Clinical Pearls & Morning Reports
Published July 3, 2019
Chronic rhinosinusitis with nasal polyps typically manifests as nasal obstruction, reduction in sense of smell, nasal discharge, and sleep disturbance, with adverse effects on quality of life. Read the latest Clinical Practice article here.
Q: What clinical features raise suspicion for a diagnosis other than idiopathic nasal polyps?
A: The incidence of idiopathic nasal polyps increases with age to a peak in the sixth decade. Nasal polyps are very uncommon before the third decade of life; a diagnosis of polyps in childhood should prompt investigation for cystic fibrosis. Nasal polyps usually occur in both nasal passages, although they may be asymmetric in size; polyps that occur in only one nasal passage should arouse suspicion for benign or malignant tumors, particularly in the presence of bloodstained nasal discharge.
Q: Is biopsy necessary to confirm a diagnosis of nasal polyps?
A: Endoscopy is usually necessary to confirm the diagnosis of nasal polyps, although anterior rhinoscopy may allow large polyps to be visualized. Biopsy is rarely required for diagnostic purposes unless the polyps are observed on only one side. However, histopathological examination may provide useful prognostic information; tissue eosinophilia (>10 cells per high-power field) has been associated with higher rates of recurrence.
A: In patients with mild symptoms, appropriate treatment includes intranasal glucocorticoids and saline irrigation. For moderately or severely symptomatic nasal polyps, clinical experience suggests that intranasal delivery of glucocorticoids may be improved by the use of topical drops or, in patients who have had previous sinus surgery with open cavities, by high-volume irrigations. In patients with severe symptoms or in whom initial treatment has failed to achieve adequate control, a short course of oral glucocorticoids may be considered. The potential long-term harms of repeated short courses of systemic glucocorticoids (including bone loss) must be weighed carefully against potential benefits. Available data suggest that long-term use of antibiotic agents may be considered as an adjunct to treatment in patients with chronic rhinosinusitis with nasal polyps, but further evaluation is needed, including evaluation of the effect on antibiotic resistance. Endoscopic sinus surgery is usually reserved for patients who have not had a benefit from medical therapy with regard to symptoms, patients who have contraindications to or adverse effects from such therapy, or rarely, patients who have actual or impending complications, such as visual loss.
A: In a large binational cohort study, persons who underwent surgery had long-term, large improvements in health-related quality of life that were maintained over a period of 5 years. However, polyp recurrence is common. Recurrent polyps have been reported on endoscopy in 40% of patients 18 months after surgery, and in the large cohort study, 20% of patients underwent a revision sinus procedure within 5 years. Data from randomized trials indicate that postoperative use of intranasal glucocorticoids improves symptom control and endoscopic scores and reduces the need for rescue therapy with prednisolone. Ongoing medical therapy is therefore considered to be an essential part of surgical management, and patients must be counseled appropriately before and after surgery.