Nasal polyps

In this article:

• Treatment
• Medications
• Surgery
• Surgery vs medications for nasal polyps
• Nasal allergy treatment
• Systemic diseases with polyps’ treatment
• Allergic fungal rhinosinusitis treatment
• Aspirin sensitivity treatment
• Antibiotics
• Future treatments
• Natural remedies
• Ascorbic Acid
• Bromelain
• Quercetin
• Nasal Irrigation
• Urtica dioica (Stinging Nettle)
• Air Quality
• Naso-Sympatic Treatment and Aromatherapy
• Humming
• References

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Treatment

There are several methods of nasal polyp treatment. it all depends on what exactly caused the polyps to grow in the first place. We do not recommend self-treatment before you see a doctor. But there are many things you can do before jumping to the surgery. Nasal polyps can shrink and disappear if you take care of an allergy. A review of relevant medical and surgical clinical studies shows that intranasal corticosteroids, antihistamines, and allergen immunotherapy continue to be the best treatments for chronic rhinitis that leads to polyps. 

Medications

A doctor may recommend to a brief use of nasal decongestant sprays together with nasal steroidal sprays. Such combination will prevent a “rebound” congestion, which happens if you only use decongestants. There are many OTC nasal anti-inflammatory sprays that may help reduce the size of polyps. You will need to continuously use this medication if a main reason for these polyps is not identified. Remember – nasal polyp is not a disease, but rather a symptom of a disease.

Surgery

Nasal polyps can be removed surgically by an ENT specialist. Usually, this is an outpatient procedure.

Several different surgeries are known:

– endoscopic sinus surgery for nasal polyps (FESS)

– polypectomy

– Caldwell-Luc surgery

– intranasal ethmoidectomy

A recent publication describes the differences in the results of these methods: 

Of the 33 studies included, the randomized controlled trials and controlled trials reported overall symptomatic improvement that ranged from 78 to 88% for FESS compared with 43 to 84% for similar techniques (including polypectomy, Caldwell-Luc and intranasal ethmoidectomy). 

Disease recurrence was 8% for FESS compared with 14% for Caldwell-Luc and polyp recurrence was 28% for endoscopic ethmoidectomy compared with 35% for polypectomy. Revision surgery was reported in one study only and was the same for FESS and Caldwell-Luc procedures. 

Percentage of overall complications was reported in only one comparative study and was 1.4% for FESS compared with 0.8% for conventional procedures. The case series studies reported overall symptomatic improvement for patients with nasal polyps ranging from 37 to 99% (median 89%). For the mixed patient groups (with and without polypoid disease) overall symptomatic improvement ranged from 40 to 98% (median 88%). Total complications in the case series studies ranged from 22.4 to 0.3% (median 6%). Systematic review of endoscopic sinus surgery for nasal polyps. Dalziel K, Stein K, Round A, Garside R, Royle P.Health Technol Assess. 2003;7(17):iii, 1-159. doi: 10.3310/hta7170.PMID: 12969541. Review)

Surgery vs medications for nasal polyps

It is always recommended to use conservative treatment before surgery is considered. If the medications and all measures recommended by the doctor failed, the surgery is the only option. In a recent study scientists reviewed all published evidence regarding the efficiency of treatments for polyps. 

Endoscopic sinus surgery for the excision of nasal polyps: A systematic review of safety and effectiveness. Dalziel K, Stein K, Round A, Garside R, Royle P. Am J Rhinol. 2006 Sep-Oct;20(5):506-19. doi: 10.2500/ajr.2006.20.2923.PMID: 17063747 Review

Randomized controlled trials of any surgical intervention (e.g. polypectomy, endoscopic sinus surgery) versus any medical treatment (e.g. intranasal and/or systemic steroids), including placebo, in adult patients with chronic rhinosinusitis with nasal polyps were chosen. 

Conclusions: There were no important differences between groups in either the patient-reported disease-specific symptom scores or the health-related quality of life scores. Two studies (one comparing ESS plus topical steroid versus antibiotics plus high-dose topical steroid, the other ESS versus systemic steroids) failed to find a difference in generic health-related quality of life scores. 

Complication rates were not reported in all studies, but rates of up to 21% for medical treatment and 14.3% for surgical treatment are described. Epistaxis was the most commonly reported complication with both medical and surgical treatments, with severe complications reported rarely.

Nasal allergy treatment

Nasal polyp is a frequent sign of the untreated allergy. It is important to see an Allergist if you are diagnosed with polyps. If the main reason is eliminated, polyps will resolve and will not come back. Allergic rhinitis can be treated with nasal sprays, antihistamines and nasal wash. But the most effective way to get rid of the allergy is an immunotherapy (allergy shots or sublingual drops SLIT).

It is also important to do all environmental allergy control, such as air filters, dust removal, and dust mite bed covers. Your allergist will advise you on what is best and cost effective.

