Surgery for Nasal Polyps

What are nasal polyps?

A polyp is a swelling of the internal lining of the nose, which is usually caused by inflammation. They often originate from the ethmoid sinuses, one of the sinuses situated in between the eyes which drain into the side wall of the nasal cavity. Nasal polyps contain inflammatory fluid and, while they can be associated with allergy and infection, the exact reason why some people get them and not others is not known.

What other conditions are associated with nasal polyps?

Nasal polyps can occur in combination with other more general diseases, most commonly asthma, or can occur in patients with an aspirin intolerance or cystic fibrosis.

Late onset asthma is more likely to be associated with nasal polyps rather than childhood asthma. Of those patients with nasal polyps, up to 40% will have coexisting asthma. Nasal allergy is often thought to be a risk factor for the development of polyps, however more than two thirds of patients show no evidence of systemic allergic disease. Of the 15% of the population suffering from hay fever, only a small proportion of these would develop nasal polyps. Despite this, 90% of patients with nasal polyps have an increased number of eosinophils in their blood stream (eosinophils are inflammatory cells which are associated with allergy).

Aspirin hypersensitivity is not an allergic reaction in itself but occurs when there is an alteration in the production of several inflammatory markers. Asthma, aspirin sensitivity and nasal polyps sometimes occur together in 8% of polyp patients in an unusual but well-recognised subgroup known as Samters triad. The nasal polyps in these patients tend to recur more than in other conditions.

Nasal polyps are rare in children between the ages of two and 10 years. If found in this age group, cystic fibrosis should be excluded as a possible diagnosis.

Nasal polyps are more common in men (approximately 2:1). After the age of 60 the chance of developing polyps declines.

What symptoms do nasal polyps cause?

Although each individual polyp is small, multiple polyps situated together can collectively fill up the inside of the nose. As a result, the commonest symptom that they cause is a blocked nose, together with a reduced or even absent sense of smell. Other symptoms which may occur include a runny nose, sneezing and catarrh (post nasal drip).

One-sided nasal polyps are more unusual. They may be associated with a wide range of conditions and are less commonly purely inflammatory in nature. As such, they generally merit further investigation both in adults and children.

Treatment of nasal polyps

The management of nasal polyps is initially with medications in the form of either topical sprays or drops, or oral (tablet) preparations. The mainstay of treatment is with steroids, as these are effective at reducing inflammation. Depending on the size of the polyps, it may be sufficient to begin treatment with an intranasal spray as these are easy to use and generally well tolerated. They can be taken for many years as very little is absorbed into the body, although they may take up to six weeks of continuous treatment before their full effect can be felt. If the symptoms persist, steroid drops may be required. These are stronger than sprays but need to be administered in the head-down position (ie. Head upside down such as when lying flat on a bed and dangling the head over the end). Ultimately, if both of these options prove ineffective, there remains the option to give a course of oral steroids. These must be prescribed with caution and only for a short duration owing to the risk of complications including high blood pressure, tendency to diabetes, stomach ulcers, bone fractures and eye problems such as cataracts and glaucoma.

Surgical treatment of nasal polyps

If attempts at medical treatment have not been successful and the patient’s symptoms and polyps persist, surgical removal of the nasal polyps can be undertaken. This nasal polypectomy procedure is often combined with functional endoscopic sinus surgery (FESS) as the polyps usually originate from the sinuses.