Nasal Polyps

Chronic Rhinosinusitis with Nasal Polyps

Chronic rhinosinusitis with nasal polyps is a distinct subgroup of chronic rhinosinusitis. Nasal polyps are non-neoplastic, hypertrophic outgrowths or masses of oedematous nasal or paranasal sinus mucosa, leading to chronic nasal symptoms and obstruction. They develop as the end result of persistent allergy, infection or inflammation in the nasal and sinus cavities.  These polyps are typically painless and they do not bleed on touch.

Types of Nasal Polyps.

Nasal polyps are classified into two main types:

1. Antrochoanal Polyp
2. Bilateral Ethmoidal Polyp

 

Antrochoanal polyp (Killian’s polyp).

Site of Origin.

The antrochoanal polyp originates from the mucosa within the maxillary antrum near the accessory ostium. It extends into the nasal cavity, growing posteriorly toward the choana. This posterior growth pattern is influenced by factors such as:

• Ciliary Movement: Cilia in the nasal cavity beat in a posterior direction.
• Airflow: Air currents in the nasal passages flow backwards.
• Anatomy: The nasal cavity has a natural posterior bend that guides the polyp’s growth.

Parts of the Antrochoanal Polyp.

The antrochoanal polyp consists of three main sections:

1. Antral Part: This is a thin stalk, originating in the antrum.
2. Choanal Part: The choanal section is round and globular and is located near the choana.
3. Nasal Part: The nasal portion is flattened from side to side and situated in the nasal cavity.

Age Group and Prevalence.

Antrochoanal polyps are most commonly observed in children and young adults. They typically present as single, unilateral growths, and are more frequently found in males than in females.

Theories of AC polyp formation. 

1. Bernoulli Principle: Chronic rhinosinusitis can lead to anatomical changes and oedema in the nasal cavity and paranasal sinuses leading to the narrowing of the air passage in the nasal cavity. Due to the Bernoulli Principle, narrowed pathways increase airflow velocity, resulting in a drop in pressure around the inflamed areas, which draws in the surrounding structures and may contribute to polyp formation.
2. Proetz theory: It suggests faulty development of maxillary sinus ostia, wider than normal, allowing the mucosa to more easily protrude from the maxillary sinus into the nasal cavity, thus contributing to polyp formation.

Aetiology.

The exact cause of nasal polyps remains unclear. However, elevated levels of immunoglobulin E (IgE)—an indicator of allergy—are often found in individuals with nasal polyps. This suggests that allergic reactions, particularly when combined with sinus infections, may play a role in the development of AC polyps.

Symptoms.

1. Unilateral nasal obstruction is the presenting symptom.
2. Obstruction may become bilateral when the polyp grows into the nasopharynx and starts obstructing the opposite choana.
3. Allergic symptoms: watering eyes, sneezing, itching in the nose.
4. The voice may become thick and dull due to hyponasality.
5. Unilateral Nasal discharge, mostly mucoid, may be bilateral.
6. Hyposmia/ anosmia
7. Headache
8. Epistaxis due to secondary infection of the polyp.
9. Hearing loss due to eustachian tube obstruction
10. Pain over the cheek region

Signs

1. As the polyp grows posteriorly, it may be challenging to detect during anterior rhinoscopy and can only be visualized on endoscopic nasal examination.
2. In large cases, a smooth, greyish, glistening mass, often covered with nasal discharge, can be seen. The polyp is generally soft and mobile, moving up and down when probed. A large polyp may protrude from the nostril, displaying a pink and congested appearance on the exposed part.
3. Posterior rhinoscopy may reveal a globular mass filling the choana or even the nasopharynx. In some cases, the polyp may extend behind the soft palate and be visible in the oropharynx.

Management.

The primary goal of treatment is to eliminate any underlying systemic disease, relieve symptoms, restore nasal breathing and sense of smell (olfaction), and prevent recurrence.

1. DNE – to see the extent of polyp
2. C/S of discharge.
3. Imaging – X-rays of the paranasal sinuses may reveal an opaque antrum. In a lateral view, a globular swelling in the postnasal space with an air column behind the polyp distinguishes it from angiofibroma. CT scan will show a hypodense mass filling the maxillary antrum, nasal cavity and posterior choana.
4. Routine Investigations – For workup of surgery.
5. Allergic testing – Skin prick test, RAST to know the allergen. IgE and Absolute eosinophilic count will be raised.

 Treatment.

1. Functional Endoscopic Sinus Surgery (FESS) is the first-line treatment, with no requirement for prior medical management. It aims to improve sinus ventilation, improve drainage, and polyp removal. Postoperative corticosteroid sprays are not indicated.
2. Caldwell Luc operation – If there is recurrence or the polyp is very large in size.

Differential Diagnosis of Antrochoanal Polyps.

