Otorhinolaryngology & Allergology & Family Medicine
Nasal polyposis
Nasal polyposis - the accepted term for chronic rhinosinusitis with nasal polyposis (CRaNP) - is a chronic eosinophilic inflammatory disease of the upper airways characterized by the growth of bilateral polyp formations originating in the mucosa of the ethmoidal sinuses and progressively extending into the nasal cavities, causing increasing nasal obstruction, often severe loss of smell (anosmia or hyposmia), chronic recurrent rhinosinusitis and significant impairment of quality of life. It affects 1 to 4 % of the general adult population, with a male predominance (ratio 2-3/1) and a peak onset between the ages of 30 and 60. Its pathophysiology is dominated by type 2 (Th2) inflammation mediated by the interleukins IL-4, IL-5 and IL-13, leading to massive recruitment of eosinophils to the sinonasal mucosa, whose cytotoxic products (major basic protein, eosinophilic peroxidase) damage the epithelium and maintain chronic inflammation. Nasal polyposis is closely associated with two major comorbidities: asthma (present in 40 to 70 % of patients with nasal polyposis) and aspirin-exacerbated respiratory disease (AERD, formerly Samter's disease or Widal's triad) - association of aspirin-NSAIDs + nasal polyposis + severe asthma resulting from a deviation of arachidonic acid metabolism towards the overproduction of pro-inflammatory leukotrienes. The therapeutic arsenal has been considerably enriched since 2019 with the approval of biotherapies targeting the type 2 inflammation pathway - in particular dupilumab (anti-IL-4Rα), mepolizumab (anti-IL-5) and benralizumab (anti-IL-5 receptor) - which have transformed the management of severe forms refractory to conventional treatments, enabling dramatic reductions in polyp volume and restoration of the sense of smell.
Pathophysiology and clinical associations
- Eosinophilic type 2 inflammation: Imbalance of mucosal immune response → activation of group 2 innate lymphoid cells (ILC2) and T helper 2 cells → production of IL-4 (switching to IgE) + IL-5 (recruitment and survival of eosinophils) + IL-13 (mucus hypersecretion + tissue remodeling) → accumulation of eosinophils in the sinonasal mucosa → epithelial damage → stromal edema + polyp formation + polypoid mucosa often contains more than 100 times more eosinophils than normal sinonasal mucosa
- Widal's Triad (Samter's disease — AERD): Nasal polyp syndrome + severe asthma + aspirin and NSAID (COX-1 inhibitor) intolerance → mechanism: COX-1 inhibition by aspirin → reduced synthesis of prostaglandin E2 (which normally inhibits leukotriene production) → dysregulation + overproduction of leukotrienes (LTC4 + LTD4 + LTE4) → bronchospasm + worsening of polyps + AERD affects 9 to 12 % of all asthmatics and 30 to 40 % of patients with nasal polyps + it is underdiagnosed
- Cystic Fibrosis: in children and young adults with cystic fibrosis → nasal polyposis in 6-40 % of cases, more often bilateral and severe, with a different mechanism than the allergic form (neutrophilic rather than eosinophilic), and complete cystic fibrosis workup in any child with nasal polyposis (sweat test + CFTR genotyping)
- Chronic rhinosinusitis without nasal polyps (CRSsNP): distinct entity from atopic dermatitis + predominant Th1/Th17 inflammation + neutrophilic + non-eosinophilic + less responsive to corticosteroids and anti-IL-4/IL-5 biologics + the distinction between atopic dermatitis and seborrheic dermatitis is fundamental for therapeutic choice
Clinical presentation
| Symptom | Description and characteristics | Frequency and impact |
|---|---|---|
| Bilateral nasal obstruction | Permanent and progressive nasal congestion, often on both sides simultaneously (nasal polyposis is by definition bilateral – unilateral polyposis should suggest a tumor) + nocturnal mouth breathing + snoring + progressive worsening over months to years | Present in 95–100 % of cases + dominant and most disabling symptom + complete obstruction in advanced forms |
| Hyposmia or anosmia | Progressive loss of smell (hyposmia) to complete loss (anosmia) + often the most debilitating symptom for quality of life (associated loss of taste + safety risk — inability to smell gas/smoke) + the first symptom to improve with effective treatment | Present in 70-90 % of cases + complete anosmia in 50 % of advanced cases + often the revealing sign that leads to consultation + variable restoration depending on duration and severity |
