Nasal Polyposis (eBook)

T. Metin Önerci is full Professor of Otorhinolaryngology at the Hacettepe University, Faculty of Medicine, Ankara, Turkey. He serves as General Secretary of the International Rhinologic Society and is the immediate Past President of the Otorhinolaryngology-Head and Neck Society in Turkey. He recently also served as President of the International Society of Otorhinolaryngologic Allergy and Immunology, as President of the European Rhinology Society and as President of the ISIAN (International Symposium on Infection and Allergy of the Nose).

Foreword 5
Preface 7
Contents 9
1: History of Nasal Polyposis 12
1.1 Introduction 12
1.2 The History of Rhinology and Nasal Polyps 12
1.3 Etiology and Pathophysiology 12
1.4 Diagnosis of Nasal Polyps 13
1.5 Treatment of Nasal polyps 14
1.5.1 Medical Treatment 15
1.5.2 Surgical Treatment 15
1.6 Conclusions 17
References 17
2: Epidemiology of Nasal Polyps 19
2.1 Introduction 19
2.2 Allergy and Asthma 20
2.3 Gender and Age 21
2.4 Genetics 21
2.5 Aspirin Intolerance 22
2.6 Allergic Fungal Rhinosinusitis 22
2.7 Ethnicity and Geography 23
References 24
3: Pathology of Nasal Polyps 26
3.1 Introduction 26
3.2 Normal Sinonasal Histology 26
3.2.1 Structural Component 26
3.2.2 Nonstructural Components 28
3.3 Nasal Polyp Histopathology 29
3.3.1 Chronic Rhinosinusitis with Nasal Polyps 29
3.3.1.1 Macroscopic Pathology 29
3.3.1.2 Microscopic Pathology 30
3.3.2 Bone Changes 32
3.3.3 Mucus Histopathology, Including “Eosinophilic Mucus” 32
3.3.4 Antrochoanal Polyps 32
3.3.5 Noninflammatory Polypoid Lesions 33
3.4 Conclusions 34
References 34
4: The Inflammatory Process in Nasal Polyposis: Genetics, Molecular Biology, and Electrophysiology 36
4.1 The Nasal Polyp Represents an End-Stage of Chronic Inflammation 36
4.2 Genetic Predisposition and Staphylococcal Enterotoxins as Two Predisposing Factors in the Development of Chronic Hyper 37
4.3 Cytokines in the Nasal Polyp Mucosa 37
4.4 TNF-a and VCAM 1 38
4.5 The Eosinophil and Alterations in the Electrophysiology of the Nasal Epithelial Cell Sodium Channel Alterations
4.6 Summary 41
References 42
5: Eosinophil 44
5.1 Introduction 44
5.2 Pathogenesis: The Role of the Eosinophil 44
5.2.1 Development of Eosinophils 44
5.3 Trafficking of Eosinophils 45
5.3.1 Recruitment 45
5.3.2 Adhesion 45
5.3.3 Activation of Eosinophils 46
5.3.4 Eosinophil Secretory Products 46
5.4 Pharmacological Approaches to Treating Eosinophilic Sinusitis 49
5.5 Conclusion 50
Take Home Pearls 50
References 51
6: Radiologic Imaging of Nasal Polyposis 53
6.1 Introduction 53
6.2 Radiologic Appearance of Sinonasal Polyps 53
6.3 Special Types of Sinonasal Polyps 55
6.4 Complications 56
6.5 Radiologic Differential Diagnosis 58
6.5.1 Acute Rhinosinusitis 58
6.5.2 Mucus Retention Cyst 58
6.5.3 Other Benign Masses 58
6.5.4 Malignancy 59
6.5.5 Dense Secretions 59
6.5.6 Cystic Fibrosis 59
6.6 Radiologic Modalities 60
Take Home Pearls 60
References 60
7: Pathogenesis and Pathophysiology of Nasal Polyps 61
7.1 Introduction 61
