Nasal Polyps Pose Treatment Challenges

Nasal polyps, teardrop-shaped growths in the nose that clinicians can identify visually, develop in the nasal mucosa and paranasal sinuses. Although typically benign, they are the most common tumor of the nasal cavity. These growths can become large and may protrude from or be visible in the nose.¹ Their propensity to irritate and cause swelling in the nasal passages can cause distress for patients, with common symptoms including obstruction and reduced sense of smell. Patients also report nasal seepage, sleep loss, and a host of other annoying symptoms (table 1^2-4).^2,3 When sinonasal symptoms occur for more than 3 months, the condition is considered a type of chronic rhinosinusitis.⁴ Many patients have comorbid allergies or asthma.⁵

PRESENTATION AND STATISTICS

Patients are more likely to present with nasal polyps as they age, starting in their 30s and 40s, with the incidence peaking in the 50s.⁶ Biopsy of nasal polyp tissue in Western populations indicates that most polyps contain elevated numbers of eosinophils. Individuals who are allergic to aspirin or have cystic fibrosis are at increased risk.^7-9 Older data indicate that nasal polyps occur in less than 3% of the population¹⁰ and seem to have a genetic link.¹¹ The incidence of nasal polyps seems to be increasing. Experts have identified one risk factor, lengthy exposure to occupational dust, in the textiles industry.¹² One-third of patients with chronic rhinosinusitis with polyps reported that alcohol consumption exacerbated symptoms, and 83% of patients with aspirin-exacerbated respiratory disease reported this correlation.¹³ For this reason, guidelines recommend asking patients about salicylate intake in nonsteroidal anti-inflammatory drugs and dietary sources, such as fresh berries and nuts.⁴ Nasal polyps are usually bilateral, so if polyps are present in 1 nasal passage only, clinicians should suspect malignant tumors.¹⁴

TREATMENT OPTIONS

Patients with allergies or experience watery discharge, may be able to control symptoms with antihistamines. Many patients who develop nasal polyps will need surgery, but some treatment approaches can alleviate symptoms in patients with mild to moderate disease. One simple intervention is intranasal glucocorticoids. Saline irrigation, though lacking research evidence, also sometimes soothes symptoms.^4,15

Intranasal glucocorticoids (budesonide, fluticasone, and mometasone) may decrease rhinorrhea, reduce polyp size, and restore the sense of smell completely or partially.¹⁵ Experts indicate that clinicians tend to underprescribe intranasal glucocorticoids and prescribe them at doses too low to be helpful. Patients also tend to underuse these products when they are prescribed.¹⁶ In addition, prescribers need to step up from intranasal sprays to topical drops in patients with moderate to severe symptoms.⁴ Study results show that large-volume nasal steroid rinses administered using plastic squeeze bottles are superior to traditional steroid sprays.⁵ The leukotriene receptor antagonist montelukast may also provide some relief, though the evidence regarding its efficacy is conflicting.¹⁷

If topical treatment fails to produce the desired relief in 4 to 6 weeks, as is often the case, patients may need a short course of systemic steroids. Using oral glucocorticoids for 2 to 3 weeks may alleviate symptoms and reduce polyp size, improving quality of life. Unfortunately, the relief may last only 3 to 6 months, at which point patients may need another course of systemic glucocorticoids.^7-9

Interleukins 4 and 13 may aggravate nasal polyps, and inhibition with dupilumab (Dupixent) has been shown to decrease polyp burden and improve symptoms.^18,19

Clinicians should also highly suspect Staphylococcus aureus, as up to 50% of patients with chronic rhinosinusitis with nasal polyps are infected. Whether this staph infection causes or exacerbates nasal polyps is unclear. If the infection appears to be bothersome, clinicians can employ methylprednisolone to decrease inflammation and/ or a 3-week course of doxycycline.^20,21

CONCLUSION

Table 2 lists key counseling points to stress for patients who have nasal polyps.^4,22 Clinicians can sometimes manage these growths, but surgery is frequently necessary. Fortunately, nasal polyps rarely recur once they are removed.^4,22

Jeannette Y. Wick, RPh, MBA, FASCP, is the assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

REFERENCES

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• Nasal polyps. American Academy of Allergy, Asthma, & Immunology website. aaaai.org/conditions-and-treatments/library/allergy-library/nasal-polyps. Updated June 28, 2019. Accessed February 2, 2020.
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• Rudmik L, Xu Y, Liu M, Bird C, Kukec E, Quan H. Utilization patterns of topical intranasal steroid therapy for chronic rhinosinusitis: a Canadian population-based analysis. JAMA Otolaryngol Head Neck Surg. 2016;142(11):1056-1062. doi: 10.1001/ jamaoto.2016.1110.
• Smith TL, Sautter NB. Is montelukast indicated for treatment of chronic rhinosinusitis with polyposis? Laryngoscope. 2014;124(8):1735-1736. doi: 10.1002/ lary.24477.
• Laidlaw TM, Buchheit KM. Review article: biologics in chronic rhinosinusitis with nasal polyposis [published online December 9, 2019]. Ann Allergy Asthma Immunol. doi: 10.1016/j.anai.2019.12.001.
• Bachert C, Han JK, Desrosiers M, et al. Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52): results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trials. Lancet. 2019;394(10209):1638-1650. doi: 10.1016/S0140-6736(19)31881-1.
• Van Zele T, Gevaert P, Holtappels G, et al. Oral steroids and doxycycline: two different approaches to treat nasal polyps. J Allergy Clin Immunol. 2010;125(5):1069- 1076.e4. doi: 10.1016/j.jaci.2010.02.020.
• Ou J, Wang J, Xu Y, et al. Staphylococcus aureus superantigens are associated with chronic rhinosinusitis with nasal polyps: a meta-analysis. Eur Arch Otorhinolaryngol. 2014;271(10):2729-2736. doi: 10.1007/s00405-014-2955-0.
• Nasal polyps. Mayo Clinic website. mayoclinic.org/diseases-conditions/nasalpolyps/ symptoms-causes/syc-20351888. Accessed February 8, 2020.