Nasal Polyposis: Clinical Types, Pathogenesis And Management

A nasal polyp has a high recurrence rate and a chronic history. It is an edematous tissue that is continuously irritated. Polyps may or may not be present in cases of chronic rhinosinusitis.

There is inflammation in the paranasal sinuses and nose, accompanied by two or more symptoms, one of which should be nasal discharge or blockage. There ought to be one of these. There must also be decreased or absent smell and facial pain or pressure. 

Mucosal blockage, mainly in the middle meatus, must be present, as well as endoscopic evidence of polyps and/or mucopurulent discharge from the middle meatus or edema. Additionally, a CT scan should reveal sinuses and/or mucosa inside the osteomeatal complex.

Clinical Types

Polyps can be classified into two clinical types: antrochoanal and ethmoidal. Sphenochoanal and two choanal polyps are hardly observed.

Pathogenesis

Histologically, they are composed of loose connective tissue, inflammatory cells, and fluid, and they are typically coated in pseudostratified, columnar, ciliated epithelium. Metaplasia from ciliated columnar epithelium to squamous epithelium is possible.

The quantity of inflammatory cells, eosinophils, and goblet cells will all rise. The submucousal area will include oedematous tissue or fluid.There are no evidence of vasculitis.

Causes Of Polyps

1. Allergy

Between 10% and 64% of people with nasal polyps have allergies. In most individuals with nasal polyps, elevated levels of immunoglobulin E (IgE) and positive skin tests for inhaled allergens have been found. There is a significant risk of recurrence for allergy sufferers who do not receive treatment. Combination therapy is the best way to treat allergies and nasal polyps; single therapy rarely works..

2. Bacteria

Polyposis can be caused by Gram-positive organisms such as staphylococcus aureus, coagulase-negative staphylococci, and streptococci. Polyposis can also be caused by Enterobacter species, Pseudomonas species, Prevotella species, Haemophilus influenza, and Moraxella catarrhalis. 

Polyposis develops after biofilm formation. Bacteria that form biofilms are impenetrable to antimicrobial agents because they are encased in a self-developed polysaccharide matrix. In a clinical sense, nasal polyps that have biofilms present may be linked to a more advanced stage of the illness and poorer results following surgery.  If just mechanical debridement is performed, the likelihood of recurrence is significant. Antimicrobials that can break the biofilm and cycle of chronic inflammation due to infection are the treatment.

Also Read: EPISTAXIS- Anatomy, Classification and Management

Associated Diseases

Allergic fungal rhinosinusitis is a type 1 hypersensitivity reaction to fungal antigens; patients typically have unilateral (least common) or bilateral nasal polyps. Nasal polyps can also develop as a secondary symptom of other disorders. 

Fungal sinusitis is associated with nasal polyps in about 80% of cases. Bent Kuhn published his diagnosis criteria in 1994, which focused on the disease's immunologic, histological, and radiographic features.

Heterogenous densities/double densities on the AFRS CT scan; the patient should meet two main diagnostic criteria, or one major and two minor criteria. Asthma - It has been demonstrated that patients with nasal polyps also have asthma, and a clear correlation exists between the severity of asthma and the existence of nasal polyps. Effective treatment of nasal polyps is associated with an improvement in lower airway disease.

Aspirin-exacerbated respiratory disease (AERD, SAMTER’S TRIAD)

In the literature on otolaryngology, the combination of bronchial asthma, nasal polyposis, and aspirin sensitivity is well documented.  Don't provide aspirin and salicylates to patients with AERD. Aspirin has the potential to exacerbate asthma and polyposis by causing bronchoconstriction, as well as recurrence and severe asthma. Additionally, patients with AERD/Samter's triad frequently have very extensive nasal polyps, which are associated with significantly higher radiological CT scores than patients without such conditions.

Cystic Fibrosis

Gene mutations on chromosome 7 result in the autosomal recessive condition cystic fibrosis (CF).When CF patients with nasal polyps are examined, they typically have bilateral polyposis, thick rhinorrhea, and facial malformations like hypertelorism. CT scan results include nasal polyps, demineralization, and medial displacement of the uncinate process, in addition to hypoplasia of the frontal or sphenoid sinuses.

