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52]

Review article 469

Update of pathogenesis and management of nasal polyposis

Omer El Banhawya, Rashid Al Abric, Yasser Khalila, Ibrahim Abdul Shafya,
Fawzy Fayazb,d
a
Department of Otolaryngology, Faculty of
Medicine, Menoufiya University, Menoufiya,
b
ENT Department, Electrical Hospital, Ministry
of Electricity, Cairo, Egypt, cDepartment of
Surgery, ENT Division, College of Medicine
and Health Science, Sultan Qaboos University,
Muscat, dDepartment of ENT, Ibri Referral
Hospital, Ministry Of Health, Ibri, Oman
Correspondence to Fawzy Fayaz,
MBBCh, Kafer Al Mosulaha, Shebine Al Kom
City, Menoufiya Governorate, Menoufiya,
32511, Egypt
Tel: +20 482 178 040, +20 102 365 9050;
e‑mail: fawzy_fayaz@yahoo.com
Received 20 January 2015
Accepted 27 May 2015
Menoufia Medical Journal 2016, 29:469–477
Objectives
The goal of this article is to review important and recent findings relating to the pathogenesis
and management of nasal polyposis (NP). The rationale for a disease classification based
on histopathological characteristics and current concepts in therapeutic approach toward
managing the condition are summarized.
Data sources
The data sources are PubMed systemic reviews and all materials on the internet from 2004
to 2014.
Study selection
The initial search presented 6692 articles, of which 40 met the inclusion criteria: systemic
review, clinical trial types II and III, meta‑analysis, published in English language, published in
peer‑reviewed journals, and focusing on epidemiology, pathogenesis, and management of NP.
Data extraction
If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment
included ethical approval, eligibility criteria specified, appropriate controls, and adequate
information.
Data synthesis
Recommendations received were revised for the strength of evidence and strength of
recommendation then available data were tabulated.
Findings
Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a predominantly inflammatory disease
associated with dysregulated interaction between sinus epithelium and the innate lymphoid
system. Recent research suggests that chronic rhinosinusitis is neither an eosinophilic nor
a neutrophilic disorder. The goal in CRSwNP/ eosinophilic chronic rhinosinusitis is to create
a wide postsurgical corridor rather than simple polypectomy for effective delivery of topical
anti‑inflammatory therapy.
Conclusion
New classification of CRSwNP based on the endotyping characters will facilitate the development
of managements and establish genetic associations, demonstrate biomarkers for disease
subgroups, and test novel therapeutic targets until the question of NP control has been answered.

Keywords:
diagnosis, management, nasal polyposis, pathogenesis, polyps

Menoufia Med J 29:469–477

© 2016 Faculty of Medicine, Menoufia University
1110‑2098

eosinophil‑dominated and neutrophil‑dominated

Introduction
inflammation. The more common histopathological
Nasal polyposis (NP) is one of the most common mass
type is eosinophil‑dominated inflammation
lesions of the nose and was first described 4000 years
(63–95%) [3]. Population‑based studies of chronic
ago in ancient Egypt. The prevalence of NP is reported
rhinosinusitis with nasal polyposis (CRSwNP)
from 0.2 to 4.3% worldwide, with a ratio of 2–3: 1
from Sweden, Korea, Finland, and France report
between male and female individuals. In children,
the prevalence of CRSwNP to lie between 0.5 and
NP is relatively rare and has a close relationship with
4.3% [4]. Autopsy studies reveal a higher prevalence
asthma and cystic fibrosis. NP is a multifactorial
between 2 and 42%, with more polyps found in
condition that is often associated with many diseases
dissected nasoethmoidal blocks and endoscopic sinus
and pathogenic disorders, such as allergy, infection,
surgery (ESS) than with anterior rhinoscopy alone [5].
cystic fibrosis, asthma, and aspirin intolerance; the
Men and women are both affected by CRSwNP, with
underlying mechanisms interlinking these pathologic
conditions to NP formation remain unclear; and NP
This is an open access article distributed under the terms of the Creative
usually presents between the ages of 30 and 60 years.
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
There is a strong male predominance, ranging others to remix, tweak, and build upon the work non‑commercially, as
between 2: 1 and 4: 1 male to female [1,2]; the general long as the author is credited and the new creations are licensed under
histopathological classification of nasal polyps is the identical terms.

