What are Nasal Polyps?

This article was first published at SinusDoctor by Dr. G V K Chaitanya Rao, member of American Rhinologic Society (ARS) and European Rhinologic Society (ERS), and has 10+ years of experience in the field of ENT. He is one of the few Indian ENT specialists to have undergone training in Advanced Sinus Surgery at IRCAD Taiwan. His special areas of interest include Nose & sinus surgeries, Otology, Snoring, and Sleep Apnea surgeries. He is the Managing Director of Dr. Rao’s ENT and the best ENT Specialist in Hyderabad.

Are you suffering from Nasal Polyps? Are you looking for Nasal Polyps surgery in India? Let us begin by understanding what are Nasal Polyps?

Nasal polyps are grape-like masses arising from the thin lining which drapes the entirety of the nose and sinuses called nasal mucosa. Just like skin covers our entire outer body, nasal mucosal lining covers the nose and sinuses. Nasal polyps appear smooth and are soft to touch. They are usually benign, which means they are non-cancerous. Patients can have a single polyp or multiple polyps.

What causes nasal polyps?

Nasal polyps are more common in adults than children. However, the exact cause of nasal polyp formation is still unclear and under research.

Nasal mucosal lining, which lines the nose and sinuses, produces mucus that traps bacteria and viruses from the air we breathe. In addition, it humidifies the air and cools or warms the inhaled air to a suitable temperature. To simply put, the nasal mucosal lining is the functional unit of your nose and sinuses.

This nasal mucosal lining swells up and turns in grape-like polyps in response to a specific stimulus. This response to stimulation is not uniform, i.e., not all patients exposing to a stimulus will develop nasal polyps. There is a genetic angle here. These patients who develop nasal polyps have a different immune system response. Also, these patients nasal mucosal lining has an abundance of specific chemical markers and blood cells not found in ordinary people.

The common causes (stimulus) for nasal polyp formation are

Allergic rhinitis and Asthma
Recurring sinus infections
Increased sensitivity to particular pain and inflammation relieving drugs like aspirin
Patients having low vitamin D levels
Children having cystic fibrosis

What are the Symptoms of Nasal Polyps?

Nasal polyps do not produce symptoms when they are small. Instead, they produce discomfort and start causing symptoms when they enlarge in size and block the nasal passageway and sinus drainage pathways.

Five pairs of sinuses are situated around the nose and eyes – Maxillary, Frontal, Ethmoid and Sphenoid sinuses. All these sinuses are draped with sinus mucosal lining and produce a slimy liquid called mucus 24×7. Large Polyps block the sinus drainage pathways through which mucus drains from these sinuses to the back of the nose. Due to the blocked sinus drainage pathways, the mucus produced in the sinuses cannot drain out of them, leading to stasis and eventually causing the mucus to turn into pus. This condition is called chronic sinusitis.

The symptoms experienced by a patient having nasal polyps are

Nose block – Large polyps block the nasal passageways wholly or partially, causing nose block. Patients can experience nasal stuffiness and nasal congestion. Even on repeatedly blowing his nose, the block does not clear.

Facial heaviness, headache – When large polyps block the sinuses, the pus formation inside the sinuses causes bothersome heaviness over the areas where sinuses are located. Heaviness in cheeks, eyebrows, above and behind the head are commonly felt.
Postnasal discharge – Phlegm will be dripping from the back of the nose into the throat. The postnasal discharge causes throat irritation and forces the patient to repeatedly clear his throat.
Altered sense of smell – the patient can experience reduced or total loss of sense of smell. This happens because the polyps physically obstruct the air we breathe from reaching the top of the nose, where nerves that sense smell are situated.

Nose bleeding – blood spots can be seen in the phlegm coming out from the front or back of the nose. Less commonly, continuous nose bleeding can occur.
Mouth breathing – Patients having polyps blocking their nasal passageway compensate by mouth breathing.
Snoring – Because of nose block and mouth breathing, patients with nasal polyps can have snoring. Few of these patients experience trouble sleeping and can have associated obstructive sleep apnea.
Allergic symptoms – Polyps are very common in patients having allergies. Allergic patients experience recurrent sneezing, itching in the nose, watery discharge from the nose along with the above symptoms.
Increase in frequency and severity of asthmatic attacks can be seen in asthmatic patients with nasal polyps.