Primary Ciliary Dyskinesia

A uncommon autosomal recessive condition known as primary ciliary dyskinesia (PCD) prevents proper mucociliary clearance by impairing aberrant or absent cilia beating.  A source of irritation and polyps, secretory standstill results from obstructions in clearing.  Mucus retention and recurrent infections resulting in nasal polyposis and/or bronchiectasis are common presentations in the upper and lower respiratory tracts.

Young’s Syndrome

Three conditions make to the unusual disease known as Young's syndrome: sinus disease, bronchiectasis, and obstructive azoospermia.

EGPA (Churg Strauss)

 Renamed as eosinophilic granulomatosis with Polyangiitis (EGPA) in the 2022 revised nomenclature for vasculitides, this disease was formerly known as Churg Strauss syndrome. 

It is a three-phase systemic small vessel vasculitis that is linked to both eosinophilia and asthma. The prodromic phase, or allergic phase, is the first phase and is characterized by asthma and rhinosinusitis. The eosinophilic phase, or second phase, is characterized by peripheral eosinophilia and organ involvement. The vasculitic phase, or third phase, is when small vessel vasculitis causes clinical manifestations.

Ethmoidal Polyp

The ethmoidal air cells that extend to the nasal cavity anteriorly towards the vestibule are the source of these numerous, pedunculated structures that bear a resemblance to a cluster of grapes. Both sides of the nose will be affected. There will be nasal blockage, headache, mucoid nasal discharge, altered taste, hawking feeling, hypo nasal voice/rhinalalia clausa, snoring, and sleep apnea.

Signs

A defect known as a "frog face-like appearance" may result from orbital displacement or nasal bridge widening. With JNA, frog face deformities are typically observed. The cold spatula test reveals less fogging and misting. Multiple bluish-white, grape-like masses are visible in the middle meatus during anterior rhinoscopy. These tumors are soft, pedunculated, touch-insensitive, and non-bleeding.

Differential Diagnosis

A defect known as a "frog face-like appearance" may result from orbital displacement or nasal bridge widening. With JNA, frog face deformities are typically observed. The cold spatula test reveals less fogging and misting. Multiple bluish-white, grape-like masses are visible in the middle meatus during anterior rhinoscopy. These tumors are soft, pedunculated, touch-insensitive, and non-bleeding.

Ethmoidal polyps can also be present in mucosal polyps such as AC polyps or sphenoidal polyps. Ethmoidal polyps are many, bilateral, and go anteriorly, whereas AC polyps are single, posterior, and originate from the maxillary sinus.  It may develop as a sequel to granulomatous diseases such as rhinoscleroma and rhinosporidiosis.  The papilloma inverted.  Its surface features finger-like projections and a blood-stained discharge.

Antrochoanal Polyp

Biofilm development and infection—most frequently streptococcus pneumonia—are the secondary causes. Staph. Influenza, H. The antrochoanal polyp is composed of three parts: the antral, nasal, and choanal.

Pathogenesis

The maxillary sinus contains two ostia: the accessory ostium and the natural ostium. Whereas the accessory ostium is situated posteriorly, the natural ostium is situated anteriorly. The maxillary antrum will develop polyps when there is a protracted mucosal infection. 

The polypoidal mucosa is a flat, tube-like structure in the nose that enters the nasal cavity from the accessory ostium. It will then proceed posteriorly to the choana, where a large amount of space will result in a globular mass. The antral part is the first part, followed by the narrow constriction (accessory ostium) in the second, the flat nasal part in the third, the second constriction, or the choana, in the fourth, and the globular part in the fifth.

Possible Reasons For Posterior Extension Of The Polyp

The accessory ostium is located farther behind. The nasal cavity's slope.
Movement of the cilia.  More room in the posterior choana.  Strong inspiratory current.

Symptoms

Nasal blockage on one side.  Nasal discharge on one side and postnatal drip. Heavily felt on one side.  Anosmia in one person.

