenile angiofibroma, antrochoanal polyp or nasal cancer (see below). The medical treatment for benign, bilateral nasal polyps is centred on steroids in the form of topical nasal sprays and systemic oral tablets. Generally, polyps have the tendency to recur after stopping the medical treatment and many patients will either require multiple courses or long term administration of the medication. Such patients will benefit from surgery for the endoscopic removal of the nasal polyps and concurrent sinus surgery (FESS). The latest evidence in the literature suggests that operating on the affected sinuses can provide better control of the symptoms and longer patient relief post-operatively.

A CT scan showing nasal polyps and the affected ethmoid and frontal sinuses

Some patients present with extensive polyposis (polyps filling the whole of the nasal cavity and sinuses) or their polyps recur quickly following an operation. Such cases should raise the suspicion of the clinician to consider other possibilities and initiate further investigations. Patients with Samter’s triad will normally present with nasal polyps, a previous medical history of asthma and hypersensitivity to non-steroidal anti-inflammatory medications (NSAIDs) like aspirin or ibuprofen. These patients benefit from a more radical, initial operation followed by aspirin desensitisation. Even then, a small proportion of patients will require frequent operations to remove their polyps. Another group of patients that might be resistant to medical treatment are those with Allergic Fungal Sinusitis that present with fungal debris in their paranasal sinuses. They benefit from early FESS to remove the polyps and clear the fungi, otherwise the symptomatic relief from the treatment is minimal. Nasal polyps are rare in children and always require further investigations to exclude cystic fibrosis and primary ciliary dyskinesia – conditions that affect the ability of the nasal mucosa to clear secretions.

Persistent headache and facial pressure, epistaxis (nasal bleeding), eye symptoms like double vision, or colour blindness and rapidly changing symptoms should always be investigated by the ENT surgeon.

  • Inverted papilloma presents as a benign, unilateral nasal polyp that has the potential to transform into cancer. It needs to be surgically removed once the diagnosis is made and requires long term follow-up.

  • Juvenile Angiofibroma presents in young males with regular, heavy epistaxis. The treatment is surgical excision once the tumour is embolised to reduce the risk of bleeding and mortality during the operation.

  • Antrochoanal polyp is another benign, unilateral mass that continues to grow until it fills the nasal cavity, causing significant nasal obstruction. It is important to remove it completely to prevent recurrence.

  • Cancer of the nasal cavity can be primary or metastatic from other areas of the body. It is removed surgically and almost always followed by post-operative radiotherapy.

  • Tumours of the skull base and other tumours that were traditionally dealt with a neurosurgical approach are now accessible through the nose with the use of endoscopes.

Endoscopic sinus and skull base surgery:

The surgical treatment of choice for polyps and tumours of the nasal cavity and beyond is endoscopic resection, without any external scars and rapid recovery period. Angled, rigid endoscopes allow the experienced ENT surgeon to access narrow spaces and operate behind bony ridges of the nasal cavity and skull base. The technology development allows the projection of the surgical field on large, high definition screens with the ability to adjust the image magnification and colour in real time. In addition, the rapid advancement in designing surgical instruments and job specific tools, combined with the use of navigation systems, assist the experienced surgeon and improve the economy of movement, making such operations safe and reducing patient morbidity and mortality.

Dr. Panayiotis Symeonides MBChB MRCS DOHNS

Ear, Nose & Throat – Rhinology & Anterior Skull Base Surgeon

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