Diagnosis of Nasal Polyps

Detailed patient history: Your ENT doctor will take a thorough history regarding your symptoms, their severity, and duration. The focus will be on ascertaining allergy and asthma history and specifically allergic to NSAIDS/ pain-relieving medications.
Headlight examination: He will examine your nose under the headlight. Large polyps situated in the front of the nose can be visualized easily with this simple examination.
Nasal endoscopy: To visualize polyps situated in the back of the nose and get a wholesome understanding of your nose and sinus disease, He may perform a nasal endoscopy. During nasal endoscopy, a rod or fibre endoscope fitted with a camera and light is gently advanced from the front of the nose to the back, and all the crucial areas are examined in detail.
CT scan of nose and sinuses: A CT scan of the nose and sinuses is commonly done in patients with nasal polyps to know the extent of sinuses involvement and notice any destruction/ displacement of bony boundaries between nose sinuses and orbit, brain. Such destruction is seen in patients having cancers and other similar conditions presenting as nasal polyps.
MRI of nose and sinuses: MRI nose and sinuses will be advised for such doubtful presentations.

Allergy testing: Allergy skin prick test or allergy panel blood test is done in patients with co-existing allergies to single out the allergens causing allergy symptoms.
Blood tests: Blood tests to determine the vitamin D levels can be recommended as low vitamin D levels in the blood can
Genetic testing: Genetic tests will be ordered in children having nasal polyps to diagnose cystic fibrosis

Complications of Nasal Polyps

If nasal polyps are not treated adequately, it can lead to

Recurrent sinus infections – With polyps blocking the sinus drainage pathways, recurrent sinus infections are prevalent.
Increase in frequency and severity of asthmatic attacks – Like the nose, i.e., the air filter of our body is blocked, asthmatic patients breathe through the mouth, which provokes the asthmatic attacks. Also, the postnasal drip, which drops from the back of the nose into the throat in nasal polyps patients, can initiate asthmatic attacks. The mucosal lining of the nose and lining of the lungs are connected, making it “one continuous airway”, and the disease affecting one can affect the other.

Sleep apnea – Sleep apnea of obstructive type in which the patient ceases to breathe for a few seconds during sleep. These are called apneic spells, and this condition can cause dangerous consequences if left untreated.

Prevention of Nasal Polyps

The below measures can be followed to avoid nasal polyps formation and prevent recurrence of nasal polyps in a patient already treated for nasal polyps.

Keeping allergies under check: The allergies and asthmatic attacks must be treated adequately. Allergen identification, avoidance, and regular use of nasal sprays and inhalers recommended by your ENT doctor/ Pulmonologist must be strictly followed. In case of inadequate response to prescribed medications, doctor review and step-up medication must be sought.
Saline sprays: Saline sprays like Netiwash and Solspre can be used regularly in patients at risk of developing nasal polyps. These saline sprays wash away the allergens depositing in the nose and reduces the allergy burden.

Humidification: Dry air irritates the nose, causing the nasal mucosal lining to swell, predisposing it to polyp formation. So, during dry seasons humidifiers must be used. Nowadays, air purifiers are being sold with humidifiers. These can play a dual role in removing allergens from the air and humidifying the air together.
Irritant avoidance: Like dry weather, tobacco smoke (active or passive), strong smells, dust, chemical fumes can irritate the nose and cause the nasal mucosal lining to swell. Avoiding continuous exposure to them is recommended.

How are Nasal Polyps treated?

Nasal polyposis treatment begins with medical management, allergy treatment and progresses to surgical management.

Nasal steroid sprays: Your ENT doctor will prescribe nasal corticosteroid sprays to reduce the inflammation, swelling of your nasal mucosal lining. The nasal polyps on which the steroid spray mist settles shrink in size. Therefore, these sprays are more effective in the early stages of the disease. Nasal steroid sprays can be of different types – Fluticasone (Allegra nasal spray, Nazobic nasal spray etc.), Mometasone (Nasonex nasal spray, MMTS nasal spray etc.). These nasal sprays are sometimes sold as combination sprays where nasal antihistamine spray is combined with a steroid spray, e.g., Duonase, Furamist AZ.
Oral steroids: Oral steroids play a similar role to nasal sprays. These medications can be more effective for reducing the size of large polyps. Oral steroids can only be used in short bursts in a tapering fashion under strict doctor supervision. Oral steroid usage is to be avoided in diabetics, hypertensives and patients having gastric and cardiac issues. Examples of oral steroids include prednisolone (Wysolone, Omnacortil etc.), deflazacort (Medcort, Cortimax etc.)
Injectable corticosteroids: Injectable corticosteroids can be administered in patients having severe nasal polyposis. Also, it can help in reducing bleeding and reduce the operating time when administered before surgery.
Antihistamines, antibiotics, and saline sprays: are commonly recommended in patients with nasal polyps to reduce allergy-induced swelling and fight the co-existing sinusitis infection.

