Tinnitus

Benign oedematous outgrowths of sinonasal mucosa arising most often from the ethmoid sinuses and prolapsing into the middle meatus and nasal cavity. They are a manifestation of chronic rhinosinusitis rather than a disease in themselves, and their presence defines the polyp phenotype of chronic rhinosinusitis.

Prevalence and associations

Around 1 to 4 percent of the general population. Associations that must be actively sought:

• Asthma in 40 to 65 percent of polyp patients.
• Aspirin exacerbated respiratory disease, comprising asthma, polyps and nonsteroidal anti inflammatory drug sensitivity, in around 10 percent. This subgroup has more aggressive disease, higher recurrence and a distinct treatment pathway.
• Cystic fibrosis, which must be excluded in every child with nasal polyps, where the prevalence of polyps is 20 to 50 percent. Polyps in a child are cystic fibrosis until proven otherwise.
• Primary ciliary dyskinesia.
• Allergic fungal rhinosinusitis.
• Eosinophilic granulomatosis with polyangiitis.
• Non steroidal exacerbated disease and, in some series, allergic rhinitis, though the association with atopy is weaker than commonly assumed.

Pathology

Polyps are oedematous stroma with a loose extracellular matrix, sparse blood vessels and glands, and dense inflammatory infiltrate. In Western populations the infiltrate is predominantly eosinophilic with type 2 cytokines interleukin 4, 5 and 13, local immunoglobulin E production frequently against Staphylococcus aureus superantigens, and reduced tissue plasminogen activator with excess fibrin deposition producing the characteristic oedema. In East Asian populations a higher proportion are neutrophilic with a type 1 or type 3 profile, which is less corticosteroid responsive.

The critical rule on laterality

Bilateral polyps are inflammatory disease. Unilateral polyps are a neoplasm until proven otherwise and require imaging and histology in every case. The differential includes inverted papilloma, juvenile nasopharyngeal angiofibroma in an adolescent male, antrochoanal polyp, squamous cell carcinoma, adenocarcinoma, olfactory neuroblastoma, lymphoma, melanoma, encephalocele and meningocele. Never remove a unilateral nasal mass in clinic without imaging, since biopsy of an encephalocele or an angiofibroma has catastrophic consequences.

Antrochoanal polyp: a solitary polyp arising from the maxillary sinus, passing through an accessory ostium and extending posteriorly into the choana and nasopharynx. It occurs in younger patients, is unilateral, is not associated with eosinophilic disease, and does not respond to steroid. Treatment is complete surgical removal including the maxillary antral origin, since incomplete removal causes recurrence.

• Progressive bilateral nasal obstruction, which is the dominant symptom and is typically constant rather than alternating.
• Hyposmia progressing to anosmia, which is often complete and is frequently the most distressing symptom for patients. It results both from mechanical obstruction of the olfactory cleft and from inflammatory damage to the olfactory neuroepithelium.
• Loss of taste as a consequence.
• Rhinorrhoea and postnasal drip, usually mucoid.
• Facial pressure rather than severe pain.
• Sleep disturbance, snoring, mouth breathing and fatigue.
• Recurrent acute exacerbations with purulent discharge.
• Poorly controlled asthma, which frequently improves when the polyps are treated.

Examination

• Pale, greyish, translucent, grape like masses in the middle meatus, insensitive to touch, which distinguishes them from a hypertrophic middle turbinate, which is sensitive and bleeds.
• Polyp grading 0 to 3 per side as described under chronic rhinosinusitis.
• Broadening of the nasal dorsum and hypertelorism in massive long standing polyposis, indicating bone remodelling and requiring imaging.
• Assess smell formally.
• Examine the chest and ask specifically about nonsteroidal anti inflammatory drug reactions, since the aspirin exacerbated group must be identified.

Red flags

• Unilateral polyp or mass.
• Bleeding, which polyps rarely cause.
• Facial pain that is severe and unilateral.
• Proptosis, diplopia, epiphora or reduced vision.
• Facial numbness in the infraorbital distribution.
• Cranial neuropathy.
• A polyp in a child, which requires cystic fibrosis testing.
• A polypoid mass in an adolescent male with epistaxis, which is angiofibroma until excluded and must never be biopsied without imaging.

• Nasal endoscopy after decongestion, defining polyp origin, grade and extent, and assessing the postnasal space.
• Non contrast computed tomography of the sinuses, which stages the disease using the Lund Mackay score, defines the anatomy for surgery, and identifies bone erosion or expansion that would suggest neoplasm, mucocele or fungal disease. Obtain this before any surgery.
• Magnetic resonance imaging where the computed tomography shows bone erosion, expansion, orbital or skull base involvement, unilateral disease, or where malignancy, fungal disease, mucocele or an encephalocele is suspected. It distinguishes tumour from retained secretions, which computed tomography cannot.
• Histology of tissue removed at surgery in every case, and specifically before or at removal of any unilateral lesion.
• Objective smell testing with a validated instrument, both at baseline and to measure response.
• Blood eosinophil count and total immunoglobulin E, for endotyping and biologic eligibility.
• Skin prick testing or specific immunoglobulin E for aeroallergens.
• Sweat chloride testing and cystic fibrosis genetics in all children with polyps and in adults with bronchiectasis, pancreatic insufficiency or male infertility.
• Nasal nitric oxide screening and ciliary studies for primary ciliary dyskinesia.
• Antineutrophil cytoplasmic antibody, urinalysis, renal function and eosinophil count where vasculitis is suspected, particularly with asthma, peripheral eosinophilia and mononeuritis.
• Immunoglobulins and specific antibody responses where infection is recurrent.
• Aspirin challenge under supervision where aspirin exacerbated respiratory disease is suspected and desensitisation is contemplated.
• Symptom scoring with the Sino Nasal Outcome Test 22 at baseline and follow up.

