Nasal Polyps

What are nasal polyps?

Have you ever felt like you have a cold that doesn’t go away? Nasal congestion that doesn’t seem to stop, even with over-the-counter cold or allergy medication, may be due to nasal polyps.

Nasal polyps are benign (noncancerous) growths of the lining tissues, or mucosa, of your nose.

Picture of nasal polyps

What are the causes of nasal polyps?

Nasal polyps grow in inflamed tissue of the nasal mucosa. The mucosa is a very wet layer that helps protect the inside of your nose and sinuses and humidifies the air you breathe. During an infection or allergy-induced irritation, the nasal mucosa becomes swollen and red, and it may produce fluid that drips out. With prolonged irritation, the mucosa may form a polyp. A polyp is a round growth (like a small cyst) that can block nasal passages.

Although some people can develop polyps with no previous nasal problems, there’s often a trigger for developing polyps. These triggers include:

• chronic or recurring sinus infections
• asthma
• allergic rhinitis (hay fever)
• cystic fibrosis
• Churg-Strauss syndrome
• sensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin

There may be a hereditary tendency for some people to develop polyps. This may be due to the way their genes cause their mucosa to react to inflammation.

What are the symptoms of nasal polyps?

Nasal polyps are soft, painless growths inside the nasal passages. They often occur in the area where the upper sinuses drain into your nose (where your eyes, nose, and cheekbones meet). You may not even know that you have polyps because they lack nerve sensation.

Polyps can grow large enough to block your nasal passages, resulting in chronic congestion. Symptoms can include:

• a sensation that your nose is blocked
• runny nose
• postnasal drip, which is when excess mucus runs down the back of your throat
• nasal stuffiness
• nasal congestion
• reduced sense of smell
• breathing through your mouth
• a feeling of pressure in your forehead or face
• sleep apnea
• snoring

Pain or headaches may also occur if there’s a sinus infection in addition to the polyp.

How are nasal polyps diagnosed?

A nasal polyp will likely be visible if your doctor looks up into your nasal passages with a lighted instrument called an otoscope or nasoscope. If the polyp is deeper in your sinuses, your doctor may need to perform a nasal endoscopy. This procedure involves your doctor guiding a thin, flexible tube with a light and camera at the end into your nasal passages.

A CT scan or MRI scan may be necessary to determine the exact size and location of the polyp. Polyps show up as opaque spots on these scans. Scans can also reveal whether the polyp deformed the bone in the area. This can also rule out other kinds of growths that may be more medically serious, such as structural deformities or cancerous growths.

Allergy tests can help doctors determine the source of persistent nasal inflammation. These tests involve making tiny skin pricks in your skin and depositing the liquid form of a variety of allergens. Your doctor will then see if your immune system reacts to any of the allergens.

If a very young child has nasal polyps, tests for genetic diseases, such as cystic fibrosis, may be necessary.

What treatments are available for nasal polyps?

Medications

Medications that reduce inflammation may help reduce the size of the polyp and relieve symptoms of congestion.

Spraying nasal steroids into the nose can reduce your runny nose and the sensation of blockage by shrinking the polyp. However, if you stop taking them, symptoms may quickly return. Examples of nasal steroids include:

• fluticasone (Flonase, Veramyst)
• budesonide (Rhinocort)
• mometasone (Nasonex)

An oral or injectable steroid, such as prednisone, may be an option if nasal sprays don’t work. These aren’t a long-term solution due to their serious side effects, including fluid retention, increased blood pressure, and elevated pressure in the eyes.

Antihistamines or antibiotics may also treat allergies or sinus infections caused by inflammation in the nose.

Surgery

If your symptoms still aren’t improving, surgery can remove the polyps completely. The type of surgery depends on the size of the polyp. A polypectomy is an outpatient surgery done with a small suction device or a microdebrider that cuts and removes soft tissue, including the mucosa.

For larger polyps, your doctor can perform an endoscopic sinus surgery using a thin, flexible endoscope with a tiny camera and small tools on the end. Your doctor will guide the endoscope into your nostrils, find the polyps or other obstructions, and remove them. Your doctor may also enlarge the openings to your sinus cavities. This type of surgery is an outpatient procedure most of the time.

After surgery, nasal sprays and saline washes can prevent polyps from returning. In general, reducing the inflammation of the nasal passages with nasal sprays, anti-allergy medications, and saline washes can help prevent nasal polyps from developing.