Systemic diseases with polyps’ treatment

Cystic Fibrosis treatment is usually recommended by Pulmonologist after the diagnosis is done. It is a life-long disease and needs to be taken care of by specialists. Polyps are usually surgically removed by ENT.

Allergic fungal rhinosinusitis treatment

Environmental mold Aspergillus is responsible for polyps in certain people who are genetically susceptible. You must see an Allergist if you suspect that this can be a problem. It can also cause severe asthma and fungal sinusitis when a fungus is actually growing inside the sinus cavity or in the lungs. The treatment involves a systemic antifungal drug, oral steroids, and surgical removal of polyps.

Treatment of suspected invasive aspergillosis should be initiated promptly as the patient’s condition can decline quickly. Intravenous therapy for critically ill patients can include voriconazole (4 mg/kg, twice daily), posaconazole (300 mg IV, daily), micafungin (150 mg IV, daily) or amphotericin B (1 mg/kg, daily) for a 6 to the 12-week course. Voriconazole is considered the first-line treatment. While amphotericin is considered effective, it is deemed a second-line agent due to its adverse effect profile. Consideration should also be taken to resolve the patient’s immunocompromised state as much as possible considering their comorbid conditions.

Aspirin sensitivity treatment

Polyps may indicate that a person has an aspirin or NSAIDS sensitivity. A visit to the Allergist will be extremely helpful in this situation. Here is what can be done:

• Aspirin allergy test
• Aspirin desensitization
• Aspirin avoidance recommendations if the desensitization procedure cannot be performed

If aspirin allergy is treated correctly, the polyps will shrink and will not require surgical removal. When aspirin sensitivity is not addressed, even after the surgery the polyps continue to grow causing chronic congestion and respiratory problems (aspirin sensitivity syndrome also causes severe and difficult to control asthma).

Antibiotics

Nasal polyps should not be treated with antibiotics as they are not caused by a bacterium. Sometimes sinusitis develops due to swelling and blockage of the nasal passages. Only if an ENT exam confirms a bacterial infection, antibiotics should be used (based on bacterial culture sensitivity).

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Future treatments

Advances in understanding the pathogenic mechanisms of both rhinitis and chronic rhinosinusitis have resulted in new treatment options, especially for chronic rhinosinusitis. Dupilumab is the first biologic drug approved for chronic rhinosinusitis with polyps. Omalizumab, mepolizumab, and benralizumab may have a future role in the treatment of chronic rhinosinusitis. 

Here is most current review of evidence: In adults with severe chronic rhinosinusitis and nasal polyps, using regular topical nasal steroids, dupilumab improves disease-specific HRQL compared to placebo, and reduces the extent of the disease as measured on a CT scan. It probably also improves symptoms and generic HRQL and there is no evidence of an increased risk of serious adverse events. It may reduce the need for further surgery. There may be little or no difference in the risk of nasopharyngitis. In similar patients, mepolizumab may improve both disease-specific and generic HRQL. 

It is uncertain whether it reduces the need for surgery or improves nasal polyp scores. There may be little or no difference in the risk of nasopharyngitis. It is uncertain if there is a difference in symptom severity and the risk of serious adverse events. We are uncertain about the effects of omalizumab. (read more in the article cited)

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Natural remedies

Natural remedies are traditionally used by Naturopathic doctors to reduce symptoms of the allergic rhinitis and prevent forming of the polyps. Here we present the published evidence for the various options.

Ascorbic Acid

Vitamin C is maintained in phagocytes and lymphocytes at 100 times greater concentration than the plasma56 and inhibits histamine secretion by white blood cells. As plasma ascorbic acid levels decrease, histamine levels increase significantly. Oral dosing of vitamin C appears to reliably lower blood histamine levels. Vitamin C, vitamin E, copper, and zinc levels were significantly lower in the chronic sinusitis group compared to controls. 

In a clinical trial in which intranasal vitamin C was used to treat allergic rhinitis, 48 subjects received either ascorbic acid solution (n=27) or placebo (n=21) sprayed into the nose three times daily. After two weeks, 74 percent of subjects treated with the ascorbate solution exhibited a decrease in nasal secretions, blockage, and edema, compared to 24 percent of controls. 

Bromelain

Bromelain, a proteolytic enzyme complex from pineapple, has commonly been used in sinusitis as an anti-inflammatory and mucolytic. A 2005 German clinical study found children with acute sinusitis exhibited statistically significant faster symptom recovery (p=0.005) compared with standard treatment,60 confirming clinical findings from the 1960s. One 1967 study reported 85 percent of sinusitis patients receiving bromelain obtained complete resolution of inflammation of the nasal mucosa.

Quercetin

Quercetin is widely distributed in the plant kingdom and is the most abundant of the flavonoid molecules. Quercetin’s anti-inflammatory activity appears to be due to its antioxidant and inhibitory effects on inflammation-producing enzymes. Quercetin inhibits cyclooxygenase and lipoxygenase, which regulate the production of the inflammatory mediators – leukotrienes and prostaglandins.

