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Expert Q&A

Chronic Sinusitis With Nasal Polyps

Deya N. Jourdy, MD
10/19/2023

Nasal polyps are benign, inflammatory growths on the inside of the nose and are common among individuals with chronic rhinosinusitis and asthma.1

To answer our questions about the clinical features, prevalence, diagnosis, and treatment options for nasal polyps, Consultant360 reached out to Deya N. Jourdy, MD, the director of rhinology, sinus, and skull base surgery at Phelps Hospital Northwell Health, assistant professor of otolaryngology at The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, adjunct assistant professor of otolaryngology and neurosurgery at New York Medical College Westchester Medical Center, and otolaryngologist with ENT and Allergy Associates, LLP. 

Consultant360: What are nasal polyps, and what are the clinical features?
Deya Jourdy: Nasal polyps are benign inflammatory growths, arising from the mucosa of the nasal cavity and paranasal sinuses. Most commonly, nasal polyps present as bilateral, fleshy-appearing inflammatory lesions originating in the middle meatus and extending down into the nasal cavity beneath the middle turbinate and into the nasal airway. By contrast, unilateral nasal lesions may represent other benign clinical entities such as antrochoanal polyps, inverting papillomas, and encephaloceles, or malignancies such as squamous cell carcinomas or esthesioneuroblastomas. Similarly, presumed nasal polyps in patients younger than age 20 years or older than age 80 years also raise suspicion for other clinical conditions, such as cystic fibrosis in children and possible neoplasm in the elderly.

Patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) may present with any combination of the 4 cardinal symptoms of chronic rhinosinusitis (CRS), including nasal congestion (present in up to 97% of cases), decreased sense of smell (present in up to 90% of cases), mucous drainage, and less frequently, facial pressure or pain.1 Sleep disturbance is also common among patients with CRSwNP. Not surprisingly, the severity of the nasal polyps typically correlates well with subjective nasal obstruction.2

C360: What is the prevalence and what are the demographic characteristics of nasal polyps?

DJ: CRS is common, affecting up to 16% of the US population.3 Although nasal polyps are observed in various clinical conditions, they are most frequently associated with a subset of CRS appropriately named CRSwNP. Nasal polyps affect approximately 4% of the US population, and CRSwNP makes up approximately 25% to 30% of patients with CRS.4 Men are more likely to have CRSwNP, but women have been observed to have more severe manifestations of this disease.5,6

CRSwNP most commonly presents between ages 40 and 60 years, with the average age of onset being 42 years.5 CRS is associated with significant morbidity and decreased quality of life; patients with CRS report health state utility values that are significantly lower than the US population average. In fact, scores in the CRS population are similar to those reported for other chronic health conditions, such as congestive heart failure, moderate asthma, moderate chronic obstructive pulmonary disease, and Parkinson disease.7

C360: How are nasal polyps diagnosed?
DJ: CRSwNP can be difficult to distinguish from CRS without nasal polyps (CRSsNP) and from other entities that can present with similar symptoms. This includes chronic rhinitis (which affects up to 30% of the US population and commonly presents with nasal congestion and mucous drainage), anatomical abnormalities such as a deviated septum, benign and malignant sinonasal neoplasms, and neurologic causes of hyposmia.

Any patient with CRS must have at least 2 of the 4 previously mentioned hallmark symptoms of CRS for a duration of at least 12 weeks. Patients with CRSwNP generally tend to have more severe sinonasal symptoms with nasal obstruction and hyposmia being more common, while facial pain/pressure appears to be more common in patients with CRSsNP.8

In addition to these subjective findings, the diagnosis of CRSwNP is typically made with objective evidence of nasal polyps, most commonly identified on a computed tomography (CT) scan and/or on nasal endoscopy. Polyps can sometimes be visualized with anterior rhinoscopy in patients with particularly large nasal polyps.

C360: How is CRSwNP treated?

DJ: Both standard topical corticosteroids sprays and nasal saline irrigations are generally recommended as first-line medical therapies for CRSwNP patients.9 Intranasal corticosteroids can decrease nasal polyp size and decrease symptoms, but up to 80% of patients report frustration with symptom relief when using a standard intranasal corticosteroid spray.10

More recently, the use of corticosteroid nasal sprays utilizing an exhalation delivery system (EDS) has been recommended as the next treatment option in a multidisciplinary consensus on a stepwise treatment algorithm for management of CRSwNP. The EDS has been shown to better deliver the corticosteroid into the middle meatus where most polyps originate and decrease both patient symptoms and polyp grade on endoscopy.11-13

Oral corticosteroids can also reduce polyp size and improve symptoms; however, caution must be taken given their association with serious systemic adverse effects.