7.2 Adenoma and Fibroma theory 61
7.3 Necrotizing Ethmoiditis Theory 61
7.4 Glandular-Cyst Theory 62
7.5 Mucosal Exudate Theory 62
7.6 Theory on Cystic Dilatation of the Excretory Duct of Nasal Glands and Vessel Obstruction 64
7.7 Blockade Theory 64
7.8 Peri-Phlebitis and ­Peri-Lymphangitis Theory 64
7.9 Glandular Hyperplasia Theory 64
7.10 Epithelial Rupture Theory 65
7.11 Mucous Glands in Nasal Polyps 65
7.12 Formation and Growth of Glands 67
7.13 Gland Degeneration 67
7.14 Cellular Infiltration in the Pathophysiology of Nasal Polyps 68
References 71
8: Mucin Expression in Nasal Polyps 72
8.1 Introduction 72
8.2 Mucin Genes 72
8.3 Sources of Mucus Hyper-Secretion in Nasal Polyps 73
8.4 Studies of Mucin Gene Expression in Nasal Polyps 73
8.4.1 Techniques 73
8.4.2 Control Mucosa for Mucin Gene Studies in Nasal Polyps 73
8.4.3 Main Studies 74
8.5 Mucin Gene Expression in Nasal Polyps 74
8.5.1 General Mucin Gene Expression Profile 74
8.5.2 Individual Mucin Genes 76
8.5.2.1 MUC1 76
8.5.2.2 MUC2 76
8.5.2.3 MUC3 and 6 76
8.5.2.4 MUC4 76
8.5.2.5 MUC5AC 77
8.5.2.6 MUC5B and 7 77
8.5.2.7 MUC8 77
8.6 Steroids and Mucin Expression in Nasal Polyps 77
8.7 Discussion 78
8.8 Future Work 78
References 78
9: Biofilms 81
9.1 Introduction 81
9.2 What is a Biofilm? 81
9.3 Biofilms and Chronic Rhinosinusitis: What is the Evidence? 82
9.4 Chronic Biofilm Diseases 83
9.5 Pathophysiology 83
9.6 Antibiotic Resistance 84
9.7 Mucociliary Clearance Effects 85
9.8 Treatments 85
9.9 Conclusions 86
References 86
10: Staphylococcus-aureus.-derived Superantigens in Nasal Polyp Disease 88
10.1 Introduction 88
10.2 Superantigenic Properties of Staphylococcus aureus Enterotoxins 89
10.3 Invasion of Nasal Tissue by Staphylococcus aureus 91
10.4 Augmented Immune Response to SAE in Polyps 92
10.5 Mechanisms Leading to Polyps 93
10.6 Relation to Eicosanoid Metabolism and Aspirin Sensitivity 95
10.7 Clinical Implications 96
10.8 Summary and Perspectives 97
References 98
11: Fungal-Induced Inflammation and Nasal Polyps 100
11.1 Introduction 100
11.2 Fungus Is Among Us 100
11.3 The Immune Response to Fungi 101
11.4 The Destructive Power of Eosinophils 102
11.5 An Immunologic Defense? 103
11.6 Alternaria-Induced Eosinophil Degranulation 103
References 105
12: Categorization of Nasal Polyps 107
12.1 Symptom Scores 107
12.2 CT Imaging Categorization 109
12.3 Endoscopic Scoring 110
12.4 Specific Nasal Polyp Scoring 110
12.5 Objective Measures of Nasal Function for Categorization 111
12.6 Histologic Categorization 112
12.7 Presence of Bacteria or Fungus 112
12.8 Categorization by Disease Severity and Medication Requirements 112
References 114
13: Nasal Polyps and Lower Respiratory Tract Relationship 115
13.1 Introduction 115
13.2 Prevalence of Nasal Polyps in Diseases of Lower Respiratory Tract 115
13.3 Link Between Nasal Polyps and Lower Airways 116
13.4 Inflammatory Mechanisms of NP in Diseases Other than Bronchial Asthma 116
13.5 Inflammatory Mechanisms in NP and Bronchial Asthma 116
13.6 The Role of Cysteinyl Leukotrienes in Nasal Polyps and Bronchial Asthma 117