1110-2098 © 2016 Faculty of Medicine, Menoufia University DOI: 10.4103/1110-2098.198570

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470 Menoufia Medical Journal, Volume 29 | Number 3 | July-September 2016
some discordance in the literature as to which sex
is more frequently affected. In general, nasal polyps
occur in all races and become more common with age,
with the average age of onset being 42 years [4]. The
clinical evaluation of patients with polyps begins with
a detailed history. The primary complaints are nasal
obstruction and olfactory dysfunction. Headaches
are possible in this setting; severe headaches are not
typical. The physical examination evaluates for signs
of the sinus disease spreading beyond the sinus
cavities, such as proptosis or double vision indicating
involvement of the orbits by expansion of the sinuses
or neurologic symptoms. Endoscopic evaluation
visualizes the nasal cavity better than an anterior
examination with a nasal speculum, and it can be
used for collection of cultures of purulent secretions
to guide medical intervention or for the diagnosis
of small polyps. Be aware of unilateral polyps,
because ~30% of such cases are tumors that require
a distinct work‑up and treatment [6]. When patients
have persistent symptoms despite optimal medical
treatment or a complication is suspected based on
the history or physical examination, a sinus computed
tomography scan is recommended, and it can be useful
when the clinician is suspicious of malignancy, extra
sinus involvement by inflammatory disease, or a severe
headache initially suspected of not being of sinus
origin [6]. With regard to the etiology of CRSwNP,
numerous hypotheses have been proposed with a great
deal of overlap, supporting a multifactorial basis. One
classification method separates potential contributing
entities into host and environmental factors but
fails to illustrate causal relationships and host–
environment interactions (Table 1) [7]. CRSwNP
in the Caucasian population is associated with high
tissue eosinophilia and increased T‑helper (Th)‑2
cytokine expression [interleukin (IL)‑5 and IL‑13], as
well as nasal obstruction and smell loss. Meanwhile,
chronic rhinosinusitis with nasal polyps may have more
Th‑1 polarization and less eosinophilic infiltration.
Table 1 Host and environmental factors in the pathogenesis
of nasal polyposis
Systemic host Local host factors Environmental factors
factors
Allergy Mucociliary function Microorganisms
(bacteria, fungi, virus)
Immunodeficiency Epithelial damage Environmental damage
(e.g. pollution)
Mucociliary Loss of epithelial
dysfunction integrity
Cystic fibrosis Genetic
predisposition
Granulomatous Acquired epigenetic
diseases defects
GERD
Aspirin
intolerance
However, these characterizations may not hold true for
other ethnic populations [8]. Treatment of CRSwNP
is a challenge because the disease is heterogeneous,
with multiple mechanisms leading to the same clinical
end point [9]. In addition, few treatments have been
studied in randomized trials. Apart from intranasal
and oral steroids, most other treatment options have
failed to prove efficacy. One must also note that
children differ from adults in their pathophysiology
because their immune system is not fully mature. In
addition, NP in children warrants consideration of
cystic fibrosis as a diagnosis. The unifying theme for
the treatment of nasal polyps is that chronic, severe
mucosal inflammation needs to be controlled; acute
infections need to be treated with antibiotics (ideally
culture directed); and surgery is reserved for medical
failure to provide access for postoperative topical
anti‑inflammatory treatment [10]. The goals of
treatment are to eliminate or reduce polyp size, restore
nasal breathing, restore the sense of smell, reduce
symptoms of rhinitis, reduce the number of bacterial
infections, and prevent recurrence [6]. Corticosteroids
have been the mainstay of treatment of NP. Topical
intranasal corticosteroids are more effective for
chronic rhinosinusitis with polyps than for chronic
rhinosinusitis without polyps. Oral steroids have
been shown to reduce the polyp size and symptoms
temporarily, but the optimum dose has not been
established, and many regimens exist. The reduction
in polyp size with oral steroids can be extended by the
use of intranasal steroids after the systemic treatment
is concluded [11]. Antibiotics are used to eliminate
infection and reduce inflammation. Only one of seven
randomized, placebo‑controlled studies of topical
antibiotics showed a positive effect [12]. Short‑term
oral antibiotics have been used for the treatment
of acute exacerbations of chronic rhinosinusitis.
Studies on the long‑term use of antibiotics for their
anti‑inflammatory properties have had mixed results.
Doxycycline had a modest and significant effect on