C360: What are the surgical treatment options for nasal polyps and how have they evolved over the recent years?

DJ: For patients who are refractory to medical management, functional endoscopic sinus surgery (ESS) may be recommended. A delay of more than 5 years from initial diagnosis to ESS is associated with greater postoperative health care utilization, compared with when surgery was performed within 1 year of diagnosis.14 ESS can improve symptoms as well as objective evidence of sinonasal inflammation on both endoscopy and CT scan. It is important to note that nasal polyps can still reoccur despite ESS, and this is especially true in patients with asthma. Recurrent polyps have been reported on endoscopy in up to 40% of patients 18 months after surgery.15 However, despite the high probability of polyp recurrence after ESS, it has been demonstrated that patients who undergo ESS can have long-term, large improvements in health-related quality of life that are maintained over a period of at least 5 years.14

ESS is conventionally performed while the patient is under general anesthesia and usually involves both the removal of polyps obstructing the nasal cavity, in addition to accessing the affected paranasal sinuses to remove polyps from within. More recent advances in the field of rhinology and endoscopic skull base surgery have made extended endonasal approaches much more commonplace allowing minimally invasive access to historically difficult-to-reach areas in the paranasal sinuses; thus, more complete eradication of polyps with minimal morbidity to the patient is now possible.

Biodegradable stents that elute mometasone are also now available for insertion into the sinus cavities at the time of surgery with the aim of higher local corticosteroid concentrations and greater control of inflammation; these implants have been shown to reduce polyp recurrence, reduce the need for revision surgery, and reduce post-operative oral corticosteroid use.16 Furthermore, office-based procedures performed under local anesthesia while the patient is awake are also becoming much more widespread, eliminating the risk of anesthesia in some cases.

C360: What role do biologics play in the treatment of CRSwNP?
DJ: Several promising biologics are now approved for the treatment of CRSwNP. These monoclonal antibodies (mAb) directly target the type 2 (T2) inflammatory pathway that commonly characterizes CRSwNP resulting in eosinophilia and the presence of high levels of T2 cytokines, such as interleukin 5 (IL-5) and IL-13. Omalizumab (a human anti-IgE mAb), mepolizumab (a human anti-IL-5 mAb), and dupilumab (a human mAb that binds to the IL-4 receptor α subunit and inhibits signaling of IL-4 and IL-13) have all been shown to significantly reduce nasal polyp size and symptoms of sinusitis when compared with placebo in patients with CRSwNP.17-19

Although these treatment options are promising, limiting factors for widespread use include high costs, the risk of anaphylaxis, and the need for regular subcutaneous injection for administration. Additional studies to classify CRS into different endotypes based on the predominant inflammatory mediators and to identify clinically relevant biomarkers may help develop more effective individualized treatment options in the future.

For more information, visit https://mysinusdoctor.com/. 

References

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  2. Hox V, Bobic S, Callebaux I, Jorissen M, Hellings PW. Nasal obstruction and smell impairment in nasal polyp disease: correlation between objective and subjective parameters. Rhinology 2010;48(4):426-432. https://doi.org/10.4193/rhino10.049
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  6. Stevens WW, Peters AT, Suh L, et al. A retrospective, cross-sectional study reveals that women with CRSwNP have more severe disease than men. Immun Inflamm Dis. 2015;3(1):14-22. https://doi.org/10.1002/iid3.46
  7. Soler ZM, Wittenberg E, Schlosser RJ, Mace JC, Smith TL. Health state utility in patients undergoing endoscopic sinus surgery. Laryngoscope. 2011;121(12):2672-2678. https://doi.org/10.1002/lary.21847
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  9. Han JK, Bosso JV, Cho SH. Multidisciplinary consensus on a stepwise treatment algorithm for management of chronic rhinosinusitis with nasal polyps. Int Forum Allergy Rhinol. 2021;11(10):1407-1416. https://doi.org/10.1002/alr.22851
  10. Palmer JN, Messina JC, Biletch R, Grosel K, Mahmoud RA. A cross-sectional, population-based survey of US adults with symptoms of chronic rhinosinusitis. Allergy Asthma Proc. 2019;40(1):48-56. https://doi.org/10.2500/aap.2019.40.4182
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