Nasal Irrigation

Numerous studies support adjunctive use of nasal irrigation in sinusitis. Although nasal air flow was not significantly improved with saline irrigation in chronic sinusitis, improvements in subjective complaints, endonasal endoscopy, and radiography were noted.

Urtica dioica (Stinging Nettle)

Urtica dioica, commonly known as stinging nettle, has been traditionally used to treat allergies.

Air Quality

Modern indoor living is often a perpetuating influence in sinusitis. Household mold levels often outstrip ubiquitous outdoor airborne fungi levels, although use of high quality particulate air (HEPA) filtration reduces indoor levels and sinusitis risk.

Naso-Sympatic Treatment and Aromatherapy

An osteopathic technique involves direct massage of the sinus ostea with surgical cotton swabs. In chronic sinusitis, Mark Lamden, ND, retains the swabs at the ostea for 20-30 minutes and reports 50-percent efficacy when using naso-sympatico in conjunction with allergy treatment. 

The most common essential oils used include eucalyptus, lavender, pine, thyme, and clove. Camphor oil inhalation has traditionally been used to help liquefy the tenacious mucus of sinusitis, although its employment in naso-sympatico treatment is undocumented. These and other essential oils are also antifungal in nature, which may provide another mechanism for their benefit in CRS.

Humming

The humming technique was described as being one that maximally increased intranasal vibrations, but less than that required to produce dizziness. The morning after the first 1-h humming session, the subject awoke with a clear nose and found himself breathing easily through his nose for the first time in over 1 month. During the following 4 days, CRS symptoms slightly reoccurred, but with much less intensity each day. By humming 60-120 times four times per day (with a session at bedtime), CRS symptoms were essentially eliminated in 4 days. Coincidentally, the subject’s cardiac arrhythmias (PACs) were greatly lessened. It is hypothesized that strong, prolonged humming increased endogenous nasal NO production, thus eliminating CRS by antifungal means.

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References

Nasal Polyps. del Toro E, Portela J.2021 Aug 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.PMID: 32809581 Free Books & Documents. Review.

Aspergillosis. Fosses Vuong M, Waymack JR.2021 Aug 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.PMID: 29489184 Free Books & Documents. Review.

Chronic Sinusitis. Kwon E, O’Rourke MC.2021 Aug 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.PMID: 28722963 Free Books & Documents. Review.

Systematic review of endoscopic sinus surgery for nasal polyps. Dalziel K, Stein K, Round A, Garside R, Royle P.Health Technol Assess. 2003;7(17):iii, 1-159. doi: 10.3310/hta7170.PMID: 12969541 Free article. Review.

Anosmia. Li X, Lui F.2021 Jul 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.PMID: 29489163 Free Books & Documents. Review.

Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps.

Rimmer J, Fokkens W, Chong LY, Hopkins C.Cochrane Database Syst Rev. 2014;(12):CD006991. doi: 10.1002/14651858.CD006991.pub2. Epub 2014 Dec 1.PMID: 25437000 Review.

Natural treatment of chronic rhinosinusitis. Helms S, Miller A.Altern Med Rev. 2006 Sep;11(3):196-207.PMID: 17217321 Free article. Review.

Sublingual immunotherapy in the treatment of children. Pham-Thi N, de Blic J, Scheinmann P.Allergy. 2006;61 Suppl 81:7-10. doi: 10.1111/j.1398-9995.2006.01162.x.PMID: 16792599 Review.

The role of decongestants, cromolyn, guafenesin, saline washes, capsaicin, leukotriene antagonists, and other treatments on rhinitis. Kushnir NM. Immunol Allergy Clin North Am. 2011 Aug;31(3):601-17. doi: 10.1016/j.iac.2011.05.008.PMID: 21737044 Review.

Biologics for chronic rhinosinusitis. Chong LY, Piromchai P, Sharp S, Snidvongs K, Philpott C, Hopkins C, Burton MJ.Cochrane Database Syst Rev. 2020 Feb 27;2(2):CD013513. doi: 10.1002/14651858.CD013513.pub2.PMID: 32102112 Free PMC article. 

Current and Future Treatments of Rhinitis and Sinusitis. Patel GB, Kern RC, Bernstein JA, Hae-Sim P, Peters AT.J Allergy Clin Immunol Pract. 2020 May;8(5):1522-1531. doi: 10.1016/j.jaip.2020.01.031. Epub 2020 Jan 28.PMID: 32004747 Free PMC article. Review.

Strong humming for one hour daily to terminate chronic rhinosinusitis in four days: a case report and hypothesis for action by stimulation of endogenous nasal nitric oxide production. Eby GA.Med Hypotheses. 2006;66(4):851-4. doi: 10.1016/j.mehy.2005.11.035. Epub 2006 Jan 10.PMID: 16406689