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Nasal Polyps Treatment & Management

  • Author: John E McClay, MD; Chief Editor: Ravindhra G Elluru, MD, PhD  more...
 
Updated: Jun 17, 2016
 

Approach Considerations

Historically, children diagnosed with cystic fibrosis (CF) already had digestive and pulmonary disease and were the children with the more severe form of disease. These children were often treated with intravenous antibiotics directed at the most common pathogens found in the lungs and the sinuses (eg, Pseudomonas aeruginosa,Staphylococcus aureus), both preoperatively and postoperatively.

Additionally, these children had pulmonary toilet to increase their lung function in the perioperative period, including intravenous (IV) steroids, percussion therapy, and inhaled bronchodilators. Much of this process can now be performed on an outpatient basis, depending on the severity of the associated disease.

For patients with severe asthma and polyposis requiring surgery, postoperative admission for observation of respiratory compromise or spasm is determined on an individual basis.

Outpatient surgery is usually performed for older children undergoing endoscopic sinus surgery (ESS) for nasal polyposis without coexisting medical conditions.

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Medical Care

Oral and topical nasal steroid administration is the primary medical therapy for nasal polyposis.[14, 15, 16] Antihistamines, decongestants, and cromolyn sodium provide little benefit. Immunotherapy may be useful to treat allergic rhinitis but, when used alone, does not usually resolve existing polyps. Administer antibiotics for bacterial superinfections.

Corticosteroids are the treatment of choice, either topically or systemically. Direct injection into the polyp is not approved by the US Food and Drug Administration (FDA) because of reports of unilateral vision loss in three patients after intranasal steroid injection with Kenalog. Safety may depend on specific drug particle size; high-molecular-weight drugs such as Aristocort are safer and less likely to be transferred to the intracranial area. Avoid direct injection into blood vessels.

Oral steroids are the most effective medical treatment for nasal polyposis. In adults, most authors use prednisone (30-60 mg) for 4-7 days and taper the medicine for 1-3 weeks. Dosage varies for children, but the maximum dosage is usually 1 mg/kg/day for 5-7 days, which is then tapered over 1-3 weeks. Responsiveness to corticosteroids appears to depend on the presence or absence of eosinophilia; thus, patients with polyps and allergic rhinitis or asthma should respond to this treatment.

Patients with polyposis not dominated by eosinophilia (eg, patients with CF, primary ciliary dyskinesia syndrome, or Young syndrome) may not respond to steroids. Long-term use of oral steroids is not recommended because of the numerous potential adverse effects (eg, growth retardation, diabetes mellitus, hypertension, psychotropic effects, adverse GI effects, cataracts, glaucoma, osteoporosis, and aseptic necrosis of the femoral head).

Many authors advocate topical nasal steroid administration for nasal polyps, either as the primary treatment or as a continual secondary treatment immediately after oral steroids or surgery. Most nasal steroids (eg, fluticasone, beclomethasone, budesonide) effectively relieve subjective symptoms and increase the nasal airflow when measured objectively (primarily in double-blind placebo-controlled studies).[17]

A systematic review of 19 studies found similar results. The topical steroid preparations fluticasone, mometasone, and budesonide were shown to improve nasal symptoms in patients with nasal polyposis.[18] Some studies indicate fluticasone has a faster onset of action and possible mild superiority to beclomethasone.[19]

Topical corticosteroid administration generally causes fewer adverse effects than systemic corticosteroid use because of the former's limited bioavailability. Long-term use, especially at high dosages or in combination with inhaled corticosteroids, presents a risk of hypothalamic-pituitary-adrenal axis suppression, cataract formation, growth retardation, nasal bleeding, and, in rare cases, nasal septal perforation.

As with any long-term therapy, monitor use of topical corticosteroid sprays. However, long-term (>5 years) studies evaluating the use of beclomethasone have shown no degradation of the normal respiratory epithelium to squamous epithelium seen in chronic atrophic rhinitis. Additionally, the newer generation of systemic steroids (eg, fluticasone, Nasonex) appears to have less bioavailability than older nasal steroids, such as beclomethasone.