Medical therapy first, with surgery for failure, and lifelong maintenance therapy in every case because polyps are a manifestation of persistent inflammation that surgery does not cure.

Foundation medical therapy

• Intranasal corticosteroid used continuously and indefinitely: mometasone furoate 200 micrograms per nostril twice daily, or fluticasone propionate 100 micrograms per nostril twice daily. Higher doses are appropriate in polyp disease than in rhinitis.
• Corticosteroid delivered by high volume irrigation gives markedly better distribution to the sinuses than a spray, particularly after surgery. Budesonide 0.5 mg respule added to 240 mL saline irrigation once or twice daily is widely used, with counselling about the possibility of systemic absorption in prolonged use and periodic consideration of adrenal function in patients on high doses long term.
• Nasal saline irrigation, high volume, at least twice daily.
• Steroid drops applied in the head down and forward position to reach the olfactory cleft, for anosmia.
• Smoking cessation.

Oral corticosteroid

• Prednisolone 0.5 mg/kg daily, generally 25 to 50 mg, for 5 to 10 days, or a tapering course over 2 to 3 weeks.
• Reliably shrinks polyps and restores smell, with benefit lasting weeks to a few months.
• Limit to a maximum of one or two courses per year. Cumulative exposure causes avascular necrosis of the femoral head, osteoporosis, diabetes, cataract, glaucoma, hypertension, weight gain and mood disturbance.
• The need for repeated courses is an indication to escalate to surgery or biologic therapy, not to keep prescribing steroid. Patients who have had multiple courses should have bone density and glucose assessment.

Aspirin exacerbated respiratory disease

• Strict avoidance of aspirin and nonsteroidal anti inflammatory drugs, with paracetamol and selective cyclo oxygenase 2 inhibitors as alternatives, the latter after supervised challenge.
• Aspirin desensitisation followed by maintenance aspirin, commonly 650 mg twice daily and often reduced to 325 mg twice daily for tolerability, reduces polyp recurrence, reduces the need for revision surgery and improves asthma control. It requires supervised graded challenge in a specialist unit with resuscitation facilities, and it is contraindicated in peptic ulceration, bleeding disorders, pregnancy and severe uncontrolled asthma. Adherence must be lifelong, since desensitisation is lost within days of stopping.
• Montelukast 10 mg daily as an adjunct, which is more effective in this subgroup than in unselected polyp disease.

Biologic therapy

For severe type 2 polyp disease, usually after surgery or where surgery is contraindicated.

• Dupilumab 300 mg subcutaneously every 2 weeks, which produces the largest reductions in polyp score and the most reliable recovery of smell, and simultaneously treats asthma and atopic dermatitis. Monitor for conjunctivitis and transient blood eosinophilia.
• Omalizumab, dosed by weight and total immunoglobulin E, every 2 to 4 weeks.
• Mepolizumab 100 mg subcutaneously every 4 weeks.
• Assess at 4 to 6 months against defined response criteria and discontinue non responders.

Antibiotics and antifungals

• Antibiotics only for acute bacterial exacerbations, culture directed where possible, for 7 to 14 days.
• Long term macrolide therapy has less evidence in polyp disease than in non polyp chronic rhinosinusitis, and is most useful in patients with low immunoglobulin E and neutrophilic disease.
• Topical and systemic antifungals have no established role in ordinary polyp disease and should not be used.

Surgery

Indications: failure of appropriate medical therapy including a trial of oral corticosteroid; complications such as mucocele, orbital involvement or bone erosion; unilateral disease requiring histology; and to create access for topical therapy in extensive disease.

• Endoscopic polypectomy with ethmoidectomy as the minimum, since simple polypectomy alone without addressing the ethmoid has high recurrence.
• Complete or full house functional endoscopic sinus surgery with maxillary antrostomy, complete ethmoidectomy, sphenoidotomy and frontal recess clearance for extensive disease.
• Extended approaches for severe eosinophilic disease: the endoscopic modified Lothrop or Draf III procedure for the frontal sinus, and reboot surgery with removal of diseased mucosa down to periosteum, which reduces recurrence at the cost of prolonged crusting and the need for meticulous postoperative care.
• Image guidance navigation for revision surgery, frontal and sphenoid disease, distorted anatomy and skull base or orbital proximity.
• Antrochoanal polyp requires removal of the antral origin, through a middle meatal antrostomy with an angled endoscope, or with an additional canine fossa or inferior meatal approach where the origin cannot be reached.

Postoperative care, which determines recurrence rates

• Saline irrigation from day 1 or 2, high volume, twice daily.
• Topical corticosteroid resumed at 1 to 2 weeks, preferably as steroid irrigation.
• Oral corticosteroid in the early postoperative period for eosinophilic disease, which reduces early recurrence.
• Endoscopic debridement at 1 to 2 weeks and as needed thereafter.
• Emphasise from the outset that surgery removes polyps but does not cure the disease, and that stopping topical treatment leads to recurrence. This must be said before surgery, not afterwards.

Follow up

Endoscopic review at 2 weeks, 6 weeks, 3 months, then 6 to 12 monthly. Track polyp grade, symptom score and smell. Recurrence occurs in up to 40 percent within 5 years in eosinophilic disease, and revision surgery is needed in around 20 percent. Escalate to biologic therapy rather than to repeated oral steroid courses or repeated surgery in patients with rapid recurrence.