patients with nasal polyps, potentially because of dual
antibacterial and anti‑inflammatory effects [13].
Surgery is clearly indicated for intracranial and
intraorbital complications, mucoceles, anatomic
variations, allergic fungal disease, massive polyps with
bony remodeling, and antrochoanal polyps. However,
the category leading to the majority of surgical
interventions is that of patients who are symptomatic
despite medical treatment. Smith and colleagues
showed better improvement in quality of life, with a
1‑year follow‑up of patients electing ESS experiencing
significantly higher levels of improvement in outcomes
compared with patients managed by medication
alone. In addition, subjects in a crossover cohort who
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initially elected medical management experienced
improvement in several outcomes after crossing over
to ESS [14]. The surgical approach aims at removing
inflamed sinus tissue and bony septae within the
sinus cavities. A large audit of patients at 5 years after
surgery in England and Wales showed a 20% revision
rate overall but marked and persistent improvement
in results on the Sino‑Nasal Outcome Test, a quality
of life measure. Worse outcomes for surgery are found
for patients who have aspirin‑exacerbated respiratory
disease, asthma, and frontal sinus disease [15].
Materials and methods
Search strategy
We searched PubMed systemic reviews for
papers (2004–2014) using ‘nasal polyposis’, ‘polyps’,
‘diagnosis’, and ‘management’ as keywords.
Study selection
All the studies were independently assessed for
inclusion. They were included if they fulfilled the
following inclusion criteria: systemic review, clinical
trial types II and III, meta‑analysis, published in
English language, published in peer‑reviewed journals,
and focusing on epidemiology, pathogenesis, and
management of NP. If a study had several publications
on certain aspects, we used the latest publication giving
the most relevant data.
Data extraction
If the studies did not fulfill the above criteria, they
were excluded: report without peer review, not within
national research programs, and letters/comments/
editorials/news.
Quality of evidence
The evidence‑based methodology applied when
research to select the studies by systematic reviews,
clinical trials II and III and meta-analysis were selected.
Recommendations received were revised for the
strength of evidence and strength of recommendation
then available data were tabulated.
Strength of evidence
Evidence was obtained from the following:
Ia evidence from meta‑analysis of randomized
controlled trials;
Ib evidence from at least one randomized
controlled trial;
IIa evidence from at least one controlled study
without randomization;
Nasal polyposis El Banhawy et al. 471
IIb evidence from at least one other type of
quasi‑experimental study;
III evidence from nonexperimental descriptive
studies, such as comparative studies, correlation
studies, and case–control studies;
IV evidence from expert committee reports
or opinions or clinical experience of respected
authorities, or both.
Strength of recommendation
The strength of recommendation was graded as
follows:
(1) Directly based on category I evidence
(2) Directly based on category II evidence or
extrapolated recommendation from category I
evidence
(3) Directly based on category III evidence or
extrapolated recommendation from category I or
II evidence
(4) Directly based on category IV evidence or
extrapolated recommendation from category I, II,
or III evidence.
Data synthesis
Recommendations received both strength of evidence
and strength of recommendation ratings, and available
data are tabulated.
Results
Study selection and characteristics
We searched PubMed systemic reviews for papers
(2004–2014); initially 6692 records were found, which
reduced to 70 after they were filtered by systemic
reviews, meta‑analysis, full text, humans, and published
in English; after screening of titles and abstracts, the
number reduced to 39 studies, plus one study from the
authors (Fig. 1).
Phenotypes and endotypes of chronic rhinosinusitis with
nasal polyposis
Extensive scientific evidence is accumulating that
justifies a differentiation of sinus disease not only by
phenotype but also by recognition of more detailed
endotypes by differences in pathogenic mechanisms
that can be discerned by the presence of particular
patterns of biomarkers. Definition of different
endotypes is mandatory for the development of a
better understanding of the pathophysiology of chronic
rhinosinusitis (CRS) and holds promise for guiding
the development of innovative therapeutic approaches
based on that knowledge (Fig. 2) [9].
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472 Menoufia Medical Journal, Volume 29 | Number 3 | July-September 2016

