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Tuesday, August 28, 2018

Should I be Worried About Nasal Polyps?


Nasal Polyps are common in both men and women. As we grow older, the chances of developing a nasal polyp increases. Most people usually develop a nasal polyp by the time they are 40. Since it is such a common health issue, today we will discuss what nasal polyps are and should you be worried about them.




    What are Nasal Polyps

    Polyps are small growths, usually benign that originates from a mucus membrane. Nasal Polyps are benign growths that frequently occur in the nose or sinuses. It is often difficult to find a cause for their development. However, factors such as chronic sinusitis and different allergies are known to promote their growth. It is predicted that 40% of people will develop a nasal polyp at some point in their life.

    Causes of Nasal Polyps


    As mentioned before, nasal polyps are idiopathic in nature, which means usually no specific cause can be attributed towards their development.

    However, some conditions have been identified which are commonly associated with nasal polyps. All these conditions have one common feature and that is that they all cause long-term inflammation of the mucous membrane of the sinuses.

    Conditions Associated with Nasal Polyps

    • Chronic rhinitis
    • Chronic sinusitis
    • Asthma
    • Aspirin allergy
    • Cystic fibrosis
    • Allergic fungal sinusitis
    • Kartagener's syndrome
    • Young's syndrome
    • Eosinophilic granulomatosis with polyangiitis
    • Nasal mastocytosis

    To understand nasal polyps better we need to learn a little about the anatomy of paranasal sinuses.

    Anatomy of Paranasal Sinuses

    The word para- means besides or adjacent to and sinus means a cavity in a bone or other tisses. So paranasal sinuses mean cavities which are present on the bones surrounding the nasal cavity.


    There are altogether 4 paranasal cavities and they are all filled with air. They are named according to the bone in which they are present.

    The paranasal sinuses are:
    • Maxillary sinus
    • Frontal sinus
    • Ethmoidal sinus
    • Sphenoid sinus

    For our present discussion, only the maxillary sinus and ethmoidal sinus are important.

    So let's discuss a little about these two sinuses.

    A. Maxilary sinus

    The maxillary sinus is the largest air-filled sinus in the body. It is pyramidal in shape and also called the antrum of Highmore.


    It is present in the maxilla which is a bone which forms the upper jaw.

    The mucus that is produced by the maxillary sinus drains into the nasal cavity via an opening that is located in the medial wall of the sinus. The opening is located so high up near the roof of the sinus and as such gravity cannot drain the sinus when a person is standing straight. This is why infections can easily occur in the maxillary sinus.

    The nasal polyp that grows in maxillary sinuses is called antrochoanal polyp. The term is derived from two words: antrum and choana. An Antrum is similar to a sinus, that is, it is a natural cavity in a bone or other tissues. Choana (plural choanae) refers to either of the posterior openings of the nasal cavity that opens into the nasopharynx. Antrochoanal polyps grow from the mucous membrane of the maxillary sinus and reach the choana and that is why they are called antrochoanal polyps. Since they block the choana, nasal obstruction is one of the main symptoms of antrochoanal polyps.




    B. Ethmoid sinus

    The ethmoidal sinuses are present within the ethmoid bones and are located between the eyes and the nose.


    Ethmoid sinuses are divided into three groups: anterior, middle and posterior. The ethmoid sinus can develop infection due to a variety of reasons and are usually treated with nasal decongestants and antibiotics. However, in the case of severe and persistent sinus infection, the infected sinus needs to be surgically drained.

    The polyps that develop in ethmoid sinuses are called ethmoidal polyps.

    Types of Nasal Polyps

    Nasal Polyps are mainly of two types: Ethmoidal nasal polyps and Antrochoanal nasal Polyps.

    A. Ethmoidal polyps

    Ethmoidal polyps arise from the ethmoid sinus and extend into the nasal cavities. They are usually bilateral, multiple, pearly white, grape-like masses. They are common in adults and both sexes are equally affected.

    Cause of ethmoidal polyps

    Ethmoidal polyps are usually allergic in origin.

