Nasal polyps are frequently dealt-with cases in day-to-day practice. Among its different varieties, simple mucus polyps are very common. It has two distinct varieties – ethmoidal and antro-choanal polyps. Almost always, an allergic or infectious etiology is present. Nasal obstruction, rhinitis, headache, loss of smell, snoring, sleep apnea etc. are some of the very disturbing complaints from which the patients suffer. Appropriate diagnosis, correct general measures and judicious homeopathic approach not only uproot the disease, can also prevent recurrence quite effectively.
Keywords: Ethmoidal and Antro-choanal Polyps, Pathology, Allergic Polyp, Infective Polyp, Treatment, Homeopathic Remedies.
Introduction: The para-nasal air sinuses are the cavities within the skull that open into the nose. If the soft tissue lining of the sinuses becomes inflamed, it fills the available space and expands into the nose forming a growth, called polyp (also called ‘mucus retention cysts’). As there are a number of small sinuses between the eye and the nose, when polyps do occur, there will usually be several of them. The tendency to manifest multiple polyps is called polyposis. The word ‘polyp’ (Gr.) actually has been coined from two Greek words – ‘poly’ means many and ‘pous’ means footed.
Definition: Nasal polyp is hypertrophied, pedunculated, loose, fibro-edematous mucosa of nose and the paranasal air-sinuses. The surface is lined with pseudo-stratified ciliated columnar epithelium.
- 0.1% children and 1% adult population is affected.
- Male: Female = 3:1
- Chance of developing is 1-20 in 1000, after the age of 60.
- No racial predilection.
- Ethmoid Polyps: These are better seen on anterior rhinoscopy. These polyps are very common, especially in middle age and in elderly people. These arise from the ethmoid cells and grow towards the anterior nares. There are multiple, bluish-white or grayish, grape-like, pedunculated mass, usually bilateral, coming from the ethmoid area. There may be associated infection (pus) in the meati. Polyps, reaching anterior nares may be pinkish in color due to exposure and squamous metaplasia. Probe test shows soft, mobile, insensitive mass and differentiates from edematous turbinate. In long standing cases, there may be expansion or broadening of the external nose, called ‘frog-face‘, due to large number of polypoid mass coming out through anterior nares.
- Antro-choanal Polyps: These are common among children and adolescents and can be better seen in posterior rhinoscopy. They arise from the maxillary antrum and extend backward to the posterior nares or choana. There is bluish-white smooth polypoid mass coming out of choanal aperture arising from the middle meatus. In advanced cases, polyp may be seen hanging behind soft palate in the oropharynx.
Diagram of sites of origin of nasal polyps
Multiple nasal polyps protruding from the left nostril
As in the picture above, if untreated, nasal polyps may cause gradual widening of the nasal bridge
In some instances, because of obstruction, a bacterial infection sets in and green nasal discharge may be seen trickling around the polyp
Endoscopic view of an ethmoid polyp in the left middle meatus
Etiological factors: Allergy, infection, deviated nasal septum (DNS), chronic rhino-sinusitis, genetic predisposition, autonomic nerve dysfunction, Bernoulli phenomenon etc.
Pathogenic theories: Though inconclusive, names of few accepted theories are given below –
- Adenoma and fibroma theories;
- Necrotizing ethmoiditis theory;
- Glandular cyst theory;
- Glandular hyperplasia theory;
- Mucosal exudates theory;
- Blockade theory;
- Cystic dilatation of the excretory duct and vessel obstruction theory;
- Periphlebitis and perilymphangitis theory;
- New gland formation theory;
- Epithelial rupture theory;
- Ion transport theory.
Etiology: The polyps are the end-product of prolonged allergic edema of the mucosa and sub-mucosa of nose and the para-nasal air-sinuses. The sub-mucosa surrounding the middle meatus is lax and gets filled up with intracellular serous fluid and shows edematous hypertrophy. The mucosal swelling gets aggravated by traction of discharge, poor aeration of the middle meatus, efforts to clear the nose and possible interference with lymphatic flow. The edema blocks the ostium of the ethmoid air-cells and cause secondary bacterial infection. Gravity and narrowness of the meatus promote downward extension and formation of ethmoid polyps. The antro-choanal polyp arises from edematous mucosa of the maxillary sinus near the ostium and grows by edematous hypertrophy through the ostium into posterior part of the nasal cavity and nasopharynx. The ostium is directed backward; so part of the polyp is in the sinus and part in the nose and nasopharynx.
- Infective sinusitis (Streptococcus pneumoniae, Staphylococcus aureus, Bacteroides fragilis, Pseudomonas aeruginosa etc.) (87%);
- Cystic fibrosis / CF (3-48%);
- Sampter’s triad: Aspirin sensitivity + Asthma + Nasal polyps (60%);
- Asthma – allergic/non-allergic (20-50%);
- Fungal sinusitis (80%);
- Kartagener’s syndrome (27%);
- Others; e.g. Churg-Strauss syndrome, non-allergic rhinitis with eosinophilic syndrome (NARES), Young’s syndrome, primary ciliary dyskinesia, selective IgA deficiency, common variable immunodeficiency (CVID), alcohol intolerance, smoking etc.