13.7 The Role of Microorganisms in Nasal Polyps and Bronchial Asthma 117
13.8 Effect of Nasal Polyps on Bronchial Hyperreactivity 117
13.9 Effect of Sinus Surgery on Clinical and Therapeutic Outcomes of Bronchial Asthma 118
13.10 Effect of Pharmacotherapy of Nasal Polyps on Bronchial Asthma 118
13.10.1 Corticosteroids 118
13.10.2 Leukotriene Inhibitors 119
13.10.3 Zileuton 119
13.10.4 Leukotriene Receptor Antagonists 119
13.10.5 Aspirin Desensitization 119
13.10.6 Other Agents 119
References 120
14: Nasal Polyp, Analgesic Intolerance, and Bronchial Hyperreactivity 123
14.1 Introduction 123
14.2 Histopathology 124
14.3 Bronchial Hyperreactivity, Bronchial Asthma, and Aspirin-Induced Asthma 125
14.4 Clinical Features, Associated Conditions, and Quality of Life 126
14.5 Diagnosis of AI and BHR 127
14.6 Treatment 128
References 128
15: Allergic Fungal Sinusitis 131
15.1 Introduction/History 131
15.2 Epidemiology and Microbiology 132
15.3 Clinical Presentation 132
Diagnostic Criteria for AFS 132
15.4 Diagnostic Criteria 133
Imaging Findings in AFS 134
15.5 Radiologic Features 134
15.6 Pathophysiology 136
Treatment of AFS 136
15.7 Treatment 136
15.8 Natural Course 138
Take Home Pearls 138
References 138
16: Vasculitis Including Churg–Strauss Syndrome 140
16.1 Introduction 140
16.2 Vasculitic Diseases 140
16.2.1 Wegener’s Granulomatosis 140
16.2.2 Churg–Strauss Syndrome 143
16.2.3 Microscopic Polyangiitis 143
16.2.4 Polyarteritis Nodosa 144
16.2.5 Cryoglobulinemic Vasculitis 144
Take Home Pearls 145
References 145
17: Nasal Polyps in Cystic Fibrosis 147
17.1 Introduction 147
17.2 Epidemiology of Sinonasal Disease in Cystic Fibrosis 147
17.3 Etiology 147
17.3.1 Genetics 147
17.3.2 Pseudomonas Colonization 148
17.3.3 Allergy 148
17.4 Pathology 148
17.5 Clinical Presentation 149
17.6 Investigations 149
17.6.1 Radiology 149
17.6.2 Microbiology 150
17.7 Management 150
17.7.1 Medical 150
17.7.2 Surgery 150
17.7.2.1 Extent of Surgery 151
17.7.3 Novel Treatments 151
17.7.3.1 Dornase Alfa 151
17.7.3.2 Ibuprofen 151
17.7.3.3 Antibiofilm Therapies 152
17.7.4 Management of Nasal Polyps Prior to Lung Transplantation 152
17.8 .Conclusion 152
References 152
18: Nasal Polyposis in Children: A Differential Diagnosis and Algorithm 155
18.1 Introduction 155
18.2 Antrochoanal Polyp 155
18.3 Cystic Fibrosis 156
18.4 Encephaloceles or Meningoencephalocele 158
18.5 Idiopathic Nasal Polyposis 158
18.6 Primary Ciliary Dyskinesia (PCD) 159
18.7 Saccharin Test 159
18.8 Ciliary Beat Frequency 159
18.9 Electron Microscopy 159
18.10 Immunodeficiency 160
18.11 Allergic Aspergillosis 161
18.12 Tumours 162
References 162
19: Olfaction and Nasal Polyposis 165
19.1 Introduction 165
19.1.1 Bullet Messages 166
19.2 Impaired Olfaction: An Important Primary Symptom in CRS with Nasal Polyposis 166
19.3 Clinical Olfactory Testing 166
19.4 Taste and Smell 166
19.5 Subjective Test Methods 167
19.6 Trigeminal Nerve Assessment 169
19.7 Objective Test Methods 169
19.7.1 Bullet Messages 170