    Common symptoms of ethmoidal polyps

    • Bilateral nasal obstruction
    • Loss of smell (anosmia)
    • Watery nasal discharge
    • Headache
    • Excessive tear production due to nasal obstruction
    • Sneezing

    Clinical finding / Signs of ethmoidal polyps

    • Hyponasal Speech: This is also called Rhinolalia Clausa. The person sounds like he is suffering from nasal congestion. This happens due to the nasal obstruction caused by the ethmoidal polyps resulting in hampered air flow through the nasal cavity.
    • Broadening of the nasal bridge

    Investigations done in ethmoidal polyps

    • X-ray paranasal sinus: This determines how fur the polyp has progressed
    • CT scan of paranasal sinus: This is usually the preferred investigation provided appropriate facilities are available. However, in developing countries, it is usually not the first investigation that is done.



    B. Antrochoanal Polyps

    Antrochoanal polyps arise in the maxillary sinus where they grow and extend into the nasopharynx. They are usually pedunculated, painless, pearly white masses. Antrochoanal polyps are more common in childhood and males are more commonly affected than females.

    Causes of antrochoanal polyps

    • Infection: Infection is usually the cause of antrochoanal polyp
    • Other possible causes of antrochoanal polyps
      • Bernoullis phenomenon due to negative pressure
      • Changes in the polysaccharide of the ground substance of the maxillary sinus
      • Vasomotor imbalance

    Symptoms of antrochoanal polyps

    • Nasal obstruction: This is commonly unilateral and not relieved by nasal decongestants
    • Nasal discharge: The discharge is usually unilateral, mucopurulent and sometimes mixed with blood
    • Post-nasal drip: This is a common feature and is mucopurulent in nature
    • Most patients come with the history of chronic cold


    Clinical findings / Signs of antrochoanal polyps

    • Hyponasal speech or Rhinolalia Clausa: Just like the ethmoidal polyp, this happens due to obstruction of the nasal cavity and the subsequent impaired airflow through the nasal cavity.
    • Broadening of the nasal bridges

    Investigations done in antrochoanal polyps

    • X-ray paranasal sinus: Just like the ethmoidal polyp, x-ray paranasal sinus helps to show the extent of the polyp. The antrochoanal polyp is usually seen as a soft-tissue shadow with upward convexity.
    • CT scan of paranasal sinus: This is the investigation of choice. CT helps to show the progression of the disease, eye involvement, and abnormal anatomical features.

    Histological Examination of Nasal Polyps

    Histologically nasal polyps consist of hyperplastic and edematous connective tissue cells. Hyperplasia means an increase in the cell number and edematous means filled with fluid. Some glandular and inflammatory cells (mostly eosinophils and neutrophils) are also found. Polyps have no nerve connections and that is why they are painless.

    So, Are Nasal Polyps Harmful?

    By themselves, nasal polyps are not cancerous and are only harmful because of the symptoms they create. Symptoms usually take years to develop. As the polyp grows larger symptoms start to deteriorate. Thus smaller polyps usually require no treatment and it has been seen in various studies that no treatment is usually adequate. However, larger polyps which cause troublesome symptoms do need treatment with medications or surgery.


    Can Nasal Polyps turn into Cancer?

    True nasal polyps are always benign in nature. Nasal polyps are different from colon polyps. Colon polyps can be cancerous or pre-cancerous but nasal polyps are always benign. However, there are some lesions which look like a nasal polyp but in fact, they are other cancerous or pre-cancerous lesions which can turn into cancer. Let's learn about them.

    Diseases that Mimic the Appearance of Nasal Polyps

    There are some diseases which can mimic the appearance of a nasal polyp and may confuse a non-trained eye. That is why it is important to differentiate between these diseases and nasal polyp. These diseases are:
    • Inverted papilloma
    • Fungal sinusitis
    • Nasal Cavity and Paranasl Sius Cancer
    • Encephalocele
    • Glioma

    A. Inverted Papilloma

    Inverted papillomas are benign tumors of epithelial cells that grow downward and inward into the supporting tissue it is present on. It may occur in the nose, paranasal sinuses and urinary tracts.

