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Review

Nasal polyposis (or chronic olfactory rhinitis)

R. Jankowski , C. Rumeau , P. Gallet , D.T. Nguyen ∗
Service d’ORL, chirurgie cervico-faciale, hôpitaux de Brabois, Bât-Louis-Mathieu, CHRU de Nancy, rue du Morvan, 54500 Vandoeuvre-les-Nancy, France

a r t i c l e i n f o a b s t r a c t

Keywords: The concept of chronic rhinosinusitis with or without polyps is founded on the structural and functional
Nasal polyposis unicity of the pituitary mucosa and its united response to environmental aggression by allergens, viruses,
Chronic rhinosinusitis bacteria, pollution, etc. The present review sets this concept against the evo-devo three-nose theory, in
Nitric oxide (NO)
which nasal polyposis is distinguished as specific to the olfactory nose and in particular to the non-
Ethmoid
olfactory mucosa of the ethmoid, which is considered to be not a sinus but rather the skull-base bone
Paranasal sinuses
CT harboring the olfactory mucosa. The evo-devo approach enables simple and precise positive diagnosis of
nasal polyposis and its various clinical forms, improves differential diagnosis by distinguishing chronic
diseases of the respiratory nose and those of the paranasal sinuses, hypothesizes an autoimmune origin
specifically aimed at olfactory system auto-antigens, and supports the surgical concept of nasalization
against that of functional sinus and ostiomeatal-complex surgery. The ventilation function of the sinuses
seems minor compared to their production, storage and active release of nitric oxide (NO) serving to
oxygenate arterial blood in the pulmonary alveoli. This respiratory function of the paranasal sinuses may
indeed be their most important. NO trapped in the ethmoidal spaces also accounts for certain radiographic
aspects associated with nasal polyposis.
© 2018 Published by Elsevier Masson SAS.

1. Introduction “nasal polyposis” as an entity in itself, suspected to be allergic in eti-

Nasal polyposis has a foggy and ambiguous past, which loses
itself in the recent history of rhinology. Hippocrates gave the name
“polyp” to any macroscopic tissue mass with a bell-clapper shape in
the nasal cavity, by analogy with aquatic polyps. Nasal specula and
Clar mirrors were long the only means of examining the nostrils,
but from the early 20th century rhinologists were able to base their
diagnoses on facial X-ray, with four views [1]. In the same period,
nasal and facial sinus anatomy was masterfully described, with the
ethmoid considered to be the hub of sinus pathology [2]. The advent
of computed tomography (CT) in the late 20th century enabled fine-
grained radiologic exploration of the sinuses, and in particular of
the ethmoid, which had hitherto been poorly visualized on X-ray.
At the same time, rigid and later flexible endoscopy was developed,
becoming the gold-standard exploration of the nasal cavities and
sinuses [3].
Clar mirrors and nasal specula revealed nasal polyps, which
turned out histologically to be either tumoral or inflammatory. The
very large number of polynuclear eosinophils found in inflamma-
tory polyps, which tended to be bilateral, led to the definition of
∗ Corresponding author.
E-mail address: dt.nguyen@chru-nancy.fr (D.T. Nguyen).
ology. However, radiography revealed systematic sinus opacity in
these patients, and the term “sinonasal polyposis” came to be pre-
ferred. In the same period, the otologic operative microscope was
used to treat polyposis; in the 1980s, however, endoscopy proved
better suited for intranasal surgery. High-resolution CT scans then
drew attention to the ostiomeatal complex as the hub of ventilation
and drainage of the anterior facial sinuses [4,5].
In 1994, a CT study of the common cold [6] found more or less
extensive opacities in the sinuses even in the absence of any clini-
cal symptoms of acute sinusitis, highlighting the apparently unitary
response of the nasal and sinus mucosa to aggression; this unity was
suggested in the 17th century by Schneider, for whom this mucosal
membrane was named [7], and strengthened by Zuckerkandl’s
work in the 19th century [2]. In parallel to this CT study, the main
international consensus statements agreed on the term “chronic
rhinosinusitis” as designating this unity [8–10], clinically differ-
entiating rhinosinusitis with and without nasal polyps (CRSwNP,
CRSsNP), but maintaining the hypothesis of unitary causes and
inflammatory pathology underlying both, rejecting the earlier posi-
tion statement which distinguished nasal polyposis from other
polyps [11].
The aim of the present review is to put forward an original
description of nasal polyposis based on an evo-devo approach
to nasal and sinus pathology, characterizing it as a chronic

https://doi.org/10.1016/j.anorl.2018.03.004
1879-7296/© 2018 Published by Elsevier Masson SAS.

