presentation - friedman, bryan - nasal polyposis · • lavigne p, et al. immunomodulators in...
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NASAL POLYPOSISBRYAN FRIEDMAN, D.O.
NO DISCLOSURES
• No Disclosures
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OVERVIEW
• Nasal polyps are benign, common, tear dropped shaped growths that form in the nose or sinuses
• Found around the area where the sinuses open into the nasal cavity OS, OMC, osteomeatal complexes, recess
• When mature, polyps resemble “peeled” grapes
• Linked with inflammation, allergies or asthma
• If small, may never even know of their presence
• Larger ones may lead to sinus obstruction mucus builds up Infection
• Known to recur
NASAL POLYP @ OSTEOMEATAL COMPLEX
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POLYP APPEARANCE
• Grape like consistency
SYMPTOMS• Congestion, “stuffy”
• Sneezing
• Post Nasal Drip
• Rhinitis
• Facial Pain
• Loss of Smell, olfactory issues
• Loss of Taste
• Itching around the eyes
• Recurrent sinus/pulmonary infections
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NASAL POLYPOSIS; COMMON COMPLAINTS
• Up to 75% of those with polyps will present with problems with sense of smell
• Wheezing, chronic sinusitis
• Sensitivity to fumes, odors, dust and chemicals
• If presents with severe allergy to Aspirin and has asthma . . .
SAMTER’S TRIAD
• a.k.a. Aspirin‐exacerbated respiratory disease (AERD), ASA triad
• Chronic condition defined by asthma, sinus inflammation with nasal polyposis and aspirin sensitivity
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WHO IS AT RISK?
•More common in adults over the age of 40
• Twice as likely to affect men as women
• Children under the age of 10 rarely get them
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CRS WITH POLYPOSIS VS. CRS W/O POLYPOSIS
• Certain genetic propensity to the development of polyps
• Family history of polyps may increase one’s propensity
• Evidence suggests variations in the immune system responses, chemokines, cytokines, interleukins in mucus membranes of those who develop polyps versus those that do not
• Genes that play a role in the immune system and the inflammatory response
• Churg‐Strauss Syndrome: Eosinophilic Granulomatosis with Polyangitis
A 4‐YEAR‐OLD PRESENTS WITH . . .
•Recurrent bouts of sinusitis and pneumonia
• Physical Exam
•Nasal endoscopy reveals bilateral nasal polyps
•What to order?
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PEDIATRIC NOSTRIL EVALUATION
CYSTIC FIBROSIS
•SWEAT CHLORIDE TEST
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NASAL POLYPOSIS
• Nasal polyps are linked to allergic rhinitis, asthma, aspirin allergy
• Sinus issues, acute and chronic infections
• Cystic Fibrosis
• Exact cause is still unknown
• Sometimes, they develop as a precursor to asthma or sinusitis
• Allergic symptoms, such as rhinitis, sneezing, pruritis, varying inflammatory culprits make for propensity for their development
DIAGNOSIS/IMAGING
•Anterior Rhinoscopy•Nasal Endoscopy•CT scan•MRI
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NASAL ENDOSCOPY
•Antrochoanal polyp
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CT SCAN
• Take note of the polyps
• Take note of mucosal thickening
CT SCAN WITH DISEASE PROGRESSION
• Pan‐sinus involvement
• No bony invasion
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TREATMENT • An ounce of prevention . . .
• Avoidance of inflammatory mediators
• Manage allergies and asthma
• Avoid nasal irritants
• Good hygiene
• Air humidifier
• Saline irrigations
TREATMENT
• Once diagnosed . . .
• First line of treatment Intranasal steroid spray
• Allow for shrinking or elimination of smaller polyps
• Allergy testing if positive Immunotherapy
• Oral Steroids, Prednisone
• Up to three times a year
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IF LEFT UNTREATED . . .
• Meningitis
• Orbital Cellulitis
• Osteitis
• Facial distortions
• Certainly, polyps as they increase in size can lead to dynamic changes of the surrounding structures, yet it is the infections from obstructive rhinosinusitis secondary to polyp growth that is most concerning
MRI AND CT SCAN
• Lamina papyracea erosion
• CT preferable to MRI
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ORBITAL CELLULITIS
FACIAL DISTORTION
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MENINGITIS RISK
• Polypoidal tissue of frontal sinus leading to bony erosion of frontal sinus and intra‐cranial complications
RECURRENCE• Ongoing nasal hygiene, consisting of nasal saline spray, intra‐nasal steroid spray to reduce inflammation and risk of recurrence
• Quarterly, nasal endoscopies to evaluate for recurrence
• While anti‐histamines and various decongestants do not eliminate nasal polyps, they have benefits in reducing allergic suffering and allergic inflammation
• Antibiotics
• If acute sinus infection is to develop, bacterial in nature
• Doxycycline‐anti‐inflammatory properties
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SURGICAL EXCISION
• Sinus surgery with polypectomy often needed for recurrent cases of nasal polyposis
• Steroid releasing stents/Implants
• Mometasone Furoate
SHAVER
• Careful attention to surrounding anatomy
• Suction and shaving device can easily remove the polypoidal tissue
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NASAL POLYP
• Polyp removed from the nasal/sinus cavity
DRUG ELUTING STENT
• Mometasome steroid to prevent polypoidal recurrence
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ETHMOID CAVITY
• Stent placed into ethmoid surgical site allowing for steroid slow delivery preventing recurrence and aiding with healing process
AFTER SURGERY . . .