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Surgical Care

Surgical intervention is required for children with multiple benign nasal polyposis or chronic rhinosinusitis in whom maximal medical therapy fails. Simple polypectomy is effective initially to relieve nasal symptoms, especially for isolated polyps or small numbers of polyps. (See the image below.) In benign multiple nasal polyposis, polypectomy is fraught with a high recurrence rate.

Scale is in inches. The left side of the lesion wa Scale is in inches. The left side of the lesion was the portion of the polyp in the nasal cavity. The right was a stalk attached to the medial maxillary wall.

ESS is a better technique that not only removes the polyps but also opens the clefts in the middle meatus, where they most often form, which helps decrease the recurrence rate. The exact extent of the surgery needed, whether complete extirpation (ie, Nasalide procedure) or simple aeration of the sinuses, is not entirely known, simply because of the dearth of studies. Rare comparisons show that complete extirpation procedures are as effective as or superior to aeration of the sinuses; complication rates are low with experienced surgeons. The use of a surgical microdebrider has made the procedure safer and faster, providing precise tissue cutting and decreased hemostasis with better visualization. (See the images below.)

A surgical microdebrider entering the middle meatu A surgical microdebrider entering the middle meatus. The septum is on the far left. The middle turbinate is in the left center. The surgical microdebrider is on the inferior center. Inferior turbinate is seen on the bottom right. Some blood overlying the ethmoid cavity is noted where polyps were present in the center of the picture.
Endoscopic view of the left middle meatus, showing Endoscopic view of the left middle meatus, showing the septum on the left, the middle turbinate in the center superiorly, and a large maxillary antrostomy with a curved suction on the right. This is following antral-choanal polyp removal.

Surgery is directed at diseased tissue that is apparent on the computed tomography (CT) scan at the time of surgery. Patients with diseases such as CF, primary ciliary dyskinesia syndrome, or Young syndrome may proceed to surgery without extensive medical treatment because these diseases usually do not respond well to corticosteroid treatment. Once diseased tissue has been removed from the nasal cavity and sinuses, the pulmonary systems usually improve.

Consider use of an image-guided system to define the exact location of intranasal, sinus, orbital, and intracranial structures for massive polyposis or revision surgery because surgical landmarks may be absent or altered.

For specific techniques in pediatric sinus surgery, with and without polyps, see Pediatric Sinusitis, Surgical Treatment.

Nasal polyposis occurs in 6-48% of children with CF. Surgery is performed when children become symptomatic. Recurrence of polyps in CF is almost universal, necessitating repeat surgery every few years. In fact, recurrence is typical for many diseases that cause nasal polyps; patients should receive preoperative counseling about this possibility.

For lesions other than benign nasal polyps that result in a nasal polyp, the polyp should be biopsied or removed, depending on the disease process.

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Complications

Massive polyposis or a single large polyp (eg, an antral-choanal polyp) that obstructs the nasal cavities and/or nasopharynx can cause obstructive sleep symptoms and chronic mouth breathing. Rarely, massive polyposis, observed in CF and in allergic fungal sinusitis (AFS) can alter the craniofacial structure. This can result in proptosis, hypertelorism, and diplopia.

In a retrospective study, McClay et al reported that 42% of children with AFS (compared with 10% of adults) presented with craniofacial abnormalities.[7] Massive polyposis rarely causes enough extrinsic compression on the optic nerve to decrease visual acuity. One study reported that three of 82 patients with AFS had vision changes from compression of the optic nerve in the sphenoid sinus that resolved over time with removal of disease. However, because these polyps are slow-growing, they usually cause no neurologic symptoms, even when they extend into the intracranial cavity.

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Diet and Activity

Treatment of nasal polyps involves no special diet.

No activity restrictions are necessary for a child with nasal polyps. The child's activity level may decrease because of diminished ability to breathe through the nose, decreasing sport or physical activity performance. After sinus surgery, activities are limited; these limitation recommendations vary from surgeon to surgeon. Most surgeons specifically restrict nose-blowing because it may increase intranasal pressure and cause potential problems in areas of already thinned bony dividers in patients with nasal polyposis.