Please cite this article in press as: Jankowski R, et al. Nasal polyposis (or chronic olfactory rhinitis). European Annals of Otorhinolaryn-
gology, Head and Neck diseases (2017), https://doi.org/10.1016/j.anorl.2018.03.004
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inflammatory disease specifically of the non-olfactory ethmoid
mucosa, rather than as a form of chronic rhinosinusitis, which
would be a non-specific inflammatory disease of the nasal and sinus
mucosa as a whole.
2. Clinical presentation
Diagnosis of nasal polyposis is entirely based on an aspect of
edematous polyps in both nasal cavities [8–11]. They appear to
prolapse outward (middle meatuses) or inward (olfactory grooves)
with respect to the middle turbinates [12].
Polyp volume in the two nasal cavities tends to be asymmet-
ric, and is classically graded as stage 0 = no polyps, stage 1 = polyps
only in the middle meatus, stage 2 = polyps projecting beyond the
middle meatus without entirely obstructing the nose, and stage
3 = polyps entirely obstructing the nose [8]. We use this classifica-
tion, with the following refinements: in stage 1, polyps do not go
beyond the free edge of the middle turbinate, whether located in the
middle meatus or in the olfactory groove; in stage 2, polyps touch
the back of the inferior turbinate; in stage 3, polyps touch the floor
of the nasal cavity; and in stage 4 polyps reach the nasal vestibule.
Certain cases of polyposis developing more posteriorly and prolaps-
ing into and obstructing the nasopharynx can also be classified as
stage 4, distinguishing stage 4a (anterior or vestibular) and stage 4b
(posterior or nasopharyngeal). Conversely, certain florid forms of
unilateral polyposis may be associated with contralateral polypoid
edema of the middle meatus or olfactory groove, and can be classi-
fied as stage 0a if the polypoid edema is visible only unilaterally or
as stage 0b if it is visible on both sides of the middle turbinate.
In reporting polyposis stage, it is important to specify whether
endoscopy was performed with or without vasoconstrictors.
The symptomatology of nasal polyposis is polymorphous, ran-
ging from no functional trouble to various isolated symptoms such
as nasal obstruction, anosmia, etc., to unbearable chronic or recur-
rent nasal dysfunction [13]. In case of olfactory fluctuation or loss,
however, polyposis should be screened for when endoscopic diag-
nosis is difficult, especially in the early stages of the disease.
3. CT presentation
A search of PubMed for 1980–2017 with the search-terms “nasal
polyposis” and “nasal polyps” found no studies of CT imaging of
nasal polyposis as clinically defined. There are not even any sections
focusing on imaging of “chronic rhinosinusitis withy polyps” in any
of the international position papers [8–10].
Fig. 1. CT, coronal slices: nasal polyposis: a: coronal slice through frontal sinuses; b: coronal slice through the maxillary sinus ostia (more precisely, through the maxillonasal
canals). Arrow shows left maxillonasal canal; asterisk shows aspect of suspected prolapse of ethmoidal polyp in right maxillary sinus. R: right; L: left.
Please cite this article in press as: Jankowski R, et al. Nasal polyposis (or chronic olfactory rhinitis). European Annals of Otorhinolaryn-
gology, Head and Neck diseases (2017), https://doi.org/10.1016/j.anorl.2018.03.004
Many articles, on the other hand, have studied and classified
ethmoidal and sinus opacity in chronic rhinosinusitis without and
without polyps: no correlations emerged between CT aspect and
clinical presentation [14–17]. The various position papers advise
against founding diagnosis of chronic rhinosinusitis on CT alone
rather than on chronic symptomatology, with endoscopy to distin-
guish rhinosinusitis with and without polyps [8–10]. However, not
all functional disorders of the nose are due to inflammation, and
the term “chronic nasal dysfunction” seems more appropriate than
“chronic rhinosinusitis” as an a-priori designation of nasal func-
tional pathology as such [18] and to assess its specific impact on
quality of life [19].
Nasal and sinus CT does, however, enable the concept of chronic