    Papill means a projection and oma is a suffix meaning a tumor. Papillomas are basically warts that can grow and destroy surrounding healthy tissues. Inverted Papillomas are called inverted because they grow into the structure they are located on and in the process destroy the surrounding tissues. Even though inverted papillomas are benign tumors, they are locally aggressive and as such are treated with the same concern as cancer. Surgical resection of the inverted papilloma is the treatment of choice.

    Sometimes a Squamous cell carcinoma may also develop in the inverted papilloma.

    B. Fungal Sinusitis

    Fungal sinusitis means inflammation of the paranasal sinuses due to a fungal infection. The most commonly involved sinus is the maxillary sinus.

    Fungal sinusitis usually develops in people who are immunocompromised, for example, people suffering from cancer, HIV infection, diabetes mellitus or chronic steroid use.

    The most commonly involved fungi are Aspergillus fumigatus (90%), Aspergillus flavus, and Aspergillus niger.

    The treatment of fungal sinusitis involves surgery and antifungal drugs such as echinocandins, voriconazole, and amphoterecin.

    C. Nasal Cavity and Paranasal Sinus Cancers

    The cells that make up the mucous membrane of the nasal cavity and paranasal sinus may undergo cancerous transformation and may give rise to cancer. Some of these cancers are discussed below.

    Squamous cell carcinoma

    Squamous cell carcinomas arise from the squamous epithelial cells. This is the most common type of cancer of the nose and paranasal sinuses.

    Adenocarcinomas, Adenoid Cystic Carcinomas, and Mucoepidermoid Cancers

    These arise from the Minor salivary gland cells of the nose and paranasal sinus. These are also common cancers of the nasal cavity and paranasal sinuses.

    Melanomas

    Melanomas usually occur in sun-exposed areas. However, they can also occur on the lining of the nasal cavity and paranasal sinus.

    Esthesioneuroblastoma

    Esthesioneuroblastoma is a cancer of the olfactory nerve. This is also called olfactory neuroblastoma. Olfactory nerve allows us to smell.

    Lymphomas

    Lymphomas are cancers originating from immune cells called lymphocytes.

    Sarcoma

    Sarcomas are cancers of muscle, bone, cartilage, and fibrous cells. These can occur anywhere in the body.

    Treatment of Nasal Polyps

    The treatment of nasal polyps include medications and surgical interventions.


    A. Medications for the treatment of nasal polyps


    Steroids

    Steroids mainly topical steroids (such as nasal sprays) are the first line of treatment for nasal polyps. Steroid decreases the inflammation and reduce the size of the polyp and thus improve symptoms. Topical sprays are usually preferred in the beginning as they do not have the systemic side effects of oral steroids. However, topical steroids do not relieve symptoms in all nasal polyps.

    Examples of nasal steroid sprays are:
    • Fluticasone
    • Budesonide
    • Mometasone

    Oral steroids such as Prednisolone improve symptoms very quickly but they should not be used for long periods as they have serious side effects.

    Nasal decongestants

    Nasal decongestants such as oxymetazoline and xylometazoline do not reduce the size of the polyp. However, they do reduce nasal secretions and can provide symptomatic relief to the patient.

    Antibiotics

    Antibiotics are only prescribed when there is a concomitant bacterial ifection.

    Antihistamines

    Antihistamines are also used sometimes to treat allergies related to the inflammation in the nose.

    B. Surgical treatment of Nasal Polyps

    Functional Endoscopic sinus surgery is the treatment of choice. Previously large holes used to be created to access the sinus for maximum drainage and in the process destroyed the surrounding structures and lining of the sinus cavity.

    However, now we know that these lining tissues have important functions to keep our sinus healthy. As such old school surgery is no longer preferred and functional endoscopic sinus surgery which put heavy emphasis on the function is used.

    Functional endoscopic sinus surgery creates adequate ventilation and drainage along natural pathways along with preserving the normal anatomy of sinus lining.

    That's all for today!
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