Nasal Polyps and Chronic Hypertrophic Sinusitis
Nasal polyps most commonly refer to pale looking tumor like growths that arise from the mucosal surface of the nose and sinuses. Patients who have these are often diagnosed with chronic sinusitis and nasal polyposis. Those who tend to form thick “peanut butter” like secretions with stringy, tenacious mucus with polypoid mucosal changes may have allergic fungal rhinosinusitis. Those who have nasal polyposis or allergic fungal sinusitis have “chronic hypertrophic sinusitis”.
NORMAL SINUS CT SCAN
So what is chronic hypertrophic sinusitis and how is this different from the “normal” sinus disease? Acute sinusitis refers to a sinus infection that lasts less than 4 weeks. Symptoms may include nasal congestion and obstruction, discolored rhinorrhea (nasal discharge), facial pain and pressure, headache, sore throat, cough, decreased sense of smell, foul nasal odor, and fever. These symptoms tend to get worse after 5 days or persist beyond 2 weeks without treatment. (A cold or upper respiratory illness caused by a virus tends to get better after 5 days with most symptoms resolving within 2 weeks.)
Chronic sinusitis is characterized by any of the following symptoms that last longer than 3 months: nasal congestion, nasal obstruction, decreased sense of smell, facial pain or pressure, foul odor, and possibly headache when associated with one of these other symptoms. These individuals may have had recurrent sinusitis (more than 3 episodes of acute sinusitis per year) in the past and now simply cannot breathe as well as they used to. Often this may initially manifest with night-time nasal obstruction or increased nasal resistance leading to less restful sleep and morning fatigue. These individuals may have increased headache, ear pain, or discomfort. Others may have a “sinus” infection that never goes away. Others may simply think that they now have “allergies”.
Chronic sinusitis can be treated surgically resulting in a significant improvement in or resolution of symptoms. This treatment may be done in the office (See balloon sinuplasty) or the operating room. If allergic and/or nonallergic rhinitis are persistent issues then these will need to be treated with consistent medical therapy. Predisposing factors to chronic sinusitis may be anatomical (openings to the sinuses are too small or have become narrowed by inflammation), recurrent infection, and inflammation from untreated allergic or nonallergic rhinitis. Allergic and nonallergic rhinitis are significant problems that people in the dfw area deal with.
Chronic hypertrophic sinusitis describes a condition where the mucosal surface reacts abnormally. This results in thick inspissated secretions, nasal edema (swelling), mucosal hypertrophy (excessive mucosal tissue thickening), and nasal polyps. What would cause the tissue to react this way? Several theories exist. One is that certain fungi (mold) that land on the mucosal surface cause a “reaction”. This reaction is unnecessary and self-destructive. It may be a typical allergy reaction. This can be measured with allergy testing and often improved with immunotherapy (injections or sublingual (SLIT). It may also be an atypical “allergy” reaction. This cannot be measured with available testing. Other theories include Staph superantigens which may disrupt the body’s immune system causing dysfunction leading to hypertrophic disease.
ABNORMAL SINUS CT SCAN
NASAL POLYP DISEASE
Patients who have chronic hypertrophic sinusitis (the nasal polyp group) historically have endured multiple sinus surgeries. This may be every 6 months to every 10 years. Fortunately, medical treatment now exists to make this much less necessary. Patients may present with completely occluded sinuses and nasal passageways. Initial medical therapy to prepare the individual for surgery may include a course of steroids, antibiotics, and nasal steroid sprays. After surgery, where all disease and diseased tissue has been removed and access to involved sinuses achieved; topical medical therapy in the form of topical rinses, nebulizer treatments, and/or nasal steroid spray is necessary to maintain a disease-free state. For patients who have positive allergy testing to fungi, immunotherapy (injections or SLIT) can also be very helpful. Post surgery endoscopic debridement procedures are absolutely necessary to maintain an environment where sinuses can heal properly. Medicated solution can be instilled into sinuses if necessary during these procedures. After the sinuses have fully healed and the disease state reduced to a minimum, long-term medical maintenance therapy in some form (medicated topical rinse and/or nasal nebulizer, nasal steroid spray) is necessary to maintain healthy mucosal tissue. Ongoing followup visits where nasal endoscopy can be performed to thoroughly examine the state of health of the mucosal surface is absolutely necessary to maintain a disease-free state. These may be performed at 6 month to 1 year intervals after a healthy-state is reached 3 to 6 months after surgery. Often patients do not become symptomatic for months to years after changes can be seen to the mucosal surface endoscopically. Endoscopic surveillance greatly reduces the chance of needing further surgery.
Chronic hypertrophic sinusitis can be a very frustrating disease for some patients. Treatment often seems inadequate and multiple surgeries have historically been the norm. But it doesn’t have to be that way. I have treated many patients with this disease successfully. Success is not always easy to achieve, but it can be achieved. Good surgical technique, proper after surgical care, and ongoing medical management with endoscopic surveillance is a must. All of this is provided by my practice.