rhinosinusitis to be reconsidered in the light of the new concepts
of evo-devo theory [20] and sinusology [21].
Fig. 1, for example, shows CT imaging of a case of nasal polypo-
sis comprising two coronal slices: one through the frontal sinuses,
and one through the ostium (or more precisely, the maxillonasal
canal) of the maxillary sinuses. How then does classic sinus venti-
lation/drainage theory explain the radiotransparency of the frontal
and maxillary sinuses in the patient seen in Fig. 1, in whom the
two ostiomeatal complexes containing the frontal and maxillary
ostia seem opacified by the edematous ethmoidal pathology? And
how to explain the gaseous aspect in the superior ethmoidal spaces
(Fig. 1b)? The explanatory power of classical sinus ventilation the-
ory should be compared to that of evo-devo theory.
The hypothesis of sinus ventilation renewing the “intrasinus air”
derives from the late 19th century description of cavities devel-
oping from and dependent on the nasal cavities [22]. There are,
however, few studies in healthy volunteers seeking to confirm this
sinus ventilation in the strict sense of the term (i.e., renewal of
intra-sinus air by nasal cavity air), and their conclusions have been
unsure and unconvincing [23,24]. Probable ostial dysfunction due
to eosinophil inflammation in polyposis further hinders under-
standing of frontal and maxillary sinus ventilation in Fig. 1 (the
sphenoidal sinuses were also radiotransparent in this patient).
The evo-devo hypothesis regarding paranasal sinus formation
offers a more rational explanation. The maxillary, frontal and sphe-
noidal sinuses (the ethmoid not being a sinus in evo-devo theory
[20]) result from bone cavitation following red marrow degenera-
tion. This “pneumatization” also concerns the vertebrae, sternum
and avian wing bones, and is poorly understood biologically; at
all events, it leaves a bone cavity covered by epithelium generat-
ing nitric oxide (NO) [25]. Thus, even in case of ostial dysfunction
due to inflammation in nasal polyposis, NO production by the sinus
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mucosa would be enough to account for the gaseous radiotrans-
parency of the cavity. The gaseous aspect in the superior ethmoidal
spaces (Fig. 1b) would then be boli of NO released from the sinus
cavities, and trapped between the polyps in the lateral ethmoidal
masses.
In evo-devo theory, the paranasal sinuses and the ethmoid have
different origins, which helps understand the difference in patho-
logical aspect on CT. The radio-opacities seen in Fig. 1, caused by
nasal polyposis confirmed on endoscopy, are basically ethmoidal.
They support the findings of exploration during endoscopic surgery
to determine the origin of the polyps, showing that they are clearly
of ethmoidal origin, prolapsing into the middle meatus and/or the
olfactory groove [12]. Once the ethmoid is not seen as a sinus, it can
be phylontogenically considered as the skull-base bone contain-
ing the sensory mucosa of the olfactory nose [26]. Human bipedal
stance may be responsible for its division into olfactory grooves,
of which only the superior recess is covered by olfactory mucosa,
and lateral masses covered by non-olfactory or, more likely, ves-
tigial olfactory mucosa [20]. Phylontogenically, the non-olfactory
ethmoid mucosa may result from degeneration of olfactory mucosa
originally covering the ethmoidal bone entirely, and thus in fact be
vestigial olfactory mucosa. Immunohistochemical study of the lat-
eral ethmoid mucosa has never been undertaken with this point
of view in mind, and this hypothesis of vestigial mucosa requires
further evidence.
Ethmoidal polyps may prolapse into the paranasal sinuses, as
Fig. 1b suggests on the right. Ethmoidal polyp prolapse into the
maxillary sinus may be a simple mass effect due to their volume,
while prolapse into the frontal and sphenoidal (and indeed maxil-
lary) sinuses may be due to depression following each active release
[27] of a bolus of NO [21].
At all events, polyps and nasal polyposis never in our experience
develop from the paranasal sinuses or from the respiratory nose.
4. Clinical forms
Nasal polyposis is defined as a chronic inflammatory disease of