19.8 Nasal Airflow Patterns and Olfaction 170
19.8.1 Bullet Messages 170
19.9 Location of the Olfactory Epithelium 170
19.9.1 Bullet Messages 171
19.10 The Medical Management of Disordered Smell in CRS with Nasal Polyposis 171
19.11 Sinus Surgery and Olfaction in CRS with Nasal Polyposis 172
19.12 Tailor the Surgery to the Extent of the Problem 172
19.12.1 Bullet Messages 172
19.13 Impact of Endoscopic Sinus Surgery on Olfactory Function in CRS with Nasal Polyposis 173
19.13.1 Bullet Messages 173
19.14 Conclusions and Perspectives 173
References 174
20: New Areas for Investigation: Nitric Oxide 176
20.1 Introduction 176
20.2 Nitric Oxide Synthesis and Metabolism 176
20.3 Biological Activities 178
20.4 Considerations of Nitric Oxide Measurement 178
20.5 Nitric Oxide in Airway Physiology 179
20.6 Nitric Oxide in Chronic Airway Inflammatory Diseases 180
20.6.1 Primary Ciliary Dyskinesia 180
20.6.2 Cystic Fibrosis 180
20.6.3 Allergic Rhinitis 180
20.6.4 Chronic Rhinosinusitis with and Without Nasal Polyposis 181
20.7 Future Perspectives 182
References 182
21: Current Concepts on the Pathomechanisms of Chronic Rhinosinusitis and Nasal Polyps 185
21.1 Introduction 185
21.2 Etiology 185
21.3 Inflammatory Mechanisms in CRS and Nasal Polyps 186
21.4 Remodeling in CRS and NP 187
21.5 Conclusion 188
References 188
22: Relapses After Surgery and Their Prevention 191
22.1 Introduction 192
22.2 Clinical Prevention 193
22.3 Prevention of Eosinophilic Inflammation 193
22.4 Prevention of Changes in Arachidonic Acid Metabolism 194
22.5 Prevention of Edema Formation 194
22.6 Prevention of Tissue Growth/Remodeling 195
22.7 Antimicrobial Prevention 195
22.8 Antifungal Prevention 196
References 197
23: Cortison Therapy in Nasal Polyposis 199
23.1 Introduction 199
23.2 Intranasal Steroids (INS) 200
23.2.1 Postoperative Use of Topical Corticosteroids 201
23.2.2 Side Effects of Intranasal Steroids 202
23.2.3 Oral Corticosteroids and Maximal Medical Therapy 203
23.3 Perioperative Use of Oral Corticosteroids 203
23.3.1 Allergic Fungal Sinusitis 203
23.4 Risks and Side Effects of Oral Corticosteroids 204
23.4.1 Risks of Corticosteroids 204
23.4.2 Risks of Intrapolyp Injection 204
References 205
24: Antifungal Treatment (Topical/Systemic) 207
24.1 Introduction 207
24.2 Topical Antimycotics: An Open Debate 208
24.3 Systemic Oral Antimycotics 212
24.4 Antimycotics After Endoscopic Sinus Surgery 212
24.5 Effects of Amphotericin B 212
24.6 Side Effects of Antimycotics 213
24.7 Conclusions 214
References 215
25: Antibiotic Treatment (Topical/Systemic) 217
25.1 Background 217
25.2 Potential Therapeutic Actions of Antibiotic Agents 218
25.3 Topical Intranasal Antibiotic Agents (Table 25.1) 224
25.4 Systemic Antibiotic Agents 224
25.4.1 Does Short-Term Antibiotic Treatment Confer a Benefit? (Table 25.2) 225
25.4.2 How Do Different Antibiotics Compare? (Table 25.2) 225
25.4.3 Does Long-Term Macrolide Treatment Confer a Benefit? (Table 25.3) 225
25.5 Antibiotic Agents After Endoscopic Sinus Surgery (Table 25.3) 227