Histological characteristics criterion, the proportion of eosinophilic allergic

Polyps may be roughly classified into one of two
types: eosinophilic nasal polyp and noneosinophilic
nasal polyp (neutrophil dominant). Tissue eosinophil
proportion of more than 11% is a criterion for
eosinophilic allergic polyp. When using this
Figure 1
polyp among nasal polyps was 62.7% [16]. Nasal
polyp had significantly higher levels of eosinophilic
markers (eosinophils, eotaxin, and eosinophil cationic
protein) compared with CRS, controls, and cystic
fibrosis with nasal polyp (CF‑NP). Nasal polyp and
CF‑NP were discriminated by edema from CRS and
controls, with CF‑NP displaying a very prominent
neutrophilic inflammation. On the basis of cellular
and mediator profiles, we suggest that CRS, NP, and
CF‑NP are distinct disease entities within the group
of chronic sinus diseases [8].

Genetic and genetic polymorphism associated with nasal

polyposis
Many genes and gene products have been implicated
in chronic sinusitis with polyps, and the search
for causative genes has led to the discovery of
numerous candidates [17]. Pathway analysis applied
to these candidate genes identified common central
molecules (tumor necrosis factor–nuclear factor κB)
that are likely to be key mediators of the disease
process. Novel therapies targeting these molecules may
be applicable for the treatment of chronic sinusitis
with polyps [17]. Genetic association in NP was
Flow chart of study selection.
associated with specific polymorphisms only when it

Figure 2

Phenotype and endotype of chronic rhinosinusitis (CRS). IL, interleukin; IgE, immunoglobulin E. Phenotyping and endotyping of CRS was based
on recently published findings on asthma comorbidity and recurrence after surgery (Ghent classification of CRS). Licensee BioMed Central
Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.
[Downloaded free from http://www.mmj.eg.net on Saturday, November 18, 2023, IP: 119.92.14.52]

