​Kembara Xtra - Medicine - Nasal Polyps

​Kembara Xtra - Medicine - Nasal Polyps 
Chronic benign inflammatory lesions of the nasal mucosa can occasionally develop in the maxillary sinus mucosa but typically begin close to the ethmoid sinus.The nasal cavity or the paranasal sinuses may appear edematous or have a pedunculated mass, which frequently results in blockage, discharge, or a loss of smell.
 When bilateral, malignancy should be on the differential; when unilateral, it should not be.

The average age of diagnosis is between 40 and 60 years old, and incidence rises with age to reach a peak in the sixth decade.
Prevalence: 0.1% in children and related with cystic fibrosis; 4% in the general population; up to 65% of patients have asthma.

Pathophysiology and Etiology 

Separate pathways driven by T helper 1 and T helper 2 White patients with chronic rhinosinusitis and nasal polyps: The majority exhibit type 2 inflammation.
- Eosinophilia and increased levels of the cytokines interleukin-4, interleukin-5, and interleukin-13 are present.

Genetics
More nasal polyp patients than controls report having a first-degree family who has the condition.


Risk Elements 
Nasal polyps are more common among textile workers who have been exposed to occupational dust, especially those who have had longer exposure times.


Basic Prevention 
After polyp ectomy surgery, using intranasal corticosteroids has proven successful in preventing recurrence.


Asthma, bronchiectasis, aspirin sensitivity, allergic rhinitis, chronic sinusitis, allergic fungal sinusitis, cystic fibrosis (in children), primary ciliary dyskinesia (Kartagener syndrome), laryngopharyngeal reflux, and sleep apnea are all conditions that are related to each other.


Diagnosis 
based on the observation of polyps in the nasal cavity and the presence of sinonasal symptoms for more than three months.

History symptoms include dull headaches, facial pain/pressure over the center third of the face, rhinorrhea, nasal congestion, postnasal discharge, hyposmia/anosmia, and sleep disturbances.
There might not always be any symptoms.


clinical assessment 
No other physical exam findings other than rhinorrhea, sinus pain to palpation, and/or polyp visibility are conclusive.

Differential diagnoses include rhinitis, structural issues with the nose, chronic rhinosinusitis without nasal polyps, and neurologic causes of hyposmia.
 Additional benign or cancerous tumors. such as encephalocele, fibroma, hemangioma, osteoma, and chondroma
Malignant melanoma and squamous cell carcinoma


Laboratory Results 

Initial examinations (lab, imaging) reveal a pale, transparent mass, most frequently on the lateral wall of the middle meatus.


Tests in the Future & Special Considerations
If there are significant posterior nasal polyps, check the tympanic membrane for a dysfunctional Eustachian tube.
If a polyp is unilateral, a histologic examination may be used to rule out cancer.
Children with polyps should be tested for cystic fibrosis.
A sinus CT scan may be useful to confirm endoscopic and historical findings.
Inability to distinguish a polyp from other soft tissue lumps; reveals the depth of the disease; and requires the development of a strategy for surgical intervention, if necessary
MRIs can help with diagnosis if there is a possibility of neoplasia, mycetoma, or encephalocele.
Flexible/rigid endoscopy is essential for a thorough evaluation of the nasal cavity in diagnostic procedures/other.
Diagnostic gold standard

Management 

Because nasal polyps can clog the nasal cavity and impair sense of smell, impede the capacity to breathe through the nose, and obstruct sinus drainage, the goal is to minimize their size or eliminate them.

First Line of Medicine
First-line treatment involves using daily intranasal corticosteroids along with saline irrigation.
For one to three months, intranasal saline and intranasal glucocorticoids can be given to patients who do not have considerable nasal stenosis caused by polyps.
 Intranasal corticosteroids have been demonstrated to reduce the growth of nasal polyps, reduce sinonasal symptoms, and enhance quality of life.
- Budesonide 256 mg/day (two 64 mg nasal sprays each day)
- Beclomethasone dipropionate 1 to 2 sprays per nostril twice daily, 168 to 320 mg
- Fluticasone propionate 400–744 mg/day (1–2 sprays twice daily per nostril)
- 400 mg of mometasone furoate twice daily (2 sprays per nostril).
Mometasone furoate is recommended for use in children.

Next Line

Consider a brief course of oral corticosteroids (14 to 21 days) and/or doxycycline (21 days) in individuals with severe symptoms or those who cannot take intranasal steroids.
 Prednisone 30 to 50 mg per day, tapering as needed
 20–60 mg of prednisolone daily, tapering as neededDoxycycline 200 mg once, then 100 mg every day


Consider referral to otorhinolaryngologist for endoscopic sinus surgery if severe blockage symptoms or conservative therapy are ineffective if unilateral polyp for biopsy assessment.

Further Therapies 

Consider using a systemic antihistamine, a leukotriene pathway blocker, allergy immunotherapy, or biologics for patients with ongoing symptoms and concurrent allergic rhinitis.
Adding dupilumab to daily mometasone furoate nasal spray reduced polyp size, sinus opacification, and symptom severity; it was well-tolerated and decreased systemic corticosteroid medication and surgery, according to two multicentered randomized double-blinded studies. Dupilumab inhibits interleukin-4 and interleukin-13, which is how it works.
- Dupilumab also reduced asthmatic patients' concomitant symptoms and lung function.
- Omalizumab and mepolizumab are two other biologics that are effective and/or provide symptom alleviation.

Surgical Techniques 
The majority of procedures are performed endonasally. For more challenging patients, the external (Caldwell-Luc) technique is used, however there is a larger risk of complications.
Compared to intranasal polypectomy, functional endonasal sinus surgery had a somewhat lower risk of revision. Both treatments effectively reduce symptoms.
The administration of nasal corticosteroids postoperatively delays the return of nasal polyps and, consequently, the need for revision surgery.
 Postoperative use of steroid-releasing stents to reduce mucosal inflammation and prevent polyp recurrence

Recurrence up to 40% with Continuous CareAfter polyp ectomy surgery, using intranasal corticosteroids has proven successful in preventing recurrence.
Recurrence is twice as probable in asthmatics.

Prognosis Surgery patients experience significant relief in their symptoms, but the risk of recurrence is substantial.


Complications include the possibility of heterotrophic bone growth within the sinus cavity and acute or persistent sinus infections.

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