1. Mucus Blob: A blob of mucus may resemble a polyp but disappears upon nose blowing.
2. The hypertrophied middle turbinate, also known as concha bullosa, is characterized by a pneumatized, air-filled cavity within the turbinate structure. When probed (with Jobson Horne probe), a concha bullosa typically exhibits bleeding, pain, and a firm, bony sensation. Unlike nasal polyps, the probe cannot pass completely around it. Concha bullosa has a distinct pink colour, helping differentiate it from nasal polyps, which are usually pale and translucent. The firm and bony feel of a concha bullosa contrasts with the softer, more pliable texture of nasal polyps.
3. Angiofibroma: Characterized by recurrent epistaxis and a firm consistency that bleeds on touch.
4. Other Neoplasms: Differentiated by their fleshy pink appearance, friable nature, and bleeding tendency.

 

Bilateral ethmoidal polypi

Site of Origin.

Bilateral ethmoidal polyps arise from the lateral wall of the nasal cavity, typically originating in the middle meatus. Common sites include:

• Uncinate Process
• Bulla Ethmoidalis
• Sinus Ostia
• Medial Surface and Edge of the Middle Turbinate

Notably, allergic nasal polyps (including antrochoanal polyps) rarely develop from the nasal septum or the floor of the nasal cavity.

Age Group and Prevalence.

Ethmoidal polyps are most commonly observed in adults and older people. They are bilateral and are more frequently found in males than in females.

Aetiology.

Aetiology of nasal polypi is very complex and not well-understood. They may arise in inflammatory conditions of the nasal mucosa (rhinosinusitis), disorders of ciliary motility or abnormal composition of nasal mucus (cystic fibrosis). Various diseases associated with the formation of nasal polypi are:

Associated Diseases with Bilateral Nasal Polyps in Adults

1. Fungal Infection (Allergic Fungal Sinusitis). Most common (80% cases).
   • Occurs when fungi become trapped by chance in the sinuses of near-competent patients but are severely allergic to the fungus, causing thick, eosinophil-rich nasal secretions and oedema of the osteomeatal complex, eventually leading to polyps.
   • Diagnostic: CT scan shows a heterogenous appearance also called a double density or rail-track sign as the fungus has an affinity for metals and therefore entraps metals.
2. Bacterial Involvement
   • Staphylococcus aureus is frequently linked to nasal polyps, as it produces enterotoxins that intensify inflammation.
3. Asthma
   • Approximately 7% of asthma patients (both atopic and non-atopic) develop nasal polyps.
4. Aspirin Intolerance
   • Around 36% of patients with aspirin intolerance/ hypersensitivity exhibit nasal polyps, often coupled with asthma in a triad known as Samter’s Triad or Aspirin-Exacerbated Respiratory Disease (AERD).
   • Mechanism: Aspirin blocks the cyclooxygenase pathway, diverting arachidonic acid into the lipoxygenase pathway. This increases leukotrienes, leading to mast cell instability, elevated histamine, vascular permeability, and mucus production—all contributing to nasal polyps and asthma.
5. Churg-Strauss Syndrome (Eosinophilic Granulomatosis with Polyangiitis)
   • A rare condition with adult-onset asthma, eosinophilia (>10%), vasculitis, and granulomas. Symptoms include malaise, fever, weight loss, and polyarthralgia.
6. Young Syndrome
   • Characterized by chronic sinusitis (with nasal polyps), sinopulmonary disease (bronchiectasis), and azoospermia (infertility).
7. Nasal Mastocytosis
   • A form of chronic rhinitis with mast cell infiltration, although eosinophil counts and IgE levels remain normal.

Associated Diseases with Bilateral Nasal Polyps in Children

1. Cystic Fibrosis (Mucoviscidosis)
   • An autosomal recessive disorder affects chloride channels and causes impaired ciliary function leading to abnormal mucus production. This leads to thick, viscous secretions, blocking the osteomeatal complex, and resulting in chronic sinusitis and nasal polyps. The patient may also have repeated lung infections, intestinal obstruction and pancreatitis. Approximately 21% of cystic fibrosis patients develop polyps.
   • Diagnostic: Sweat chloride test (>70 meq/L), indicating abnormal chloride levels.
2. Kartagener Syndrome (Primary Ciliary Dyskinesia)
   • An autosomal recessive disorder involving absent ciliary movement, presenting with a triad: bronchiectasis, chronic sinusitis (with nasal polyps), and situs inversus (dextrocardia).
   • Tests:
     • Saccharine Test (Subjective): Normally, nasal mucus moves at a rate of about 10 mm per minute due to the action of the cilia. This process clears mucus from the nasal passages within approximately 10 minutes. Saccharine is placed on the anterior end of the inferior turbinate, and time to taste (typically <30 minutes) is measured.
     • Saccharine Colour Test (Objective): Saccharine mixed with indigo or methylene blue shows visible colour progression.
     • Nuclear Testing (Scintigraphy): Radiolabelled colloid albumin with technetium-99 is tracked, with normal radioactivity clearance within 30 minutes.
   • Biopsy: If any abnormalities are detected in the above tests, a biopsy or scraping may be taken for further examination under an electron microscope. Abnormal ultrastructural findings under electron microscopy confirm primary ciliary dyskinesia.