• 2‐3 debridements
• “cleaning the schmutz”
• Then quarterly nasal endoscopies with reiteration of nasal hygiene and allergy management
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IN MY PRACTICE . . .
• “Please, remember our office’s doors revolves, they never slams shut!”
BEEN THERE, DONE THAT
• All of the above things have been done in the past, the sinuses widely patent, allergy therapy, nasal saline, Flonase, compound sinus irrigations…..still with polyps
• Aspirin desensitization trial
• Azelastine nasal spray
• Cryotherapy of the sphenopalatine ganglia
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REFERENCES• Zitelli BJ, et al., eds. Otolaryngology. In: Zitelli and Davis' Atlas of Pediatric Physical Diagnosis. 7th ed. Philadelphia, Pa.: Elsevier; 2018. https://www.clinicalkey.com. Accessed Feb. 27, 2019.
• Mason RJ, et al. Upper airway disorders. In: Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. Philadelphia, Pa.: Saunders Elsevier; 2016. https://www.clinicalkey.com. Accessed Feb. 27, 2019.
• Goldman L, et al., eds. Approach to the patient with nose, sinus and ear disorders. In: Goldman‐Cecil Medicine. 25th ed. Philadelphia, Pa.: Saunders Elsevier; 2016. https://www.clinicalkey.com. Accessed Feb. 27, 2019.
• Nasal polyps. American Academy of Allergy, Asthma & Immunology. https://www.aaaai.org/conditions‐and‐treatments/library/allergy‐library/nasal‐polyps. Accessed Feb. 27, 2019.
• Lou H, et al. Highlights of eosinophilic chronic rhinosinusitis with nasal polyps in definition, prognosis, and advancement. International Forum of Allergy & Rhinology. 2018;8:1218.
• Bhattacharyya N. Clinical presentation, diagnosis, and treatment of nasal obstruction. https://www.uptodate.com/contents/search. Accessed Feb. 27, 2019.
• Hamilos DL. Chronic rhinosinusitis: Management. https://www.uptodate.com/contents/search. Accessed Feb. 27, 2019.
• Jankowski R, et al. Nasal polyposis (or chronic olfactory rhinitis). European Annals of Otorhinolaryngology, Head and Neck Diseases. 2018;135:191.
• Sedaghat AR. Chronic rhinosinusitis. American Family Physician. 2017;96:500.
• Sinus infection (sinusitis). Centers for Disease Control and Prevention. https://www.cdc.gov/antibiotic‐use/community/for‐patients/common‐illnesses/sinus‐infection.html. Accessed March 4, 2019.
• King TE. Clinical features and diagnosis of eosinophilic granulomatosis with polyangiitis (Churg‐Strauss). https://www.uptodate.com/contents/search. Accessed March 6, 2019.
• Safe ritual nasal rinsing. Centers for Disease Control and Prevention. https://www.cdc.gov/parasites/naegleria/ritual‐ablution.html. Accessed March 6, 2019.
• Lavigne P, et al. Immunomodulators in chronic rhinosinusitis. World Journal of Otorhinolaryngology‐Head and Neck Surgery. 2018;4:186.
• Bachert C, et al. Biotherapeutics in chronic rhinosinusitis with and without nasal polyps. Journal of Allergy and Clinical Immunology: In Practice. 2017;5:1512.
• Hamilos DL, et al. Chronic rhinosinusitis: Clinical manifestations, pathophysiology and diagnosis. https://www.uptodate.com/contents/search. Accessed March 11, 2019.
• Sweat test. Cystic Fibrosis Foundation. https://www.cff.org/What‐is‐CF/Testing/Sweat‐Test/. Accessed March 11, 2019.
• AskMayoExpert. Chronic rhinosinusitis. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2018.
• Stokes PJ, et al. The relationship between serum vitamin D and chronic rhinosinusitis: A systematic review. American Journal of Rhinology & Allergy. 2016;30:23.
• Aspirin‐exacerbated respiratory disease (AERD). American Academy of Allergy, Asthma & Immunology. https://www.aaaai.org/conditions‐and‐treatments/library/asthma‐library/aspirin‐exacerbated‐respiratory‐disease. Accessed March 18, 2019.
• FDA approves first treatment for chronic rhinosinusitis with nasal polyps. U.S. Food and Drug Administration. https://www.fda.gov/news‐events/press‐announcements/fda‐approves‐first‐treatment‐chronic‐rhinosinusitis‐nasal‐polyps. Accessed July 3, 2019.