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Consultations

First notify a pediatric otolaryngologist, especially if medical therapy has failed or if the origin or diagnosis of the underlying pathology of the nasal polyp is unknown.

Consider consultation with a pulmonary specialist when benign nasal polyps are identified because they could result from asthma, allergy, or CF. Patients with these diseases often have associated pulmonary problems.

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Long-Term Monitoring

Closely monitor children with benign multiple nasal polyps, whatever the cause, because recurrence is likely, regardless of whether the polyps were treated medically or surgically. Postoperative follow-up should occur three or four times in the first month to monitor healing of the sinus cavities; frequency depends on the patient's own geographic location and symptoms.

A patient with CF can be monitored symptomatically because surgery is not performed until these patients are symptomatic, even if nasal polyposis is seen on CT or nasal endoscopy. Certainly, each patient is treated on an individual basis.

For polyps associated with AFS, close follow-up by an otolaryngologist is recommended until the patient is deemed free of disease, which may be several years or more.

Any accumulation of fungus may accelerate the antigenic process, which causes symptoms and disease to recur. Recurrence is especially common for polyps, which may be controlled more simply and effectively if recognized early.

Small nasal polyps are recognized early on a routine follow-up in patients with benign multiple nasal polyps.

Other diseases may be treated medically or with smaller surgical procedures. For diseases resulting in nasal polyps other than benign multiple nasal polyps, the need for inpatient or outpatient care is determined by the extent of disease, symptoms and situation of the patient, and associated medical conditions.

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Contributor Information and Disclosures
Author

John E McClay, MD Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical Center

John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Alan D Murray, MD Pediatric Otolaryngologist, ENT for Children; Full-Time Staff, Medical City Dallas Children's Hospital; Consulting Staff, Department of Otolaryngology, Children's Medical Center at Dallas, Cook Children's Medical Center; Full-Time Staff, Texas Pediatric Surgery Center, Cook Children's Pediatric Surgery Center Plano

Alan D Murray, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, American Academy of Pediatrics, American College of Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Ravindhra G Elluru, MD, PhD Professor, Wright State University, Boonshoft School of Medicine; Pediatric Otolaryngologist, Department of Otolaryngology, Dayton Children's Hospital Medical Center

Ravindhra G Elluru, MD, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, Association for Research in Otolaryngology, Society for Ear, Nose and Throat Advances in Children, Triological Society, American Society for Cell Biology

Disclosure: Nothing to disclose.

Acknowledgements

Orval Brown, MD Director of Otolaryngology Clinic, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center at Dallas

Orval Brown, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, American Society of Pediatric Otolaryngology, Society for Ear, Nose and Throat Advances in Children, and Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Nothing to disclose.