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Allergic Rhinitis

Allergic rhinitis is a diagnosis associated with a group of symptoms affecting the nose. These symptoms occur when you breathe in something you are allergic to, such as dust, animal dander, or pollen. Symptoms can also occur when you eat a food that you are allergic to.

This article focuses on allergic rhinitis due to plant pollens. This type of allergic rhinitis is commonly called hay fever or seasonal allergy.

Causes

An allergen is something that triggers an allergy. When a person with allergic rhinitis breathes in an allergen such as pollen, mold, animal dander, or dust, the body releases chemicals that cause allergy symptoms.

Hay fever involves an allergic reaction to pollen.

Plants that cause hay fever are trees, grasses, and weeds. Their pollen is carried by the wind. (Flower pollen is carried by insects and does not cause hay fever.) Types of plants that cause hay fever vary from person to person and from area to area.

The amount of pollen in the air can affect whether hay fever symptoms develop or not.

• Hot, dry, windy days are more likely to have a lot of pollen in the air.
• On cool, damp, rainy days, most pollen is washed to the ground.

Hay fever and allergies often run in families. If both of your parents have hay fever or other allergies, you are likely to have hay fever and allergies, too. The chance is higher if your mother has allergies.

Symptoms

Symptoms that occur shortly after you come into contact with the substance you are allergic to may include:

• Itchy nose, mouth, eyes, throat, skin, or any area
• Problems with smell
• Runny nose
• Sneezing
• Watery eyes

Symptoms that may develop later include:

• Stuffy nose (nasal congestion)
• Coughing
• Clogged ears and decreased sense of smell
• Sore throat
• Dark circles under the eyes
• Puffiness under the eyes
• Fatigue and irritability
• Headache    

Exams and Tests

The health care provider will perform a physical exam and ask about your symptoms. You will be asked whether your symptoms vary by time of day or season, and exposure to pets or other allergens.

Allergy testing may reveal the pollen or other substances that trigger your symptoms. Skin testing is the most common method of allergy testing.

If your doctor determines you cannot have skin testing, special blood tests may help with the diagnosis. These tests, known as IgE RAST tests, can measure the levels of allergy-related substances.

A complete blood count (CBC) test, called the eosinophil count, may also help diagnose allergies.

Treatment

LIFESTYLE AND AVOIDING ALLERGENS

The best treatment is to avoid the pollens that cause your symptoms. It may be impossible to avoid all pollen. But you can often take steps to reduce your exposure.

You may be prescribed medicine to treat allergic rhinitis. The medicine your doctor prescribes depends on your symptoms and how severe they are. Your age and whether you have other medical conditions, such as asthma, will also be considered.

For mild allergic rhinitis, a nasal wash can help remove mucus from the nose. You can buy a saline solution at a drug store or make one at home using 1 cup (240 milliliters) of warm water, half a teaspoon (3 grams) of salt, and pinch of baking soda.

Treatments for allergic rhinitis include:

ANTIHISTAMINES

Medicines called antihistamines work well for treating allergy symptoms. They may be used when symptoms do not happen often or do not last long. Be aware of the following:

• Many antihistamines taken by mouth can be bought without a prescription.
• Some can cause sleepiness. You should not drive or operate machines after taking this type of medicine.
• Others cause little or no sleepiness.
• Antihistamine nasal sprays work well for treating allergic rhinitis. Ask your doctor if you should try these medicines first.

CORTICOSTEROIDS

• Nasal corticosteroid sprays are the most effective treatment for allergic rhinitis.
• They work best when used nonstop, but they can also be helpful when used for shorter periods of time.
• Corticosteroid sprays are generally safe for children and adults.
• Many brands are available. You can buy three brands without a prescription. For all other brands, you will need a prescription from your doctor.

DECONGESTANTS

• Decongestants may also be helpful for reducing symptoms such as nasal stuffiness.
• Do not use nasal spray decongestants for more than 3 days.

OTHER MEDICINES

• Leukotriene inhibitors are prescription medicines that block leukotrienes. These are the chemicals the body releases in response to an allergen that also trigger symptoms.

ALLERGY SHOTS

Allergy shots (immunotherapy) are sometimes recommended if you cannot avoid the pollen and your symptoms are hard to control. This includes regular shots of the pollen you are allergic to. Each dose is slightly larger than the dose before it, until you reach the dose that helps control your symptoms. Allergy shots may help your body adjust to the pollen that is causing the reaction.

SUBLINGUAL IMMUNOTHERAPY TREATMENT (SLIT)

Instead of shots, medicine put under the tongue may help for grass and ragweed allergies.