Nasal polyposis El Banhawy et al. 473

occurred with related phenotypes. Results suggest that
this genetic background plays a more relevant role in
the development of the associated clinical features of
NP than in simple polyposis [18].
New concept in the pathophysiology of nasal polyposis
Van Bruaene and colleagues have indicated a number
of pathophysiologic differences between the early‑stage
polyps and mature polyps that have not been described
before in CRSwNP patients. The epithelial loss was
more prominent in the early‑stage polyps in the
middle turbinate in CRSwNP patients, coupled with
increased numbers of especially M2‑type macrophages
and markedly high expression of fibronectin. Taken
together, these findings suggest that aggravated
epithelial damage and fibronectin expression play
a crucial role in the adhesion and penetration of the
basement membrane by bacteria in the initial stages of
polyp formation. Similarly, the increased numbers of
macrophages in the polyp area of the middle turbinate
CRSwNP suggest a defective host defense mechanism
in the early stage of the disease. In contrast, a fibrotic
response builds up a defense mechanism involving
increased deposition of dense collagen fiber bundles
in the underlying mucosa to prevent spread and
generalization of edema and inflammation. Overall,
these findings suggest a complex network of processes
in the formation of the CRSwNP, including gross
epithelial damage and repair reactions, eosinophil and
macrophage cell infiltration, and tissue remodeling.
Furthermore, remodeling appears to occur in parallel,
rather than subsequent, to inflammation, as has been
shown in CRS patients without nasal polyps [19].
Role of Staphylococcus aureus effects in nasal polyposis
Nasal polyp’s pathogenesis still remains obscure, in
the past few years. A recent study aimed to document
both the adaptive immune responses that characterize
Staphylococcus aureus‑biofilm‑associated CRS and the
relative contributions of staphylococcal superantigens
and S. aureus biofilms in the inflammatory make‑up
of this disease. S. aureus enterotoxins, which act as
T‑cell and B‑cell superantigens, induce an intense
eosinophilic inflammatory process of the upper
and lower airways with polyclonal IgE production
unrelated to atopy (Fig. 3) [20].
Pathophysiological mechanism of nasal polyposis
There are two important mechanisms implicated in
the pathophysiology of NP that have recently received
much research attention, and highlight aspects in which
these mechanisms intersect: airway remodeling process
and S. aureus superantigens on CRSwNP (Fig. 4) [21].

Figure 3

Pathomechanisms of chronic rhinosinusitis with nasal polyposis (CRSwNP). In a TH2‑type microenvironment with general lack of regulatory
T (Treg) cell function, interleukin (IL)‑5 induces eosinophilia, and IL‑4 and IL‑13 induce local IgE production. An alternatively activated macrophage
subset contributes to the inflammation. The activation of epithelium colonized by bacteria and fungi leads to release of proinflammatory
chemokines and cytokines with increased thymic stromal lymphopoietin (TSLP) and IL‑32 levels. Activated epithelial cells die, with apoptosis
resulting in a compromised epithelial barrier. Bachert et al. (2014), licensee BioMed Central Ltd. This is an Open Access article distributed
under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited.
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474 Menoufia Medical Journal, Volume 29 | Number 3 | July-September 2016

Figure 4

Illustration of the influence of Staphylococcus aureus (in orange) on the remodeling process in nasal polyposis. Pezato et al. [21],
licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.

T‑cell subsets in patients with chronic rhinosinusitis Cone beam technology

The differentiation of NPs with IL‑5‑expressing
Th‑2‑biased versus non‑Th‑2‑biased polyps is of
clinical relevance. In contrast, neutrophilic polyps are
associated mainly with increased levels of interferon‑γ,
IL‑17, or both. Interferon‑γ and IL‑17 are also
predominant in neutrophilic, cystic‑fibrosis‑related
polyp disease. A mixed cytokine profile, which can be
classified as a Th‑0 profile, has been demonstrated, and
the possible existence of Th‑22 and Th‑17 cells as novel
subsets requires further investigation in patients with
different forms of CRS [9].
New surgical concept
The goal of sinus surgery is to create permanent wide
access for long‑term topical therapy rather than for
relieving sinus obstruction or promoting sinus drainage
and aeration [22].
Cone beam technology is becoming increasingly
available and is associated with lower radiation exposure
than conventional imaging. A study comparing cone
beam computed tomography with multislice computed
tomography for the sinuses in an anthropomorphic
phantom model showed that the effective dose of cone
beam computed tomography was 30 µSv as compared
with 200 and 1400 µSv for low‑dose and standard
protocols using multislice computed tomography [24].
Pulsating aerosols for intranasal corticosteroid
Pulsating aerosols can deliver significant doses into
posterior nasal spaces and paranasal sinuses, providing
alternative therapy options before and after sinus
surgery (Fig. 5) [25].