References
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Rigid endoscopic view of the left nasal cavity, showing the septum on the left. Polyps with some blood and hemorrhage are on top of them in the center portion. The rim of white from 1 o'clock to 4 o'clock indicates the lateral nasal wall vestibule. The polyps cover the inferior turbinate, which is partially visible at 4 and 5 o'clock.
Endoscopic view of the left nasal cavity, showing a polyp protruding from the uncinate process. The middle turbinate is to the left. A suction is visible on top of the inferior portion of the uncinate process and inferior portion of the polyp. The lateral nasal wall is on the far right. The polyp is directly in the center and is pale, glistening, and white.
Endoscopic view of the left middle meatus. The septum is on the far left. The middle turbinate is next to the septum on the left. A large, glistening, translucent polyp is visible in the center of the screen next to the middle turbinate. The lateral nasal wall is on the right side of the screen. The inferior turbinate nub posteriorly is in the bottom right hand corner.
Rigid endoscopic view of the left nasal cavity, showing the septum on the left, inferior turbinate on the right, middle turbinate superiorly, and antral-choanal polyp among the floor of the nose.
Rigid endoscopic view of the left anterior nasal cavity, showing the septum on the left, a suction pushing the inferior turbinate on the right, and the clear antral-choanal polyp at the center of the endoscopic view.
Close-up of the middle meatus, showing the stalk of the antral-choanal polyp emanating from the maxillary sinus behind the uncinate process on the bottom right-hand side of the picture. The left side of the picture shows the septum and the middle turbinate being pushed over via suction.
Axial CT scan section through the maxillary sinuses showing opacification of the left maxillary sinus with antral-choanal polyp in the posterior nasal cavity and choana exiting from beneath the middle turbinate in the area of the ostiomeatal complex unit. Scale is in centimeters.
Coronal CT scan through the anterior sinuses showing opacification of the left maxillary sinus with opacification of the inferior half of the nasal cavity on the left, filled by the antral-choanal polyp. The rest of the sinuses are clear.
Coronal CT scan section through the posterior nasopharynx showing the sphenoid sinus superiorly and the antral-choanal polyp filling the nasopharynx in the center of the scan.
Oral cavity and oropharyngeal view of antral-choanal polyp filling the posterior oral pharynx and pushing the soft palate anterior and inferiorly. The polyp is visible behind the uvula and the soft palate.
Scale is in inches. The left side of the lesion was the portion of the polyp in the nasal cavity. The right was a stalk attached to the medial maxillary wall.
Endoscopic view of the left middle meatus, showing the septum on the left, the middle turbinate in the center superiorly, and a large maxillary antrostomy with a curved suction on the right. This is following antral-choanal polyp removal.
An anterior endoscopic view of the nasal cavity in a 5-month-old infant. The vestibule is seen in the periphery of the picture. In the center of the picture, the septum is visible to the left, and the inferior turbinate is to the right. These structures are reddish in hue. Some congestion in the nasal cavity is usually present. These are often structures that can be seen only by anterior rhinoscopy. If the area is decongested, the area of the middle meatus can occasionally be seen.
A rigid rhinoscopy photograph of the left anterior nasal cavity of a 6-week-old infant. The middle turbinate is superiorly in the midline, and the inferior turbinate is to the right. The septum is to the left.
A 3-month-old infant with hypertelorism and bulging of the nasal dorsum, secondary to encephalocele.
Interior view of the nose and nasal cavities. To the right of the patient's left nostril, the right nasal cavity has no obstruction. On the left of the picture, a reddish polyp is visible. The reddish mass is a nasal glioma.
A close-up view of the right nasal cavity and polyp #5 in a 5-month-old infant. The obstructing reddish polyp is visible. This is an intranasal glioma that was arising from the attachment of the inferior turbinate anteriorly; it was transnasally removed.
Anterior nasal papilloma arising from the septum. The skin of the nasal vestibule is seen surrounding the papilloma in the center of the image.
Axial MRI scan of the orbits, posterior fossa, and nasal cavity. The solid tumor is seen filling the posterior ethmoid complex, brain stem, cavernous sinuses, and left anterior cranial fossa.
Axial CT scan through the orbits and ethmoid sinuses, showing the rhabdomyosarcoma in the same areas, including the posterior ethmoid complex, left middle fossa, and skull base of cavernous sinuses.
Rigid endoscopic view of left nasal cavity, showing a polyp in the center of the picture, with extension of the rhabdomyosarcoma. The septum is on the left and the middle turbinate is on the right.
Endoscopic view of the left nasal cavity posteriorly, showing a polyp emanating from the sphenoid sinus in the center of the picture and purulence above and below the polyp. On the left is the septum. On the right is the lateral aspect of the middle turbinate.