25.6 Side Effects of Antibiotic Agents 227
25.7 Conclusions 228
References 228
26: Aspirin Intolerance 231
26.1 Introduction 231
26.2 Postoperative Care and Long-Term Medical Management to Prevent Recurrence 232
26.3 Characteristics of Aspirin Intolerance in Polypous CRS 232
26.3.1 Role of an In Vitro Assay 233
26.4 Aspirin Desensitization 234
26.5 Implications of Eicosanoid Imbalance on the Pathophysiology of Nasal Polyps 235
26.6 Conclusion 236
References 236
27: Where Are We in the Medical Treatment of Nasal Polyps 238
27.1 Introduction 238
27.1.1 Treatment of Nasal Polyposis with Corticosteroids 238
27.1.1.1 Systemic Corticosteroids 242
27.1.2 Treatment of Nasal Polyps with Antibiotics 242
27.1.3 Other Medical Management for Nasal Polyposis 243
27.2 Conclusion 245
References 245
28: Anesthetic Management in Nasal Polypectomy 248
28.1 Anesthetic Management 249
References 251
29: Surgical Treatment of Nasal Polyposis 252
29.1 Introduction 252
29.2 Pathogenesis 252
29.2.1 Nasal Polyps 252
29.2.2 Antrochoanal Polyps 253
29.3 Examination 254
29.4 Imaging Studies 255
29.4.1 Computed Tomography 255
29.4.2 Magnetic Resonance Imaging 257
29.5 Surgical Therapy 257
29.5.1 General Principles 257
29.5.2 Functional Endoscopic Sinus Surgery 258
29.5.3 Image-Guided Surgery 259
29.5.4 Surgical Steps 259
29.6 Postoperative Management 261
29.6.1 Steroid Injection 262
29.7 Conclusions 262
References 263
30: Nasalisation in the Surgical Treatment of Nasal Polyposis 264
30.1 Introduction 265
30.2 Philosophy of the Nasalisation Surgical Procedure 265
30.3 Nasalisation Technique 266
30.3.1 Anatomical Considerations 266
30.3.2 Set-Up 267
30.3.3 Surgical Dissection (Video) 267
30.3.4 Post-Operative Care 269
30.4 Results 269
30.5 Discussion: Controlling the Underlying Pathophysiological Mechanism 272
References 273
31: Reasons for Failure and Complications of Surgery in Diffuse Nasal Polyposis 274
31.1 Postoperative Care 281
31.2 Nasal Polyposis in Children 281
31.3 Complications 282
31.4 Conclusion 286
References 286
32: Nasal Polyposis: Aggressive Sinus Marsupialization Including the Endoscopic Modified Lothrop Procedure 288
32.1 Introduction 288
32.2 Polypoid Chronic Rhinosinusitis with a Poor Surgical Prognosis 288
32.3 Rationale for the EMLP or Frontal Drillout 289
32.4 Surgical Plan and Surgical Technique 290
32.5 Conclusion 294
Take Home Pearls 295
References 295
33: Evaluation of Surgical Treatments 296
33.1 Introduction 296
33.2 Evidence-Based Surgical Treatment of Nasal Polyps 296
33.3 How Do We Measure the Efficacy of Sinus Surgery 297
33.4 Can We Predict the Outcomes of Sinus Surgery 297
33.5 Predictors of Outcomes of FESS in CRS with NP 298
33.6 Surgery as Part of Treatment of Nasal Polyps 299
33.7 Functional Endoscopic Sinus Surgery in Nasal Polyps 299
33.7.1 Conclusion 299
33.8 Functional Endoscopic Sinus Surgery vs. Conventional Surgery 299
33.8.1 Conclusion 300
33.9 Extent of Surgery 300
33.9.1 Conclusion 300
33.10 Revision Sinus Surgery 300
33.10.1 Conclusion 301
References 301
Index 304