Anatomical consideration for Arabic patients
Anatomical variations of sinuses from Oman
or the Arab world revealed that type 3 Karos
classification (low lying cribriform plate) is present
in over a third of the Omani population, which is in
contrast to the Caucasian and Indian populations
where type 1 and type 2 are more common,
respectively [23].
Discussion
In daily clinical practice of an ENT–Allergology
center, different forms of rhinitis, such as allergic,
nonallergic, and rhinosinusitis with or without
NP, are seen. Therefore, the specialist must adopt
increasingly complex diagnostic and instrumental
methods for diagnosis and management. In fact,
only a detailed diagnosis allows to characterize and
optimally treat nasal diseases [26]. The patient should
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Figure 5
a b
Comparison of deposition distribution of nasal pump spray (a) and
pulsating aerosol application (b) in a healthy volunteer (superposition
of the lateral gamma camera image with an individual representative
sagittal MRI slice). Möller et al. [25], this is an Open Access article
distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction
in any medium, provided the original author and source are credited.
undergo thorough diagnostic work‑up, where family
history must not be excluded, and accompanied by
imaging, functional, and immunological evaluations.
There is a high ‘global’ familial incidence of allergy,
asthma, and NP, not only between first‑degree and
second‑degree relatives (44.9 and 31.9%) but also in
third‑degree and fourth‑degree ones (23%). These
data confirm the fact that, for some diseases, genetic
background has a crucial role and should be taken
into consideration [27].
Nasal polyps are tumor‑like, hyperplastic swellings
of the nasal mucosa, most commonly originating
from within the ostiomeatal complex; the prevalence
is estimated at 0.2–4% in worldwide studies [28].
Key to understanding this philosophy is the
acknowledgement that both CRSwNP and normal
patients are exposed to the same allergens, fungi
and bacteria (including S. aureus), yet only the first
group has a heightened proinflammatory immune
response. Recent evidence suggests a crucial role for
the epithelial‑derived cytokines that mediate the cells
of the immune system [29]. Nasal polyps are thought
to be a manifestation of chronic inflammation, where
they represent the final common pathway of several
disease processes, the trigger for which is still unknown.
There are numerous theories including hereditary
factors, anatomical factors, systemic and local allergy,
and infection [6]. Nasal polyps are likely to represent
the end result of many different mechanisms, and the
search for a single etiological factor may be in vain.
Regardless of trigger, the end result is a failure to mount
an appropriate immune response to antigens in the nose
and sinuses, resulting in chronic inflammation [29].
The management of CRSwNP involves both medical
and surgical approaches and remains a controversial
subject.
Nasal polyposis El Banhawy et al. 475
A variety of intranasal corticosteroids form the
mainstay of conservative management, with good
evidence for their efficacy. A number of randomized,
placebo‑controlled trials document statistically
significant improvements in subjective symptom
scores, polyp size, and objective nasal flow rates
following topical steroid use [30]. Symptoms of nasal
obstruction can be controlled in anywhere from 50 up
to 80% of patients. However, clinical studies indicate
that the management of anosmia is poor, especially
when compared with systemic steroids. Adverse effects
from nasal steroids are few, and range from epistaxis
to headaches and dizziness. Using the more modern
formulations, such as fluticasone or mometasone,
there is minimal systemic absorption and the dose
is well below that required for adrenal suppression.
A meta‑analysis to assess the effectiveness of topical
steroids has shown that intranasal corticosteroids are
effective in the treatment of rhinosinusitis and that
prior sinus surgery and direct sinus delivery methods
enhance their effectiveness [31].
Systemic steroids (often termed medical polypectomy)
have also been shown to be effective. Two randomized
controlled trials comparing placebo with systemic
steroids show benefit with oral prednisolone [32]. The
use of oral steroids is limited by their toxicity,with adverse
effects including weight gain, immunosuppression,
and adrenal suppression. A Cochrane review supports
the use of systemic steroids in the treatment of
NP [33]. A recent systematic review by Poetker and
colleagues identified five RCTs supporting the use
of oral steroids in the short‑term management of
CRSwNP (Table 2) [35].
There is a case report by Miao, prepared in 2010, that
an Australian patient suffering from nasal polyps and
chronic rhinosinusitis had four surgical excisions of
nasal polyps treated by Chinese herbal decoction plus
acupuncture, and large amounts of mucus disappeared.
Nasal polyps did not recur. A recurrence has not occurred
for 3½ years. The application of the herbal decoction
plus acupuncture effectively prevented the recurrence of
nasal polyps in this case. Therefore, further research is
warranted in this classic method of treatment [36].
Conclusion
(1) Curative treatment is hard to achieve in polyposis,
and management is primarily aimed at reducing
symptom severity. It is therefore important to
include a measurement of health‑related quality
of life when assessing the severity of disease or
outcome of treatment.
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476 Menoufia Medical Journal, Volume 29 | Number 3 | July-September 2016