| Mucous or mucopurulent rhinorrhea | Anterior and posterior nasal discharge (posterior rhinorrhea = drainage into the throat) + often thick and viscous secretions + yellowish-green coloration with bacterial superinfections | Present in 80–95 % of cases + contributes to chronic cough and tension headaches |
| Recurrent acute rhinosinusitis | Recurrent bacterial superinfections on a background of chronic polyposis + facial pain + headaches + mild fever + worsening obstruction + *Haemophilus influenzae* + *Streptococcus pneumoniae* + staphylococci | Present in 50–70 % of patients + increased impact on quality of life + repeated antibiotic prescriptions contribute to antibiotic resistance + reduction of polyps reduces the frequency of acute sinusitis |
| Facial pressure headaches | Facial pain, described as pressure or heaviness, affecting the area around the eyes, cheekbones, and forehead. The pain is aggravated by tilting the head forward and is related to the obstruction of sinus ostia and increased sinus pressure. | Present in 40–60 % of cases + often wrongly attributed to migraines or tension headaches + improve with nasal decongestion |
Diagnosis
- Nasal endoscopy (nasal endoscopy): reference examination + directly visualizes polyps in the nasal cavities (often in the middle meatus) + assesses the degree of obstruction + appreciates the appearance of the mucosa + allows for specimens for culture or biopsy if necessary + endoscopic grading: grade 0 (absent) → grade 1 (confined to the middle meatus) → grade 2 (extending beyond the middle meatus) → grade 3 (complete obstruction) + available in ENT clinics
- CT scan of the sinuses (non-contrast): Reference imaging examination for evaluating the extent of polyposis in all sinuses (ethmoids ++, maxillary, sphenoid, frontal), Lund-Mackay score (opacification of each sinus = 0 no opacity, 1 partial opacity, 2 total opacity, max total 24), guides surgical planning, to be requested before any sinus surgery
- Allergy and immunology workup: skin tests or specific IgE + total IgE dosage + blood eosinophilia + tissue eosinophilia (polyp biopsy) + aspirin intolerance test (graduated oral challenge under medical supervision) if AERD suspected + sweat test in children (cystic fibrosis)
- Polyp biopsy: Indicated if atypical presentation (unilateral polyp + bleeding + friable tissue + appearance different from an inflammatory polyp) to exclude a tumor (inverted papilloma + sinus carcinoma) + confirms the eosinophilic infiltration characteristic of ERSOC.
Processing — Step-by-step approach
| Treatment | Procedures and protocol | Efficacy and indications |
|---|---|---|
| Nasal corticosteroids spray — first-line | Mometasone (Nasonex® 200 µg × 2/day) + fluticasone (Avamys® + Flonase®) + budesonide (Rhinocort®) + continuous maintenance treatment + correct application: head tilted slightly forward + spray towards the lateral wall of the nostril (not the septum) + lifelong for chronic forms | 20–40% % polyp volume reduction + improvement of obstruction + rhinorrhea + less effective on anosmia + basic treatment essential + not systemically absorbed if used correctly + minimal side effects (mild epistaxis) |
| Oral corticosteroids — short courses | Prednisone 0.5 mg/kg/day x 5 to 7 days (max 40 mg/day) + repeated courses 2 to 3 times per year maximum + indication: severe flare-ups + before sinus surgery + or for temporary restoration of smell | Spectacular and rapid reduction of polyps (80-90 % of patients) + restoration of smell, often within days + transient effect (relapse upon stopping within weeks) + systemic adverse effects if treatments are too frequent (osteoporosis + diabetes + hypertension + insomnia) |
| Saline nasal rinses | Daily nasal irrigation with isotonic or hypertonic saline solution (Neti pot + 60 mL syringe + Sinus Rinse® type squeeze bottles) + improves drainage + reduces secretions + moisturizes the nasal lining + to be performed before nasal corticosteroids to improve their penetration | Adjuvant treatment benefit demonstrated + well-tolerated + no side effects + modestly improves all symptoms + systematically recommended as maintenance therapy |