Histology: The polyps are sac-like structures with an eosinophil-rich edematous wall characterized by goblet cell hyperplasia and thickened basement membrane. Poor blood supply may give them a pale appearance. Histological section also reveals plasma cells, lymphocytes and mast cells. Polypoid tissue is rich in ground substance containing acid mucopolysaccharide.
- Eosinophil contains granules with toxic products (e.g. leukotrienes, eosinophilic cationic protein, major basophilic protein, platelet activating factor, peroxidases, various vasoactive substances and chemotactic factors). These toxic factors are responsible for epithelial lysis, nerve damage and ciliostasis. Specific granule proteins, LTA4 and PAF apparently are responsible for the mucosal swelling and hyper-responsiveness.
- Delayed apoptosis of eosinophils is mediated, in part, by blockage of the Fas receptors, typically by proteases that help begin the process of cell death. Delayed apoptosis is also mediated by an increase in interleukin-5, 3 and GM-CSF secreted by the T-lymphocytes. Glucocorticoids seem to help reduce polyps possibly, in part, by inhibiting IL-5.
- Another inflammatory cell neutrophil occurs in 7% of polyp cases. This type of polyp occurs in association with cystic fibrosis or Young’s syndrome. These polyps do not respond well to corticosteroids because they lack corticosteroid-sensitive eosinophils. Degranulated mast cells are also present. Degranulation presumably occurs in a non-IgE-mediated fashion. Increased number of plasma cells, lymphocytes and myofibroblasts also occur.
- There are various chemical mediators which play important roles in the formation of the polyps; e.g.
ü Cytokines: IL-1, 5 (rarely 3, 4)
ü Immunoglobulins: IgA and E
ü Growth factors: TNF-? and ?, GM-CSF, platelet derived growth factor (PDGF), vascular permeable factors (VPFs), vascular endothelial growth factors (VEGFs), insulin-like growth factor-I (IGF-I), stem cell factor etc.
ü Adhesion molecules: VCAM-1, E and P selectin.
- Nasal obstruction preventing nasal breathing is the chief and persistent symptom. It may be unilateral (common in antro-choanal polyps) or bilateral (found in ethmoid polyps). The obstruction becomes acute following a cold.
- Nasal intonation is often seen.
- Sneezing with rhinorrhea; purulent rhinorrhea may be present in ethmoid polyps due to bacterial super-infection.
- Sensation of post-nasal drip, i.e. something running down the back of throat due to trickling of mucus from the back of large polyps.
- Dull headache, itching around the eyes, hawking and cough are usually present.
- Hyposmia/anosmia; often decreased taste sensation may also be present.
- Snoring and obstructive sleep dyspnea, sometimes apnea.
- Chronic mouth breathing; may lead to recurrent mouth or throat infections.
- Extensive polyposis causing Eustachian tube dysfunction can cause fluid and infection in the middle ear space.
- Occasionally, massive polyps can give rise to cranio-facial structural abnormalities leading to proptosis, hypertelorism (increased intra-orbital distance) and diplopia. Some may grow into the cranial cavity, but they rarely cause neurological signs as their growth is very slow.
- Through examination with nasal speculum to identify the nasal polyps.
- Very large antro-choanal polyps may grow down into the oropharynx and can be visualized with a tongue depressor.
- Flexible rhinoscopy to visualize the nasal cavity and oropharynx and to localize the extent of the polyp.
- X-ray of the sinuses (rarely advised)
- In ethmoid polyps: widening of the ethmoid labyrinth; bilateral antral haziness due to associated maxillary sinus infection; haziness of ethmoid cells.
- In antro-choanal polyps: unilateral opacity of the maxillary antrum.
- CTS of the maxilla-facial area and the nasopharynx
- In ethmoid polyps: haziness of ethmoid cells.
- In antro-choanal polyps: antro-nasal mass extending into nasopharynx.
- MRI Scan, if intra-cranial growth is suspected.
Normal CT sinus showing air within sinus cavities (black), bones (white) and soft tissue (grey);
Abnormal CT sinus showing grey coloration within the sinus cavity, especially on the right side; right maxillary sinusitis with bilateral ethmoidal sinusitis; possibility of presence of polyps in these locations; also deviated septum.
- Children with polyposis that is associated with allergic rhinitis should have an evaluation for their allergies. This may include a serological radioallergosorbent test (RAST) or some form of allergic skin testing.
- A sweat-chloride test or genetic testing for cystic fibrosis in any child with multiple benign nasal polyps may be performed.
- A nasal smear for eosinophils may differentiate allergic from non-allergic cases. Presence of neutrophils may indicate chronic sinusitis.