Frontal view of a 2-day-old infant with swelling in the inferior medial canthal area on both sides. The right side appears more prominent on this picture. CT scan showed infected nasal lacrimal duct cysts.
Rigid endoscopic view of the left nasal cavity. The septum is on the left, and the lateral nasal wall is on the right. The inferior turbinate is in the center of the picture, and the middle turbinates are visible in the superior midsection of the picture. The nasal lacrimal duct cyst is the yellow dilated lesion underneath the inferior turbinate.
Axial CT scan section through the orbit, showing the dilated nasal lacrimal ducts in the medial anterior area compared to the orbits. Scale on the bottom right is in centimeters.
Axial CT scan through the inferior nasal cavities, showing the dilated nasal lacrimal duct cysts at the inferior location. Scale on the bottom right is in centimeters. The dilated cysts are in the center of the image.
A frontal view of the decompressed nasal lacrimal ducts following surgical marsupialization. Swelling in the inferior medial canthal areas prior to surgery is no longer seen.
Lateral view of a preteenaged child showing infected nasal dermoid. Note the protrusion of the dorsum of the nose.
Preteenaged boy with infected nasal dermoid. A pith is visible over the superior portion of the swelling between the eyes. Nasal pith is commonly seen with the nasal dermoid.
Frontal view of a 5-month-old infant, showing hypertelorism and protrusion in the glabellar region secondary to a small nasal dermoid.
Axial CT scan (bony windows) showing a 5-month-old infant with nasal dermoid anterior to the nasal and maxillary bones. No bony dehiscence or bony abnormalities are visible.
A coronal MRI scan through the nasal dermoid of a 5-month-old infant. The scale on the left is 2 mm per small bar and 1 cm per tall bar. The arrow points to the lesion. The lesion appears to be approximately 6-7 mm in this dimension.
An interoperative view of dermoid removal from a 5-month-old infant.
A surgical microdebrider entering the middle meatus. The septum is on the far left. The middle turbinate is in the left center. The surgical microdebrider is on the inferior center. Inferior turbinate is seen on the bottom right. Some blood overlying the ethmoid cavity is noted where polyps were present in the center of the picture.
Coronal section through the ethmoid maxillary sinuses and orbits. This is a 2-year-old child with cystic fibrosis, showing complete opacification of the maxillary and ethmoid sinuses. Bulging in the medial maxillary walls is observed.
Coronal section showing soft tissue windows rather than bony windows. It indicates the infection by the thick mucus in the maxillary and ethmoid cavities by the heterogeneity of the opacification in the sinuses. Note that the nasal cavity is completely obliterated by polyp disease.
A rigid rhinoscopy photograph of the the nasal cavity of a 6-week-old infant taken all the way back into the choanae of the left nasal cavity. The photograph shows the septum on the left, the small adenoids on the posterior superior wall of the nasopharynx in the center, and the eustachian tube orifice on the right.
A rigid rhinoscopy photograph taken in the midportion of the left nasal cavity of a 6-week-old infant showing the septum on the left, the inferior turbinate on the right, and the middle turbinate superiorly. The choanae is seen in the dark area in the center.
A rigid rhinoscopy photograph taken two thirds of the way back along the floor of the nose of the left nasal cavity of a 6-week-old infant. This photograph shows the septum on the left, the choanae straight ahead, and the posterior portion inferior turbinate to the right.
A coronal CT scan section through the orbit to maxillary sinus. The medial maxillary walls bulge medially, which is a typical CT scan view of cystic fibrosis. The ethmoid sinuses have scattered disease.
View just inside the nasal vestibule of a fifteen-year-old adolescent boy with allergic fungal sinusitis showing diffused polyposis extending into the anterior nasal cavity and vestibule; the septum is on the right, and the right lateral vestibular wall (nasal ala) is on the left. The polyps are all in the center. The polyps almost hang out of the nasal vestibule.
Coronal CT scan showing extensive allergic fungal sinusitis involving the right side with mucocele above the right orbit and expansion of the sinuses on the right.
Coronal CT scan showing typical unilateral appearance of allergic sinusitis with hyperintense areas and inhomogeneity of the sinus opacification; the hyperintense areas appear whitish in the center of the allergic mucin.
Coronal MRI scan showing expansion of the sinuses with allergic mucin and polypoid disease; the hypointense black areas in the nasal cavities are the actual fungal elements and debris. The density above the right eye is the mucocele. The fungal elements and allergic mucin in allergic fungal sinusitis always look hypointense on MRI scanning and can be mistaken for absence of disease.
Fifteen year-old adolescent boy with allergic fungal sinusitis causing right proptosis, telecanthus, and malar flattening; position of his eyes is asymmetrical, and his nasal ala on the right is pushed inferiorly compared with the left.
Nine-year-old girl with allergic fungal sinusitis displaying telecanthus and asymmetrical positioning of her eyes and globes.
 
 
 
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