Chronic Rhinosinusitis with Nasal Polyps

Chronic rhinosinusitis with nasal polyps is persistent inflammation of the nose and paranasal sinuses lasting 12 weeks or more, with bilateral polyps in the middle meatus and nasal obstruction, loss of smell, rhinorrhoea or facial pressure. It is mostly a type 2 inflammatory disease.

It affects 2% to 4% of adults, with peak onset at 40 to 60 years and a male predominance. It is associated with asthma (about 30% to 50%), aspirin exacerbated respiratory disease, allergic fungal rhinosinusitis, cystic fibrosis and primary ciliary dyskinesia. Recurrence after surgery is common, up to 40% within 5 years.

Pathophysiology.

Epithelial barrier dysfunction and type 2 cytokines (interleukin 4, 5 and 13) drive eosinophil infiltration, oedema and polyp formation. Staphylococcus aureus enterotoxins and loss of mucociliary clearance maintain the inflammation.

Nasal blockage, anosmia or hyposmia, nasal discharge, postnasal drip, facial pressure, snoring and sleep disturbance. Asthma, aspirin intolerance and wheeze often coexist.

Red flags.

• Unilateral polyp or mass, or bleeding.
• Orbital or visual symptoms.
• Severe headache or neurological signs.
• Rapid facial swelling.
• Epistaxis with bloody unilateral discharge.

Diagnosis needs two or more symptoms (one must be obstruction or discharge) for 12 weeks or more with objective evidence by endoscopy (polyps in the middle meatus) or CT (mucosal opacification). CT of the sinuses is done before surgery or when response is poor. Blood eosinophil count, total IgE, and tests for allergy, asthma and aspirin sensitivity are done. Biopsy any unilateral or atypical lesion. Test sweat chloride in children and young adults.

Differential diagnosis.

• Antrochoanal polyp.
• Inverted papilloma and other sinonasal tumours.
• Encephalocele.
• Allergic fungal rhinosinusitis.
• Granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis.
• Cystic fibrosis.

First line treatment is topical corticosteroid with saline irrigation. Add a short course of oral corticosteroid for severe disease. Endoscopic sinus surgery is for failure of medical treatment, and biologic therapy is for severe uncontrolled disease with recurrence after surgery.

• Mometasone nasal spray 50 micrograms for each spray: 2 sprays into each nostril twice daily; long term; maximum 400 micrograms daily in each nostril; monitor for epistaxis, nasal irritation and, in children, growth; use half the dose in children aged 3 to 11 years.
• Budesonide nasal irrigation: 1 mg in 240 mL saline into each nostril once or twice daily after surgery; maximum 2 mg daily; monitor for epistaxis; no renal adjustment.
• Prednisolone: 0.5 mg/kg (usually 30 to 40 mg) orally once daily in the morning for 7 to 14 days, repeated no more than 2 times each year; maximum 60 mg daily; monitor glucose, blood pressure and mood; avoid in uncontrolled diabetes, peptic ulcer and active infection; reduce in older adults.
• Dupilumab (severe disease with failure of surgery): 300 mg subcutaneously every 2 weeks; long term; maximum 300 mg every 2 weeks; monitor for conjunctivitis, injection reactions and eosinophilia; no renal adjustment.

Aspirin desensitisation is considered in aspirin exacerbated respiratory disease. Treat asthma and allergy alongside.

Monitoring. Symptoms and endoscopy at 3 months, and at 6 to 12 months afterwards; smell scoring.

Referral and escalation. ENT for failed medical treatment, a unilateral mass or orbital symptoms; respiratory physician for asthma.

Special groups. Children with polyps need testing for cystic fibrosis. Pregnancy: topical steroids and saline are used, and oral steroids are used with caution.