Outlook (Prognosis)

Most symptoms of allergic rhinitis can be treated. More severe cases need allergy shots.

Some people, especially children, may outgrow an allergy as the immune system becomes less sensitive to the trigger. But once a substance, such as pollen, causes allergies, it often continues to have a long-term effect on the person.

When to Contact a Medical Professional

Call for an appointment with your provider if:

• You have severe hay fever symptoms
• Treatment that once worked for you no longer works
• Your symptoms do not respond to treatment

Prevention

You can sometimes prevent symptoms by avoiding the pollen you are allergic to. During pollen season, you should stay indoors where it is air-conditioned, if possible. Sleep with the windows closed, and drive with the windows rolled up.

Alternative Names

Hay fever; Nasal allergies; Seasonal allergy; Seasonal allergic rhinitis; Allergies - allergic rhinitis; Allergy - allergic rhinitis

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EPISTAXIS (NOSEBLEEDS)

INTRODUCTION
Epistaxis is defined as bleeding from the nostril, nasal cavity, or nasopharynx. Nosebleeds are due to the bursting of a blood vessel within the nose. This may be spontaneous or caused by trauma. Nosebleeds are rarely life threatening and usually stop on their own. Nosebleeds can be divided into 2 categories, based on the site of bleeding: anterior (in the front of the nose) or posterior (in the back of the nose).

Approximately 60% of the population will be affected by epistaxis at some point in time, with 6% requiring professional medical attention. The cause of nosebleeds are typically idiopathic (unknown), but they may also result from trauma, medication use, tumors, or nasal/sinus surgery.

Treatment of epistaxis may include the use of local pressure (ie pinching the nose - low over the fleshy portion, not high over the bony portion), decongestant nasal sprays, chemical or electric cautery (burning the vessel shut), hemostatic agents (topical therapies to stop bleeding), nasal packing, embolization (a procedure to place material within the vessel to block it off), and surgical arterial ligation (tying off the vessel). There is no single definitive treatment for the management of nosebleeds and many factors including severity of the bleeding, use of anticoagulants, and other medical conditions can play a role in which treatment is utilized.


ANATOMY
The nasal cavity is extremely vascular, meaning it has a large blood supply. Blood is supplied via both the internal and external carotid systems. The major blood arteries in the nasal cavity include the anterior and posterior ethmoid arteries and the sphenopalatine arteries. Over 90% of nose bleeds occur in the anteroinferior (front bottom) nasal septum (wall that divides your nose between left and right sides) in an area known as Kiesselbach’s plexus, named after Wilhelm Kiesselbach, a German otolaryngologist. Keisselbach's plexus is located over the anterior nasal septum and is formed by anastomoses (coming together) of 5 arteries:

• Anterior ethmoidal artery (from the ophthalmic artery) (Figure 1)
• Posterior ethmoidal artery (from the ophthalmic artery)
• Sphenopalatine artery (terminal branch of the maxillary artery) (Figure 2)
• Greater palatine artery (from the maxillary artery)
• Septal branch of the superior labial artery (from the facial artery)

Approximately 5% to 10% of epistaxis is estimated to arise from the posterior nasal cavity, in an area known as Woodruff’s plexus. Woodruff's plexus is located over the posterior middle turbinate and is primarily made up of connection of branches of the internal maxillary artery, namely, the posterior nasal, sphenopalatine, and ascending pharyngeal arteries. Posterior bleeds usually originate from the lateral wall and more rarely from the nasal septum.

Figure 1: Endoscopic View of the Anterior Ethmoid Artery. Image courtesy of Drs. Alexander Chiu, MD and James N. Palmer, MD.

Figure 2: Endoscopic View of the Nasal Septal Artery. Legend: ST: Septum, NS: Nasal Septum, *: Nasal Septal Branch of the Sphenopalatine Artery. Image courtesy of Dr. Vijay Ramakrishnan, MD.

ETIOLOGY
Causes of epistaxis can be divided into local causes (eg, trauma, mucosal irritation, septal abnormality, inflammatory diseases, tumors), systemic causes (eg, blood disorders, arteriosclerosis, hereditary hemorrhagic telangiectasia), and idiopathic (unknown) causes. Local trauma is the most common cause; followed by facial trauma, foreign bodies, nasal or sinus infections, and prolonged inhalation of dry air. Tumors and vascular malformations are also important causes of nose bleeds. Epistaxis is also associated with septal perforations (holes in the nasal septum). 