the ethmoid or olfactory nose [20], in other words a chronic olfac-
tory rhinitis characterized endoscopically by bilateral edematous
polyps and on CT by ethmoidal opacities. Different presentations
can be distinguished:
4.1. Typical form
Typical form: that described above.
4.2. Associated forms
4.2.1. Nasal polyposis with associated sinus opacities
Maxillary, frontal and sphenoidal sinus opacities are very fre-
quent on CT scans in nasal polyposis, varying in presentation from
sinus to sinus and patient to patient. They indicate associated
paranasal sinus pathology:
• opacity suggesting a simple serous sinus cyst need not have any
impact on how polyposis is managed;
• in case of opacity suggesting mucosal hypertrophy not likely to
hinder NO production, ostial function should be preserved;
• opacity suggesting secretion retention may be an indication for
aspiration-drainage through the natural ostium, to determine the
type of secretion: seromucous, purulent, or sometimes firm and
adhesive, requiring endoscopic sinusotomy for evacuation;
• when sinus opacity is complete, this does not in itself determine
its nature;
Please cite this article in press as: Jankowski R, et al. Nasal polyposis (or chronic olfactory rhinitis). European Annals of Otorhinolaryn-
gology, Head and Neck diseases (2017), https://doi.org/10.1016/j.anorl.2018.03.004
3
• associated opacity suggestive of a sinus fungus ball may be an
indication for surgery.
4.2.2. Nasal polyposis associated with olfactory groove
hamartoma
Respiratory epithelial adenomatoid hamartoma (REAH) [28]
should be suspected in case of opacification and enlargement of
the olfactory grooves on CT [29]. Not all olfactory groove polyps are
REAHs, and only histology can confirm diagnosis if suspect polyps
are identified for pathologic analysis [30].
4.2.3. Nasal polyposis associated with septal deviation
Septal deviation may be an additional factor of nasal obstruction,
and hinder local therapy.
4.2.4. Nasal polyposis associated with allergic rhinitis
Only the clinical manifestations of seasonal allergic rhinitis can
easily be diagnosed if they have begun in adolescence, before onset
of polyposis, and if the season still exacerbates the year-long symp-
toms of the polyposis [31].
4.3. Associated respiratory and systemic forms
These will only be mentioned here, being well described else-
where:
• nasal polyposis and asthma;
• polyposis and intolerance for aspirin and non-steroidal anti-
inflammatory drugs (NSAIDs);
• Fernand Widal (or Samter) triad: polyposis + asthma + NSAID
intolerance;
• tetrad: triad + chronic otitis media with effusion [32].
• otitis media with effusion represents a spread of the inflamma-
tory disease to all the cavities formed by pneumatization, and
may be associated with general impairment of NO production.
4.4. Unilateral nasal polyposis
Unilateral nasal polyposis with healthy contralateral ethmoid
on CT represents, if not proven otherwise, a tumor masked by sen-
tinel edematous polyps.
Unilateral nasal polyposis, of whatever stage, with pathological
contralateral ethmoid on CT may represent an asymmetric polypo-
sis.
4.5. Childhood idiopathic nasal polyposis
Nasal polyposis is usually diagnosed in adulthood. In case of
diagnosis before the age of 18 years, cystic fibrosis, primary ciliary
dyskinesia syndrome and immune deficiency should be screened
for systematically. If etiological work-up is negative, childhood
idiopathic nasal polyposis can be diagnosed, with treatment as in
adults [33,34].
4.6. Non-allergic rhinitis with eosinophilia syndrome (NARES or
NAORES)
Clinical and CT symptoms are those of typical nasal polypo-
sis, but without visible polyps on endoscopy [35]. Eosinophilia
exceeding 20% on cytologic examination of nasal secretions indi-
cates NARES. In case of eosinophilia < 20%, olfactory fluctuation or
impairment may indicate NARES. Progression toward nasal polypo-
sis is possible [36]. According to the concepts of evo-devo theory,
the term NARES should be replaced by NAORES (non-allergic olfac-
tory rhinitis with eosinophilia syndrome).
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5. Differential diagnoses 5.4. Chronic respiratory rhinitis