Table 2 Randomized controlled trials evaluating oral steroids in chronic rhinosinusitis with nasal polyposis
References N Outcome measures Treatment groups Results
Hissaria 41 Symptoms, MRI, endoscopy Prednisolone 50 mg daily vs. Improved symptoms, MRI and endoscopic
et al. (2006) placebo×14 days appearance in the steroid group versus
control
Kroflic 40 Symptoms, endoscopy, Methylprednisolone 1 mg/kg daily vs. Improved symptoms and polyp size in both
et al. (2006) histology, intraoperative nasal furosemide×7 days pre‑ESS groups with no clinical difference between
bleeding groups
Van Zele 47 Endoscopy, rhinometry, Methylprednisolone taper Improved polyp size, nasal patency,
et al. [13] symptoms, SEC, nasal over 20 days vs. oral inflammatory markers, and symptoms in
IL‑5, IgE, MMP‑9, ECP doxycycline×20 days vs. placebo steroid group versus placebo
Kirtsreesakul 109 Symptoms, rhinometry, Prednisolone 50 mg daily vs. Improved symptoms, nasal patency, and
et al. (2011) endoscopy placebo×14 days polyp size in the steroid group versus
control
Vaidyanathan 60 Endoscopy, symptoms, Prednisolone 25 mg daily vs. Improved polyp size, symptoms, QoL,
et al. [11] QoL, rhinometry, CRP, EDN placebo×14 days, both followed by serum EDN, and CRP in steroid group
intranasal fluticasone versus control
CRP, C‑reactive protein; CRSwNP, chronic rhinosinusitis with nasal polyposis; ECP, eosinophilic cationic protein; EDN, eosinophil‑derived
neurotoxin; ESS, endoscopic sinus surgery; IgE, immunoglobulin E; IL‑5, interleukin‑5; MMP‑9, matrix metalloproteinase‑9; QoL, quality of
life; SEC, serum eosinophil count; vs., versus [34].

(2) Nasal polyps are not associated with allergy but
can be associated with asthma, aspirin sensitivity,
cystic fibrosis, allergic fungal sinusitis, and Churg–
Strauss syndrome.
(3) Unilateral polyps may be a sign of malignancy and
should be properly investigated.
(4) Children with nasal polyps should be referred for
further testing for cystic fibrosis.
(5) Aspirin sensitivity should be suspected in severely
affected polyp patients, especially those with
recurrent polyps and intrinsic asthma.
(6) Phenotyping of all patients is mandatory.
(7) The appropriate management for nasal polyps
must focus on controlling the common
inflammatory process rather than on treatment of
polyps per se.
(8) All patients should have a trial of medical
treatment before surgery unless the nature of the
polyps is in doubt.
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