| Dupilumab (Dupixent®) — anti-IL-4Rα biotherapy | Dupilumab 300 mg SC every 2 weeks + monoclonal antibody blocking the common receptor for IL-4 and IL-13 (IL-4Rα) → simultaneously blocks both major type 2 cytokines + approved by Health Canada for severe CRSwNP in adults + indicated if severe polyposis despite nasal corticosteroids + repeated courses of oral corticosteroids + and/or endoscopic sinus surgery | Essais SINUS-24 et SINUS-52 (Bachert 2019 — NEJM) : réduction du volume des polypes de 51 % vs placebo + restauration de l'odorat dans 60–70 % des cas + amélioration de l'asthme associé + effets indésirables : réactions au site d'injection + conjonctivite (fréquente — 5–15 %) + possible éosinophilie paradoxale initiale + remboursé par la RAMQ sous critères stricts |
| Mepolizumab (Nucala®) and benralizumab (Fasenra®) | Mepolizumab 100 mg SC every 4 weeks (anti-IL-5) + benralizumab 30 mg SC every 4 weeks then every 8 weeks (anti-IL-5 receptor) + approved for severe EGPA + particularly indicated if severe eosinophilic asthma is also present (treating one condition with the other) | Reduction in polyp volume and improvement in symptoms + less impact on anosmia than dupilumab + better profile in forms with marked blood hyperosinophilia + reimbursed by RAMQ if associated severe eosinophilic asthma |
| Functional Endoscopic Sinus Surgery (FESS) | Endoscopic nasal surgery under general anesthesia + polyp removal + meatotomy (opening of the sinus ostia) + ethmoidectomy + improves sinus ventilation and drainage + facilitates penetration of postoperative nasal corticosteroids | Symptom improvement in 80–90 % of cases + 5-year recurrence rate: 40–60 % without optimal postoperative medical treatment + reduced to 10–20 % if nasal corticosteroids + biologics are maintained + surgery does not cure polyposis (chronic inflammatory disease) → postoperative medical treatment is essential + recurrence delay is postponed by biologics |
ℹ️
Every patient with nasal polyposis and asthma should be questioned about their tolerance to aspirin and NSAIDs (ibuprofen, naproxen, diclofenac). In case of a reaction (asthma attack, worsening rhinorrhea, or hives within one hour of ingestion), aspirin-exacerbated respiratory disease (AERD) should be suspected. These patients should avoid all COX-1 inhibitors and exclusively use paracetamol as an analgesic. An aspirin challenge test under medical supervision can confirm the diagnosis and pave the way for aspirin desensitization (ATAD), which can improve both asthma and polyposis.
Medical consultation recommended
Consult a doctor or ENT specialist promptly if progressive bilateral nasal obstruction is accompanied by a persistent loss of smell for more than 4 to 6 weeks — nasal polyposis is a chronic disease that progresses insidiously, and early treatment (adequate dose nasal corticosteroids + nasal irrigation) can slow its progression and delay or avoid surgery. Unilateral polyposis, recurrent epistaxis, or an atypical appearance of polyps on fibroscopy require urgent ENT evaluation to rule out a sinonasal tumor.
For the diagnosis of nasal polyposis, nasal corticosteroid prescription, allergy testing, and referral to an ENT specialist for nasofibroscopy and discussion of biotherapy, Clinique Omicron offers medical consultations at its service points in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's physician assistants (PAs) and nurse practitioners (NPs) diagnose nasal polyposis based on clinical presentation and prescribe nasal corticosteroids and saline rinses. They refer patients to ENT specialists for nasofibroscopy and surgical planning, and coordinate allergy assessments and treatment for associated asthma—including referrals to allergists for discussion of biologic therapy (dupilumab) in severe refractory cases. Consultations are available at several service points in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.
The content of this page is for informational purposes only and does not replace the advice of a doctor or an ear, nose, and throat specialist. Nasal polyposis is a chronic condition requiring regular monitoring — any unilateral or atypical polyposis requires a biopsy to rule out a malignant tumor.
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