Edward Kuan, MD, on an Overview of Nasal Polyps
Nasal polyps are soft growths on the inside of the nose and are very common in the United States. Consulltant360 reached out to Edward Kuan, MD, a rhinologist from the University of California, Irvine, to answer our questions on the clinical characteristics, prevalence, surgery recommendations, and recurrence rates of nasal polyps. Dr Kuan specializes in treating medical and surgical disorders of the nose, sinuses, and skull base.
C360: What are the clinical characteristics of nasal polyps?
Edward Kuan: Nasal polyps are hypertrophic growths of sinonasal mucosa that form along the lining of the paranasal sinuses. They typically result from longstanding inflammation of the mucosa, are most common within the ethmoid sinuses, and when large enough, can result in bothersome symptoms such as nasal obstruction, congestion, loss of sense of smell, facial pressure, and excess mucus production. They can typically be diagnosed on nasal endoscopy, which is a noninvasive procedure conducted in the office, where a camera is placed through the nares to examine the nasal cavity and sinus outflow tracts, or occasionally on imaging, such as computed tomography scans. Polyps can come in all shapes, colors, textures, and sizes, and sometimes may not actually be what it seems, and thus it is important to be precise about diagnosing the underlying problem.
C360: What is the prevalence of nasal polyps among patients with chronic rhinosinusitis, cystic fibrosis, and malignancy? What is their association?
EK: Although there are no hard numbers, approximately 25% to 30% of patients with chronic rhinosinusitis have nasal polyps. This proportion is higher in patients with cystic fibrosis, where nasal polyps can even be found in young children. Nasal polyps typically do not result from malignancy, and there is generally no known elevated cancer risk from nasal polyps, opposed to other types of polyps in the body.
C360: What is the mechanism of action between nasal polyps, allergies, and asthma?
EK: A subtype of chronic rhinosinusitis with nasal polyposis is associated with a higher prevalence of comorbid asthma and atopy. There is a concept known as the “unified airway” where TH2-mediated inflammation affects both the upper and lower airways, which partially explains this relationship. Many patients with both nasal polyps and asthma typically have more severe disease, and this has been correlated to the need for more courses of medical therapy, more sinus surgeries, and more asthma exacerbations. However, on the flip side, patients who receive treatment for nasal polyps may also have improvement in their asthma given overall improved inflammatory control.
C360: What is the association between nasal polyps and sleep quality and obstructive sleep apnea (OSA)?
EK: In general, chronic rhinosinusitis and nasal airway obstruction does not directly lead to OSA; however, poor nasal airflow can certainly affect continuous positive airway pressure device adherence and, therefore, worsen both quality of life and hinder treatment of OSA. There is growing research in the impact of chronic rhinosinusitis on nonphysiologic symptoms, such as sleep, depression, anxiety, and mood, and there is now mounting evidence to suggest that treatment of chronic rhinosinusitis and nasal polyps appears to improve symptoms in those domains as well. It does seem that when patients breathe better and their faces feel less full, they also seem to sleep better.
C360: At what point in the treatment regimen is surgery recommended?
EK: Chronic rhinosinusitis is, overall, a quality-of-life disease. Any otolaryngologist can tell you that they have encountered patients with what appear to be relatively less severe polyps, yet the patient wants surgery today, as well as the patient with polyps growing out of the nose who does not want to pursue any treatment. It really is up to the patient’s level of tolerance and a discussion of goals of treatment.
Typically, treatment begins with medical therapy, which may include nasal saline irrigation, topical nasal corticosteroids, and antibiotics or oral corticosteroid treatment. If the patient’s symptoms persist beyond those treatments, surgery may be part of the next discussion as an escalated form of treatment. It is important to understand that surgery is not a fast fix for nasal polyps, as it merely improves sinus ventilation and the ability for topical medications to access the sinuses, and that adherence to long-term medical therapy is really the goal for optimal control.
C360: What are the recurrence rates of nasal polyps, and how can recurrence be prevented?
EK: Many cases of chronic rhinosinusitis without nasal polyps have excellent surgical outcomes. For chronic rhinosinusitis with nasal polyposis, evidence suggests that the long-term revision rate is between 15% to 25%, and this number may be higher for patients with comorbid asthma or higher-risk subtypes, such as aspirin-exacerbated respiratory disease or allergic fungal rhinosinusitis.1 With the advent of improved topical delivery of medications to the sinuses, which patients can do at home themselves, revision rates have declined, when patients may have used to undergo nasal polyp debulking every couple of years. There are also some exciting new medications called biologics, which can target the inflammatory pathway in specific areas to prevent polyp regrowth or, in some cases, cause them to regress.
- Loftus CA, Soler ZM, Desiato VM, et al. Factors impacting revision surgery in patients with chronic rhinosinusitis with nasal polyposis. Int Forum Allergy Rhinol. 2020;10(3):289-302. https://doi.org/10.1002/alr.22505