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What are the sinuses?
What are the sinuses?
The paranasal sinuses are mucosal lined and air-filled spaces in the bones around your nose. The sinuses are usually situated along the nose and drain into the nasal passages. There are typically four pairs of sinuses. The frontal sinuses are located in the forehead region, the maxillary sinuses are located the cheek region, the ethmoid sinuses are located between your eyes along the roof of your nasal cavity, and the sphenoid sinuses are located behind your nasal cavity.
Figure 1. Basic anatomy of the paranasal sinuses.
What are the functions of the sinuses?
What are the functions of the sinuses?
Under normal conditions, air enters the sinuses and mucous are drained from the sinuses into the nasal cavity through small openings called ostium. The lining of the sinuses have microscopic cilia (hair-like structure) that moves the mucous towards the ostium, called mucociliary clearance. In order for the sinuses to drain appropriately, the ostium of the paranasal sinuses must be open and the mucosa must have functional and healthy cilia.
Figure 2. Natural sinus drainage pathway.
Source: Ludman et. al. ABC of Ear, Nose & Throat
The air-filled spaces in the facial bones have a theoretical benefit of decreasing the weight of the head. In addition, the sinuses may act as a crumple zone, protecting the eyes and brain in unfortunate cases of head and facial trauma. The sinuses also help humidifies the air and increase the resonance speech. The mucus from the sinus also moisturizes the nose.
What are nasal polyps (chronic sinusitis with nasal polyposis)?
What are nasal polyps (chronic sinusitis with nasal polyposis)?
Nasal polyps are abnormal semi-transparent grape-like lesions that arise from the mucosa within the nasal cavity and/or sinuses. They are found in about 20-30% of patients with chronic sinusitis and 1-4% of the general population. They are often the end result of chronic sinonasal inflammation related to disease processes such as chronic sinusitis, allergy, allergic fungal rhinosinusitis, Samter’s triad (aspirin sensitivity & asthma), and cystic fibrosis. Nasal polyps are benign and can present as a single large polyp (antrochoanal polyp) or multiple polyps.
Figure 3. Graphic illustration of nasal polyposis. Source: JAMA.com
Animation of nasal polyps.
Source: Free Medical Education
How does nasal polyposis typically present?
How does nasal polyposis typically present?
The most common signs and symptoms of nasal polyposis are nasal congestion, loss of smell and taste, headache, and a post-nasal drip. Symptoms of nasal polyposis may be mild and insidious in development and worsen over a long period of time. As a result, patients may not be aware of the symptoms and may be “used to” the discomfort. With an acute flare-up of a sinus infection, patients may also present with thick and discolored nasal discharge, facial pressure or fullness, and fatigue. Some patients may present with concurrent asthma or recurrent bronchitis.
In severe cases, some patients may notice the polyps protruding out of the nose. In addition, while they do not invade nearby structures, large polyps can push on the skull-base and the eye, leading to thinning of the bony wall and protrusion of the eye (proptosis). An antrochoanal polyp may also cause voice change and velopharyngeal insufficiency (escape of air or food into the nose with speech and swallowing). Concurrent environmental allergy, fungal infection, asthma, or aspirin sensitivity may be present with nasal polyposis.
Figure 4. CT scan of a patient with nasal polyp (left) and intra-operative finding of a nasal polyps (middle) and antrochoanal polyp extending into the nasopharynx (right).
What can you expect during your ENT doctor visit for nasal obstruction?
What can you expect during your ENT doctor visit for nasal obstruction?
There are multiple causes of sinus symptoms. During your visit, your ENT doctor will perform a complete history and physical exam to determine the exact cause of your nasal obstruction. A procedure called a nasal endoscopy with a fiberoptic endoscope may be performed to further evaluate the nasal anatomy and sinus pathology deep inside your nose. Depending on your history and examination, your physician may refer you to obtain additional studies including blood tests, allergy tests, and radiographic exams.
Figure 5. Nasal endoscopy. Source: JAMA.com
How are nasal polyps graded?
How are nasal polyps graded?
There are multiple different grading systems for nasal polyposis. It is mostly used for surveillance purposes to determine response to treatment. Regardless of the specific system, the higher grades generally correspond to more prominent nasal polyposis. Patients with a higher grade tend to be more symptomatic and are less likely to respond to medical treatment. Below is an example of one endoscopic staging system:
Grade 0: No polyposis.
Grade 1: Mild polyposis – polyps remain above the inferior border of the middle turbinate.
Grade 2: Moderate polyposis – polyps extends between the inferior border of the middle turbinate and inferior turbinate.
Grade 3: Severe polyposis – polyps extends beyond the inferior border of the inferior turbinate, or situated medial to the middle turbinate.
Figure 6. Endoscopic staging system for nasal polyposis. Source: Stjärne et. al. Arch Otolaryngol Head Neck Surg. 2009 Mar;135(3):296-302.
How is nasal polyposis treated?
How is nasal polyposis treated?