5.1. Chronic bilateral edematous-purulent sinusitis
Nasal polyposis can be distinguished from bilateral edematous-
purulent sinusitis on the following criteria:
• edematous lesions are mainly found in the middle meatus and
only exceptionally in the olfactory grooves; they are mixed with
purulent secretions, which may present as a simple purulent flow
coming from the middle meatus or as dirty secretion spreading
through the nasal cavities;
• germ-adapted antibiotics do not prevent rapid recurrence
of pathological secretion production with nasal obstruction,
whereas they are able to “clean up” superinfected polyposis,
restoring a typical endoscopic aspect;
• CT systematically shows obvious opacities in the maxillary or
frontal sinuses, associated with ethmoidal opacity that is some-
times limited to the anterior part of the ethmoid.
Screening for dental infection, immune deficiency, bronchiec-
tasis and chronic bronchitis enhances the clinical diagnosis and
improves the treatment strategy.
Given these distinctive criteria, cystic fibrosis and primary
ciliary dyskinesia more often give rise to edematous-purulent
sinusitis than to true nasal polyposis.
5.2. Churg-Strauss syndrome
Churg-Strauss syndrome may mimic infected polyposis or bilat-
eral edematous-purulent sinusitis, but generally with associated
asthma, impaired general health status, fever, or other locations
(lung, heart, prostate, skin, etc.). Hypereosinophilia of the blood
should be screened for and the patient should be quickly referred
to internal medicine [37].
5.3. Bilateral antro(sino)choanal polyp
The most frequent presentation of sinochoanal (antro-,
sphenoido- or fronto-choanal) polyps is the typical unilateral antro-
choanal polyp with its cystic antral part and solid, fleshy nasal
or choanal part. It may be confused with nasal polyposis if bilat-
eral or if contralateral ethmoidal opacities are associated with the
classical, unilateral presentation. Surgical dissection usually cor-
rects diagnosis, as the ethmoidal opacities are found to be simply
secretion retention.
Phylontogenically, the respiratory nose develops by reposition-
ing and remodeling of the secondary palate bones, which roll
up into two air ducts under the olfactory nose. In humans, the
transverse plate separating the respiratory from the olfactory nose
has disappeared [20], but there remains a specific respiratory
nose pathology as a reminder of the original anatomic separation
[38].
In our experience, allergic rhinitis is typically restricted to the
respiratory nose. In forms progressing for several years without
treatment, nasal endoscopy finds major hypertrophy of the infe-
rior turbinates, submerged in mucosal hypersecretion, with edema
of the free edge of the middle turbinates, which may be mistaken
for nasal polyposis. CT corrects diagnosis, in case of allergic rhini-
tis showing no pathological opacity of the ethmoid or paranasal
sinuses while the two respiratory ducts are considerably narrowed
if not closed (Fig. 2). Allergy does not seem to be the only cause
of chronic respiratory rhinitis, as the presentation may occur in
association with a negative allergologic work-up [38].
6. Pathogenesis
The evo-devo theory of the formation of the nose portrays the
human and more generally mammalian nose as an evolutionary
assembly of three noses that is reiterated during development [20],
with nasal polyposis as specific to the olfactory nose.
The olfactory nose developed in the first vertebrates (fish)
by invagination of ectodermal olfactory placodes above the oral
cavity toward the primitive brain, with a connection between
the olfactory placode chemosensory cells and the primitive
neural tissue via a mesenchyme which is the origin of the
prechordal cartilage, which in turn is undoubtedly the phylo-
genic precursor of the human ethmoid bone. Bipedalism probably
induced the human compartmentalization of the ethmoid into
olfactory grooves, with only the superior recess containing
olfactory mucosa, and lateral masses in which the original
olfactory mucosa may have degenerated into vestigial olfactory
mucosa.
Secondarily, the respiratory nose developed at the expense of
the oral cavity, below the olfactory nose, by repositioning and
remodeling of the secondary palate bones in the first terrestrial
tetrapods. During the evolution of therapsids (the ancestors of
mammals), it progressively pushed back the respiratory orifices
of the amphibian olfactory nose, known as primary choanae, seen
in their vestigial state in humans as the incisive canal, which
open behind the primary palate. Two respiratory ducts open

