Nasal Polyps (Allergic, Non-Allergic, Antrochoanal, Tumor)

by Dr. Christopher Chang, last modified on 1/26/12
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In its most basic definition, nasal polyps are grape-like growths that occur in the nose and sinus cavities. The VAST majority of nasal polyps are benign growths although there are some forms that may mimic nasal polyps, but are actually aggressive tumors and in some rare instances, even cancer. Below are two pictures of the nasal cavity taken by nasal endoscopy which is the quickest way to a diagnosis. One is normal and the other containing extensive nasal polyps. At the end of this webpage are CT scans.

Normal appearing nasal cavity. Arrow is pointing at the inferior turbinate.

Extensive nasal polyps denoted by the black arrows. The white arrow is pointing at the middle turbinate and the red arrow at the septum (both normal). This image was taken from knol.com.

Although experts may bicker over classification and definition, the simplest way of approaching nasal polyps is by dividing them into 4 categories. It is important to divide the nasal polyps in this manner as the treatment is somewhat different in each case. But, keep in mind that the initial approach may be very similar:.

If nasal polyps are seen in a child, genetic diseases may need to be considered including cystic fibrosis, immotile ciliary syndrome, etc.

Treatment

At the initial visit, the workup and treatment is the same regardless of the type of nasal polyp.

To provide immediate relief, oral prednisone steroid medication with antibiotics are often provided. The steroid is probably the one and only medication that often is able to shrink the polyps significantly providing symptom relief quickly. Antibiotics are also given as there is always some baseline infection present, and since steroids are known to cause some degree of immunosuppression, provides some protection from infection initiation or exacerbation. Antibiotics without any oral steroids does pretty much nothing.

If allergic nasal polyps are suspected, the patient is immediately started on nasonex (a steroid nasal spray) and singulair. These medications are to be continued for years and potentially for life. Why? These two medications appear to help prevent the polyps from becoming larger if present, or from coming back after surgical removal. Without these medications, the polyps often come back or grow in size. It should probably be mentioned that nasonex is the ONLY steroid nasal spray that has an FDA indication for nasal polyps. No other steroid nasal spray has this indication.

Allergy testing and immunotherapy also is highly encouraged in the case of allergic nasal polyps. It is felt that such polyps are due to an underlying immune dysfunction related to allergies. As long as there is underlying allergies present, the polyps will have a tendency to come back.

Finally, surgical removal by endoscopic sinus surgery. This really is the only way to get rid of the polyps to allow the medications provided to work as best as possible. Remember, medications generally help prevent polyp regrowth or enlargement... they do NOT get rid of polyps that are already there. At time of surgery, the polyps that are removed are sent to pathology to ensure that there is no cancer or tumors present.

SO, to summarize, a typical patient who comes to see us will have the following happen:

That's the overall approach and management for patients with nasal polyps!!!

With this treatment protocol, allergic nasal polyps generally recur over a period of 5-10 years (if they even come back at all). HOWEVER, after surgical removal of allergic nasal polyps, if a patient decides to stop prescribed medications and allergy shots, the nasal polyps generally come back within 1-3 years.

In patients where the nasal polyps do not seem to respond to the above protocol (or if patient is refusing surgery), the addition of a very strong drug called Zyflo (zileuton) may be of benefit. This drug can cause liver damage (in <10% of patients) and as such, liver function bloodwork (AST/ALT) is required every month for 3 months and yearly thereafter. As long as the AST/ALT numbers do not exceed 150 (yes, it is higher than what is considered normal), it is generally considered safe to continue with this drug (though would check bloodwork weekly if that happens to ensure stability).

Please contact our office for an appointment if you suspect you have nasal polyps!

Watch Video on Image Guided Endoscopic Sinus Surgery

There are two basic reasons for needing a CT scan in patients with nasal polyps. The first reason is to delineate the exact extent of involvement of the sino-nasal cavities with polyps. Often, what one sees in the nose on nasal endoscopy is just the tip of the iceberg. The second reason for the CT sinus is that it provides a roadmap to perform endoscopic sinus surgery safely.

Normal CT Sinus: Note the air within the sinus cavities denoted by black (just like the black surrounding the head). White is bone. Grey is soft tissue.

Abnormal CT Sinus: Note the grey coloration within the sinus cavity, especially the right side. This person has right greater than left maxillary sinusitis along with severe bilateral ethmoid sinusitis. Entirely possible that nasal polyps are present in these same locations as well. This person also has a deviated septum.

Abnormal CT Sinus: This patient has severe nasal polyps involving all sinus cavities that spills out into the nasal cavity. There is absolutely no air in any sinus cavities.