The conservative treatment for nasal polyposis is similar to chronic sinusitis and depends on the underlying cause. In general watchful waiting with supportive treatment such as nasal saline irrigation and topical nasal steroid spray is adequate for early and asymptomatic nasal polyposis. Oral steroid such as prednisone can rapidly decrease the size of the nasal polyps and alleviate symptoms. However, the response is usually temporary and the recurrence rate is high in advance cases.
Recurrent or refractory nasal polyposis that is symptomatic typically requires surgical management. Certain underlying causes can be managed to reduce the risk of post-operative recurrence. In patients with aspirin sensitivity, aspirin desensitization has been shown to reduce the rate and frequency of recurrence after surgery. It does not reduce pre-operative symptoms or polyp size. Patients with allergic fungal sinusitis with nasal polyps respond well to topical steroid after sinus surgery to reduce the risk of recurrence.
Figure 7. Allergy (left) and aspirin sensitivity (right) can exacerbate symptoms of nasal polyposis. Source: uptodate.com & JAMA.com.
Recent literature suggests that environmental allergy can cause nasal polyposis. The current literature suggests that immunotherapy (allergy shots) performed pre-operatively or post-operatively does not appear to affect the progression or recurrence of nasal polyposis in patients with allergy. However, management of underlying allergy with an antihistamine (e.g. cetirizine), leukotriene antagonist (e.g. montelukast), and immunotherapy can reduce overall nasal symptoms that exacerbate symptoms of nasal polyposis. In patients with cystic fibrosis, antihistamines are usually avoided to reduce the drying effect. Recurrence of polyps after surgery in patients with cystic fibrosis is high. Current studies suggest that topical antibiotics and leukotriene antagonist may reduce the rate of recurrence.
Antibiotics are usually reserved for patients with an active sinus infection. While nasal decongestants (e.g. Afrin or Neo-Synephrine) may alleviate nasal obstruction by shrinking the turbinates, they do not reduce the size of the polyps. In general, nasal polyposis do not respond well to initial medical management and surgical treatment is often needed when the patient is symptomatic. However, judicious post-operative care can reduce the rate and frequency of recurrence and affords prolonged symptom alleviation.
When is sinus surgery indicated for nasal polyps?
When is sinus surgery indicated for nasal polyps?
Nasal polyposis can have a significant impact on quality of life with a loss of productivity at work and school. In general, the decision to proceed with sinus surgery is one that the patient and ENT surgeon makes together. Sinus surgery is usually reserved for patients who are symptomatic and do not respond to medical therapy or for patients who develop frequent recurrent sinus infections. In rare cases of severe orbital or intracranial complications, sinus surgery may be the first line if treatment in addition to medical management.
Nasal polyp.
Resected nasal polyp.
Sinus cavity after polypectomy
The most common type of surgery on the sinus is functional endoscopic sinus surgery (FESS). The goal of sinus surgery is to remove the nasal polyps and to open up the natural drainage pathways of the paranasal sinuses for better mucous clearance and aeration of the sinuses. With wider openings, topical treatments are more feasible and reduce the need for oral and systemic antibiotics. In rare cases where the polyps are located deep in the maxillary sinus, an open approach called the Caldwell-Luc procedure may be employed to remove the entire polyp.
Functional endoscopic sinus surgery is performed through the nostrils using a fiberoptic endoscope. There is typically no external incision and no external facial changes are anticipated. Depending on your surgery center and the extent of your surgery, your surgeon may use neuronavigation to achieve a safer and more thorough surgery. Learn more about sinus surgery or post-operative surgical care.
Brief polyp surgery video by Dr. Truong. Please be advised that this video contains graphic footage of surgery.
References:
References:
Laidlaw TM et al. "Chronic Rhinosinusitis with Nasal Polyps and Asthma." J Allergy Clin Immunol Pract . 2021 Mar;9(3):1133-1141.
Laidlaw TM et al. "Dupilumab improves upper and lower airway disease control in chronic rhinosinusitis with nasal polyps and asthma." Ann Allergy Asthma Immunol . 2021 May;126(5):584-592.
DelGaudio, JM et. al. "Central Compartment Atopic Disease." Am J Rhinol Allergy. 2017 Jul 1;31(4):228-234.
Hulse, K.E. et al. "Pathogenesis of Nasal Polyposis." Clin Exp Allergy. 2015 Feb;45(2):328-46.
Bachert, Claus et al. "Current and Future Treatment Options for Adult Chronic Rhinosinusitis: Focus on Nasal Polyposis." J Allergy Clin Immunol. 2015 Dec;136(6):1431-1440.
AlBader, Abdullah et al. "Does Endoscopic Sinus Surgery Improve Olfaction in Nasal Polyposis?" Laryngoscope. 2017 Oct;127(10):2203-2204.
Carlton, Daniel A. et al. "Do Preoperative Corticosteroids Benefit Patients With Chronic Rhinosinusitis With Nasal Polyposis?" Laryngoscope. 2019 Apr;129(4):773-774.
Joshua M Levy, Joshua M., and Smith, Timothy L. "Is Aspirin Desensitization Indicated for the Treatment Recalcitrant Chronic Rhinosinusitis With Nasal Polyposis in Aspirin-Exacerbated Respiratory Disease?" Laryngoscope. 2017 Apr;127(4):776-777.
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