Nasal Polyposis

Nasal polyposis is one form of chronic non-allergic rhinitis

and occurs in about 1% of the adult population, approximately 2.5 times more frequent in males. There is no racial predeliction.

It is associated with asthma in 20-50% and with aspirin intolerance in 8%. Other conditions associated with nasal polyps, include cystic fibrosis (should be suspected in children with nasal polyps), Kartagener’s syndrome, Churg Strauss syndrome and primary ciliary dyskinesis

Sinusitis is commonly associated and this can be fungal - this may not be causative but an effect of the polyposis.

The patient may be asymptomatic if the polyps are very small, but common symptoms are nasal airway obstruction, watery or mucoid rhinorrhoea, hyposmia or anosmia, dull headaches, snoring and obstructive sleep apnoea, and chronic mouth breathing

The condition should be considered a medical one, and medical treatment is vital, with surgery being used where medication is failing to control the symptoms.

• Diagnosis
• Primary Care Management
• Referral
• Surgery
• Discharge from Secondary Care

Diagnosis

• Suspect nasal polyps if marked nasal obstruction occurs after an upper respiratory infection.
• Anosmia is very common and may occur as the first symptom
• Examination should show shiny, wet glassy or opaque, (but not pink) swellings, in the nasal cavity
• Plain sinus x-rays are of no use and CT scans should not be carried out by primary care - they are only used as an adjunct to surgery, not as a means of diagnosis

Primary Care Management

Medical therapy of nasal polyps is the mainstay of treatment for nasal polyps, and can, therefore, be carried out in primary care. Treatment is with steroids, but this needs to be considered long term. Short term treatment will almost certainly be associated with recurrence, or poor control.

 Available treatments

• Steroid sprays - there are a number available, and all have approximately the same efficacy if compliance is good. They will not work if the nose is very blocked as penetration into the ansal cavity is poor
• Steroid drops, such as Betnesol or Flixonase nasules. These have the advantage of better penetration, provided they are administered with the head in an upside-down position (which may be impossible for some people)
• Prednisolone is the most potent treatment modality, but can only be used for 5-10 days

 Treatment regimes

• Mild symptoms
  Topical steroid nasal spray. Review at 3 months, if improved continue spray. If no improvement, refer.
•  Moderate symptoms
  Betnesol nasal drops 2 drops right and left bd for 2 months, then steroid nasal spray. Review at three months, if improved continue with spray, if not refer. 
• Severe symptoms
  Prednisolone 30 mg daily for 5 days and Betnesol nose drops for 6 weeks. Review at 6 week; if improved continue with steroid nasal spray, if not refer.

Referral

Referral to secondary care should be routine for patients who fail the above regimes, but urgent in the following situations:

•  Symptoms are unilateral
• There is bleeding
• If pain is present
• There is cacosmia (sense of foul smell)
• There are orbital symptoms or signs
• If the patient is less than 16

Surgery

After the diagnosis is confirmed by nasal endoscopy, treatment will be reviewed according to above regimes, and if deemed to have failed, the patient will be offered surgery. 

Surgery will be aided in most, but not all by the use of CT scanning

 Surgical procedures will vary, according to the severity of disease, from simple nasal polypectomy, endoscopic ethmoidectomy, to modified Lorthrop procedure (particularly in those who have Samter’s triad)

 All surgeries will be followed by a regime of nasal treatment with steroids.

 Discharge from Secondary care

In simple cases immediate referral will be made back to primary care for continuance of medical therapy, and an advice sheet will be issued. 

Severe or complicated cases will be monitored in secondary care, and referred back for continuing medical treatment when symptoms are stable