Pathology

Nasal polyps are composed of loose connective tissue with inflammatory cells, covered by a pseudostratified, ciliated epithelium. Due to ongoing irritation, the surface epithelium may change from ciliated columnar to transitional or squamous epithelium as the disease progresses. The submucosa has large intercellular spaces filled with serous fluid, with additional infiltration of eosinophils and other inflammatory cells.

Symptoms

They are the same as AC polyp but they are bilateral.

Signs

• Ethmoidal polyps present as smooth, multiple, grape-like masses that are usually pale in colour. They may be either sessile (without a stalk) or pedunculated (with a stalk).
• Chronic cases may lead to a broadening of the nose and increased intercanthal distance (sometimes referred to as a “frog face” appearance).
• In advanced cases, a polyp may protrude from the nostril, appearing pink and vascular, which can mimic a neoplasm.
• The nasal cavity may display purulent discharge due to concurrent sinusitis.

Management. The primary goal of treatment is to eliminate any underlying systemic disease, relieve symptoms, restore nasal breathing and sense of smell (olfaction), and prevent recurrence. 

1. DNE – to see the extent of polyp
2. C/S of discharge.
3. Imaging – to exclude the bony erosion and expansion suggestive of malignancy.
4. Routine Investigations – For workup of surgery.
5. Allergic testing – Skin prick test, RAST to know the allergen. IgE and Absolute eosinophilic count will be raised.

Treatment. It is divided into medical and surgical treatments.

Medical Management

1. Corticosteroids:

• • Topical: Intranasal corticosteroid spray reduces early polypoidal changes and recurrence. Common side effects include local irritation and rare systemic effects. Nasal drops are more effective than sprays for anosmia, but their use should be limited to avoid systemic absorption. Saline nasal spray can also be given to improve mucociliary function.
  • Systemic: Mainly used for larger polyps or severe cases. For larger polyps, short courses of systemic corticosteroids like prednisolone (0.5 mg/kg each morning for 5–10 days. ) may be used, followed by maintenance therapy with topical sprays to sustain improvement.
  • Contraindications to use of steroids, e.g. hypertension, peptic ulcer, diabetes, pregnancy and tuberculosis should be excluded.

2. Antihistamines: Beneficial only if an allergy is present.

3. Leukotriene Inhibitors: Helpful for patients with asthma or aspirin sensitivity.

4. Macrolide Antibiotics: Long-term macrolide antibiotics (e.g., for three months) can reduce inflammation but may cause cardiac side effects.

5. Nasal Douching: Regular nasal irrigation with sterilized or distilled water helps reduce symptoms and clears mucus.

Surgical Management. Surgical intervention is considered for patients unresponsive to medical therapy.

1. Functional Endoscopic Sinus Surgery (FESS) is the most common procedure, aiming to improve sinus ventilation, improve drainage, and polyp removal. FESS offers a precise view of the surgical area, allowing for effective clearance of inflammatory tissue. The extent of surgery depends on the severity of the disease, the surgeon’s expertise, and available technology. In cases of allergic fungal sinusitis and antrochoanal polyps, FESS is the first-line treatment, with no requirement for prior medical management. Following FESS, intranasal corticosteroid sprays are recommended for patients with allergic fungal sinusitis to reduce inflammation and prevent recurrence. However, in cases of antrochoanal polyps, postoperative corticosteroid sprays are not indicated. While in all other conditions, postoperative care includes nasal douching and corticosteroid therapy to minimize recurrence.
2. External ethmoidectomy for large polyps.

Important Considerations in Nasal Polyps.

1. Polyps in Infants. Nasal polyps are uncommon in infants. When present, they may indicate conditions such as glioma, encephalocele, or meningoencephalocele. To differentiate these from nasal polyps, the mass should be aspirated to check for cerebrospinal fluid (CSF) presence. Biopsies should be avoided, as improper removal can lead to CSF rhinorrhea or meningitis.

   • Furstenberg Test: For encephaloceles, this test can help with diagnosis; the mass increases in size when intracranial pressure rises (e.g., during crying or jugular vein compression).
   • Transillumination Test: A positive transillumination test also supports an encephalocele diagnosis.

2. Multiple Polyps in Children. The presence of multiple nasal polyps in children may be associated with mucoviscidosis (cystic fibrosis), a condition requiring further evaluation and management.

3. Polyps in the Elderly. In elderly patients, nasal polyps that appear red, fleshy, or granular may indicate potential malignancy. Careful examination and additional testing are recommended to exclude cancer.

4. Histological Examination: All removed polyps should be examined histologically to rule out malignancy.
5. Epistaxis and Orbital Symptoms: These symptoms in a patient with nasal polyps may suggest malignancy.

 

Table showing differences between Antrochoanal polyps and Ethmoidal polyps

 

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

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