Fig. 2. CT, coronal slices: chronic allergic respiratory rhinitis progressing without treatment for several years: a: anterior slice, showing almost closed respiratory ducts
secondary to hypertrophy of the respiratory nose mucosa. Opacities in the respiratory nose, but no pathological opacity in the olfactory nose (ethmoid) or paranasal sinuses;
b: slice through maxillonasal canals, showing persistent radiotransparency of the maxillary sinuses despite probable extension of inflammation to the maxillary ostia; sinus
NO production is maintained, and repeated NO release from the maxillary and frontal sinuses probably underlies the gaseous content of the ethmoidal spaces.

Please cite this article in press as: Jankowski R, et al. Nasal polyposis (or chronic olfactory rhinitis). European Annals of Otorhinolaryn-
gology, Head and Neck diseases (2017), https://doi.org/10.1016/j.anorl.2018.03.004
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perpendicularly to the glottis via secondary choanae, thus coming
to be interposed between the oral cavity and the olfactory nose. The
floor of the olfactory nose, separating it from the respiratory nose
and known as the transverse plate in mammals, has disappeared in
humans, probably due to bipedalism.
No aquatic animals have paranasal sinuses. In humans, they
begin to develop only postnatally. The transformation of red
marrow into fat and subsequent bone cavitation was confirmed
in children on MRI. In adulthood, the sinus mucosa continually
produces NO, actively released into the inspired air and transported
to the pulmonary alveoli where it enhances arterial blood oxygen-
ation [39]. This respiratory function of the sinuses is, more than any
of their previously supposed functions, perhaps their real purpose
and should therefore be conserved whenever the pathology allows.
In contrast to Schneider’s macroscopic theory [7] and Zuck-
erkandl’s anatomic theory [2], the pituitary mucosa, despite its
histologic aspect, does not seem to be of a single origin.
The evo-devo theory of the formation of the nose sees the patho-
genesis of nasal polyposis as very different from that of chronic
rhinosinusitis. The latter is attributed to external aggression: pol-
lution, viruses, bacteria and antigens, allergens, climatic factors, etc.
[8,10]. According to evo-devo theory, nasal polyposis is a chronic
inflammatory disease of the vestigial ethmoidal olfactory mucosa
[20].
As we learned from our teachers, “it isn’t everyone who can
get polyposis”, underlining the probable role of intrinsic factors.
If the mucosa of the lateral mass of the ethmoid really does derive
from degeneration of the olfactory mucosa originally covering the
ethmoturbinates as they curved and stacked up like the layers of
an onion during evolution and development [40], then it is possi-
ble that in some subjects this involution of the olfactory mucosa
remains incomplete, leaving some elements of the original olfac-
tory mucosa, such as Jourdan cells [41] or simply self-antigens.
The hypothesis that autoimmune inflammation may underlie nasal
polyposis remains to be investigated.
The rhinosinusitis theory of nasal polyposis is founded on the
functional surgery concept of sinus ventilation-drainage and con-
sequent maximal resection of the inflammatory mucosa with wide
opening of the sinuses so as to give access to the mucosa for local
anti-inflammatory treatment. The evo-devo concept of nasal poly-
posis, in contrast, is in line with the older surgical strategy of
radical eradication of the mucosa, but now with a precise target:
the non-olfactory ethmoid mucosa. The aim of surgery is thus to
remove this vestigial olfactory mucosa, liable to maintain chronic
ethmoidal inflammation, while conserving or restoring olfactory
function. These two contrasting surgical attitudes should be com-
pared to future medical strategies which promise to improve upon
the proven but variable efficacy of local and general corticosteroids.
7. Treatment
General route corticosteroids have been known to be effective
against nasal polyposis since they first came onto the market, but
the adverse effects of iterative or continuous administration led to
the development of local corticosteroids, which have shown good
efficacy and tolerance over the long term. Efficacy in certain cases
of polyposis, however, is variable, leading to surgical indications
and, more recently, new pharmacological solutions.
7.1. Surgical treatments
7.1.1. Functional Endoscopic Sinus Surgery (FESS)
Since 1991, functional sinus surgery has been suspected to be
insufficient [42], which was confirmed even by advocates of FESS
in 2006 [43].
Please cite this article in press as: Jankowski R, et al. Nasal polyposis (or chronic olfactory rhinitis). European Annals of Otorhinolaryn-
gology, Head and Neck diseases (2017), https://doi.org/10.1016/j.anorl.2018.03.004
5
7.1.2. Radical ethmoidal surgery (nasalization)
Since 1997, nasalization has been reputed to be more effec-
tive [44], although this remains debated [45]. Comparison between
surgical techniques, however, is obscured by the names given to
them, which do not quite represent the same surgical attitude.
Thus, radical ethmoidectomy [45] may not be comparable either
to nasalization [44] or to FESS, diplomatically referred to as “addi-
tional surgery”, as the procedures the term covers are so many
and varied [43]. Nasalization itself has been modified in terms of
performance [46], although, since its origins, the surgical objective
remains the most complete resection possible of the non-olfactory
ethmoid mucosa [44].
7.1.3. Pharmacology research
Anti-IgE [47] and anti-IL5 [48] monoclonal antibodies are
thought to be promising. The autoimmune hypothesis may also
inspire research. Nor should a possible role of NO be overlooked,
with its molecular simplicity but multiple potential functions, most
of which remain poorly known, especially in the nose [49].
8. Conclusion
The evo-devo three-nose theory is a new paradigm in rhinology.
Distinguishing nasal polyposis as specifically a disease of the olfac-
tory nose and particularly of the ethmoid seems to offer a more
precise and rigorous diagnostic approach and greater treatment
efficacy than the concept of chronic rhinosinusitis. The scientific
debate remains open.
Disclosure of interest
The authors declare that they have no competing interest.
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