Local Factors
Trauma or injury to the turbinate mucosa and septum is a frequent cause of epistaxis. Nose picking and repeated irritation caused by the tips of nasal spray bottles commonly give rise to many anterior bleeds. Certainly, traumatic deformation and fractures of the nose and surrounding structures can cause bleeding. Another common cause of nosebleeds is due to infection and mucosal inflammation. Sinusitis, upper respiratory tract infections, and allergies can damage the respiratory lining to the point that it becomes irritated. Additionally, septal deviations (bends in the wall that divides the nose between two sides), nasal fractures, and septal perforations (holes through the septum) can be a cause of irregular nasal airflow causing dryness and bleeding in some cases. Causes due to medical treatment such as after endoscopic sinus surgery, skull base surgery, and orbital surgery can also be a cause of severe epistaxis. 

Tumors of the nasal cavity, sinuses, and nasopharynx can also give rise to recurrent bleeding. In general, recurrent one sided nosebleeds should be evaluated by endoscopy (scoping) with or without imaging studies to screen for a tumor.

Systemic Factors
Hypertension, hereditary hemorrhagic telangiectasia, use of anticoagulants such as aspirin, clopidogrel, warfarin, and a variety of conditions causing vasculitis such as Wegener’s granulomatosis are common systemic factors associated with epistaxis. Epistaxis is also associated with blood disorders, patients with lymphoproliforative disorders, immunodeficiency, and liver failure. Thrombocytopenia (low platelet levels) is associated with nasal bleeding. There can be spontaneous mucous membrane bleeding at platelet levels of 10-20,000. Platelet deficiency can also result from use of chemotherapy, antibiotics, malignancies, hypersplenism, and some drugs. Platelet dysfunction can occur in patients with liver failure, kidney failure, vitamin C deficiency and in patients taking aspirin and NSAIDs. 

Clotting factor abnormalities can result in frequent, recurring epistaxis. Bleeding disorders such as Von Willabrand’s disease (most common), Factor VIII deficiency (Hemophilia A), Factor IX deficiency (Hemophilia B), and Factor XI deficiency are all common primary coagulopathies. Additionally, patients with recurrent nosebleeds should be questioned about the use of complementary and alternative medicines such as Ginkgo Biloba and Vitamin E, which may increase their risk of bleeding.

TREATMENT
Direct pressure is usually effective for stopping epistaxis by applying pressure to the front of the nose. Nasal decongestants such as oxymetazoline or neosynephrine may also be used. Gently applying Vaseline or other ointment to the front of the nose with a Q-tip on a daily basis helps to moisturize the nose and prevent nose bleeds due to dryness. It is also very important to avoid any trauma to the nose after a nose bleed by picking healing scabs or blowing the nose too aggressively. 

Chemical cauterization with silver nitrate is also used for control of epistaxis not controlled by local application of pressure. When these methods are not effective, anterior or posterior packing might be necessary. Packing can be absorbable or non-absorbable.

For complicated nose bleeds, another method of treatment is angiographic embolization of the internal maxillary artery. It has a success rate of 71% to 95%, but the procedure carries risk of stroke, ophthalmoplegia (limitation of eye movement), facial nerve palsy (not being able to move half the face), and hematomas (blood clots) at the catheterization site. Also revascularization (reopening of the blood vessel) after embolization is not uncommon. 

Direct surgical ligation or clipping is an increasing popular alternative to embolization. The traditional approach for ligation of the anterior and posterior ethmoids artery is via an external facial incision, but other approaches have been described, including an approach through the corner of the eye. Endoscopic sphenopalatine artery (SPA) ligation (Figure 3) throught the nose, has been proposed as an ideal treatment for certain nosebleeds as it takes the major arterial supply to the nasal cavity at a point closest to the bleeding, and therefore minimizes the risk of persistent bleeding from other circulation and spares the patient from a transoral incision. A review found a 92% to 100% success rate with endoscopic SPA ligation. Failures of this technique are attributed to the failure to identify all branches of the SPA, or the significant dissection that may be required in a patient with suboptimal coagulation properties. 

Figure 3: Endoscopic view of a left sphenopalatine artery (arrow) that is being ligated with a surgical clip. Image courtesy of Dr. Kevin C. Welch.

CONCLUSION
In general, non-surgical treatments are effective for control of most cases of nosebleeds. Holding pressure, nasal packing, chemical cautery, and use of nasal decongest sprays represent the first line of treatment for a majority of nasal bleeding. For persistent epistaxis, embolization and surgical ligation is sometimes required. More recently, endoscopic approaches to the sphenopalatine artery and ethmoid arteries have been utilized with promising results.

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