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Nasal polyps

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Chronic sinusitis polyposis, is characterized by chronic inflammation high and deep in the nasal passages.

Nasal polyps are benign growths that arise from inflamed tissue.

Up to 10 million adults in the United States have nasal polyps.

Usually seen with eosinophilic inflammation of the upper airways.

Originate in the sinuses and obstruct the sinus and nasal passages.

Nasal polyps are polypoidal masses arising mainly from the mucous membranes of the nose and paranasal sinuses.

Are benign inflammatory masses that arise from the mucosa of the nose and paranasal sinuses.

Nasal polyps are overgrowths of the mucosa that frequently accompany allergic rhinitis.

A subgroup of chronic rhinosinusitis.

Diagnosis is made in the presence of sinonasal symptoms lasting for more than three months and visualization of such polyps in the nasal cavity.

Nasal polyp associated symptoms, which can last up to 12 weeks include:

Nasal congestion or obstruction

Reduction or loss of sense of smell and taste

Facial pain/pressure

Rhinorrhea or postnasal drip

>80% of patients with corticosteroids with nasal polyps using an intranasal steroid report less than optimum symptom relief.

Associated with nasal obstruction and reduction in the sense of smell as the most frequent symptomatology, present and 97% and 90%, respectively.

May be associated with sleep disturbances and nasal discharge.

Nasal polyp size correlates with subjective nasal obstruction.

Nasal polyps usually occur in both nasal passages.

Nasal polyps may be asymmetric in size.

Nasal polyps that occur in only one nasal passage should arouse suspicion for benign or malignant tumors, particularly if there is a bloody nasal discharge.

Smoking is not a strong risk factor for chronic rhinosinusitis with nasal polyps.

Nasal polyps are freely movable and nontender.

Incidence increases with age, and peaks in the sixth decade.

Patients with this condition are more likely to have first-degree relatives with nasal polyps than controls, suggesting a genetic factor.

Increased prevalence among textile workers exposed to occupational dust.

Almost 1/3 of patients with chronic rhonosinusitis with polyps, and up to 83% of those with aspirin exacerbated respiratory disease report alcohol consumption exacerbates their symptoms.

Incidence twice as high among men as women and estimated to occur in 2-3% of the adult population.

They are very uncommon before the third decade of life.

Children with polyps should be evaluated for the presence of cystic fibrosis.

The majority of chronic rhinosinusitis sinusitis with nasal polyps are idiopathic or may be related to genetic, metabolic, or immunologic diseases.

Classified into antrochoanal polyps and ethmoidal polyps.

Antrochoanal polyps arise from the maxillary sinuses and are the much less common.

Ethmoidal polyps arise from the ethmoidal sinuses.

Symptoms of polyps include nasal congestion, sinusitis, anosmia, and secondary infection leading to headache.

Up to 60% of patients with nasal polyps have lower airway disease, including asthma, typically with a childhood onset.

They may be removed by surgery, but are found to recur in about 70% of cases.

Antrochoanal usually single, and unilateral.

Antrochoanal can originate from maxillary sinus, and is usually found in children.

Ethmoidal usually bilateral and usually found in adults.

Consist of hyperplastic edematous connective tissue with some seromucous glands and inflammatory cells.

Inflammatory cells are mostly neutrophils and eosinophils, with respiratory epithelium.

Sometimes there is metaplastic squamous epithelium on the surface.

Nasal polyps should be distinguished from nasal papillomas, which are benign epithelial tumors and have more serious consequences.

The pathogenesis of nasal polyps is unknown, but most commonly thought to be caused by allergy and rarely by cystic fibrosis although a significant number are associated with non-allergic adult asthma or no respiratory or allergic trigger that can be demonstrated.

Nasal mucosa, particularly in the region of middle meatus becomes edematous by the accumulation of extracellular fluid causing polypoidal change.

Polyps are sessile in the beginning become pedunculated due to gravity and excessive sneezing.

In early stages the surface of the nasal polyp is covered by ciliated columnar epithelium.

The surface of nasal polyps but undergoes metaplastic changes to squamous type on atmospheric irritation.

Chronic rhinosinusitis associated nasal polyps occur with;

Asthma

Aspirin-induced asthma, or aspirin-exacerbated respiratory disease (AERD)

Cystic fibrosis

Allergic fungal sinusitis

Kartagener’s syndrome

Young’s syndrome

Churg-Strauss syndrome

Nasal mastocytosis

Exposure to some forms of chromium.

Chronic rhinosinusitis is classified into two groups presenting either with nasal polyposis or without.

Chronic rhinosinusitis with nasal polyposis can be divided into eosinophilic chronic rhinosinusitis, which include allergic fungal rhinosinusitis and aspirin-exacerbated respiratory disease.

Chronic rhinosinusitis with nasal polyps associated with neutrophilic inflammation, which is primarily characterized by cystic fibrosis.

Diagnosis is usually confirmed by nasal endoscopy.

An anterior rhinoscopy may allow large polyps to be visualized.

Preoperatively CT scans are performed.

Biopsy is generally not required, unless the polyps are observed unilaterally.

Histopathological examination may provide prognostic information such as the presence of tissue eosinophilia which will be associated with a higher rate of recurrence.

Treatment:

Most often treated with steroids or topical, but can also be treated with surgical methods.

In patients with mild symptoms intranasal glucocorticoids and saline irrigation are appropriate.

Compared to placebo intranasal glucocorticoids have graded abatement of symptoms of the nasal obstruction, rhinorrhea, and loss of sense of smell, and reduction in polyp size.

The systemic bioavailability of second generation intranasal steroids is less than 1%.

In patients with chronic rhinosinusitis with nasal polyps that failed to achieve adequate control with initial treatments, a short course of oral glucocorticosteroids may be considered.

Staphylococcal aureus may be isolated of it up to 50% of patients with chronic rhonosinisitis with nasal polyps, and antibiotics may be appropriate.

Polyps are removed using endoscopic surgery, with recovery from from 1 to 3 weeks.

Endoscopic sinus surgery is primarily used in patients who have not had benefit from medical therapy with regard to symptoms, patients who have contraindications to conservative therapy, or patients with actual impending complications, such as loss of vision.

Surgery results in removing polyps, as well as improving access to topical therapies.

The effectiveness of intranasal glucocorticoids is enhanced after sinus surgery.

Surgery may be an office based procedure while the patient is awake or conventional and may be performed under general anesthesia.

Surgical procedures usually involves removal of polyps that are obstructing the nasal cavity, and procedures to open and extirpate polyps from paranasal sinuses.

Patients who undergo surgery have long-term improvement in health related quality of life that is maintained over a period of years.

Following surgery, polyp recurrence is common and reported in 40% of patients after 18 months after surgery.

Postoperative use of intranasal coricoteroids improves symptom control and it reduces the need for subsequent rescue therapy.

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