Signs

A unilateral, greyish-white mass that extends into the nasopharynx was observed during anterior rhinoscopy; the mass is derived from the lateral wall of the nose and cannot be passed through with a probe.The results will be confirmed by posterior rhinoscopy. It will reveal a mass of grayish white tissue pushing the palate down into the nasopharynx.

Differential Diagnosis

JNA: The main sign of a JNA is nose bleeding, whereas functional abnormalities manifest first in an antrochoanal polyp.  Although antrochoanal polyp is not an invasive condition, JNA is. 

While antrochoanal polyp is not linked to cranial nerve palsy, JNA is connected with it a crescent polyp can be visible on a CT scan of an antrochoanal polyp.  One-sided meningocele,  Polyp sphenochoanal,
Thorwald's cyst.  A craniopharyngioma that resembles a Rathake's pouch tumor.

Clinical Presentation

Rarely, changes in the craniofacial anatomy might lead to proptosis, hypertelorism, and diplopia.  Even when massive polyposis spreads into the cerebral cavity, it does not result in pain or neurological signs.

Diagnosis

Polyps should not be diagnosed with plain sinus radiographs because they are insensitive. The preferred examination to determine the anatomy and extent prior to surgery is a CT scan. When a possible cerebral extension of the disease is identified, MRI may be useful in differentiating it from the tumor. 

Tests for variables linked to nasal polyps can be carried out, and a history of systemic disease symptoms, especially symptoms affecting the lower airways, should be obtained.  Using olfactory tests, rhinomanometry, acoustic rhinometry, nasal inspiratory peak flow, and symptom grading, masses can be objectively documented.

Polyps should not be diagnosed with plain sinus radiographs because they are insensitive. The preferred examination to determine the anatomy and extent prior to surgery is a CT scan. When a possible cerebral extension of the disease is identified, MRI may be useful in differentiating it from the tumor. Tests for variables linked to nasal polyps can be carried out, and a history of systemic disease symptoms, especially symptoms affecting the lower airways, should be obtained.  Using olfactory tests, rhinomanometry, acoustic rhinometry, nasal inspiratory peak flow, and symptom grading, masses can be objectively documented.

Classification

The underlying premise of the endoscopic scoring system and the clinical staging system is that the polyp extends from the middle meatus towards the floor of the nose. The bilateral osteomeatal complex and its sinuses are included in the radiological staging scheme. There is a maximum score of 12 on each side. The Lund-Macay score increases with increasing grade of polyposis.  The system provides a score of 0–2 depending on the absence, partial or complete opacification of each sinus system and the osteomeatal complex on computed tomography scanning.

Management

The goals of treatment are to reduce nasal polyps and symptoms, restore nasal breathing and olfaction, stop recurrence, and enhance the quality of life for patients. Continuous observation is necessary. 

There are two types of treatment: surgical and medical.
• Pharmaceutical therapy
• Systemic and topical corticosteroids 

It is advised that patients begin systemic steroids, sprays, or drops according on the results of their initial examination and presentation.  Following review, a determination might be taken regarding whether to proceed with medical treatment as is, seek additional research, or contemplate surgical intervention. 

Patients with concurrent asthma and/or aspirin sensitivity may benefit from leukotriene inhibitors, and antihistamines should be used if an allergy is present. Patients with problems or those who have not responded to the fullest course of medical care may be candidates for surgical management. 

The goals of functional endoscopic sinus surgery include polyp removal and enhanced sinus drainage and ventilation. The scope of surgery depends on the disease's severity, the surgeon's experience, and the state of technology. In addition to improving the view of the sinuses, functional endoscopic surgery aids in the removal of inflammatory polyps.

The precise etiology of nasal polyps is still unknown, despite the fact that they are known to be connected to chronic inflammation and can cause severe symptoms and significantly lower quality of life. Nasal polyps can be easily diagnosed with anterior rhinoscopy and nasendoscopy. Combined medical and surgical treatment is advised for long-term control of symptoms. Nasal polyps are associated with many chronic conditions, including asthma, aspirin, exacerbated respiratory disease, and cystic fibrosis. Until a biopsy indicates otherwise, unilateral nasal polyps should be treated as suspected cancer.

Also Read: Olfactory Disorders – Pathway, Work up And Causes

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