Allergy management: Patients with allergies must undergo allergy skin prick test or IgE allergy blood tests to identify allergens causing them. Once identified, allergen exposure can be avoided or reduced. In addition, allergy management is crucial for preventing polyp formation and preventing recurrence of polyps in patients who are on medical management or underwent surgery for polyps.

Immunotherapy can provide long-lasting relief for specific allergies and is being regularly done in Sinus Doctor clinics.

Along similar lines to immunotherapy, Aspirin desensitisation can be administered for patients having aspiring sensitivity. In this treatment, gradually higher doses of aspirin are administered under allergy specialist supervision to desensitise the patient.

Surgical management of nasal polyps

As we have explained above the various ways to of treatment of nasal polyps without surgery, let us deep dive into surgically managing nasal polyps. We will now explain in detail about nasal polyps surgery in India.

Endoscopic sinus surgery and polypectomy (polyp removal) is one of the mainstay treatments for large polyps involving multiple sinuses. During this procedure, your ENT surgeon uses an endoscope to visualise the nose and sinuses. He will remove all the polyps using a micro shaver system that shaves off the polyps while preserving the nasal mucosal lining from which these polyps arise. The drainage pathways of all the involved sinuses are widened, and any polyps within the sinuses are removed. This procedure is usually done under general anaesthesia. Some of the polyp tissue removed during surgery is sent for biopsy for further confirmation of the disease.

Success rate of Nasal Polyps surgery

The success rate of nasal polyps surgery will depend on how well the underlying factor which caused polyp formation in the first place is managed. If the underlying factors are addressed well, the patient with nasal polyps will have long-lasting relief after undergoing surgery. Allergy management, i.e., allergen identification, avoidance and adequate medical management, is critical. Long-term nasal steroid spray and saline spray usage may be recommended. Immunotherapy and aspirin desensitisation are promising treatments that can reduce dependence on antiallergic medications. Vitamin D levels in the blood should be monitored once every six months and supplemented if deficient.

Recovery time from Nasal Polyps surgery

Recovery time after nasal polyps surgery is similar to any other nose and endoscopic sinus surgery. Nasal polyps surgery is done under general anaesthesia. After surgery, the patient will be monitored in a step-down unit for up to six hours. He will then be shifted to his room in which he will be kept under observation overnight and discharged the next day. Patient can resume his regular office works from the time of his discharge. Bloody nasal discharge and nasal congestion are common complaints after polyp removal surgery. The patient can drive himself home after discharge. Oral antibiotics, oral antihistamines, oral steroids, nasal saline rinses and nasal steroid sprays are commonly prescribed after surgery. In addition, pain killers, antacid and probiotics may be advised. Patient is advised not to undertake strenuous activities, flight journey up to 20-30 days after surgery.

Nasal Polyps Surgery Follow up

Follow up after nose and sinus surgery is crucial for optimal surgery results. Ten days after surgery, the patient will have to undergo nasal endoscopy and cleaning in the operating room. During this visit, the patients nose will be locally anaesthetised by placing lignocaine soaked nose packs. Crusts and nasal discharge accumulating in the nose and sinuses are cleared. This procedure will take up to half an hour. Following the procedure, the patient is observed for one to two hours, after which he will be discharged. Two more visits at ten-day intervals are advised.

Your ENT doctor will examine how your nose is healing in his OPD and perform simple nose cleaning when necessary. Further visits will depend on the status of healing of the nose and sinuses assessed during review visits.

Hope we could explain in detail about Nasal Polyps surgery in India. To know more about treatment options for nasal polyps without surgery and nasal polyps surgery cost in India, get an appointment with best Sinus Doctor in India, Dr G V K Chaitanya Rao.

Dr GVK Chaitanya Rao

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