Transcript New Insights in the pathogenesis of nasal polyps

Chronic Rhinosinusitis and
Nasal Polyposis
Philippe Gevaert , MD, PhD
Michael A. Kaliner, MD
Paul Van Cauwenberge, MD, PhD
Reviewers: Kamal Hanna, Richard F. Lockey, Todor Popov
Updated: June 2011
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(WAO). Its curriculum educates medical professionals
worldwide through regional and national presentations.
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advocate in the field of allergy, advancing
excellence in clinical care, education, research
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Module 10:
Chronic Rhinosinusitis
and Nasal Polyposis
Lecture objectives
At the end of this presentation, participants will
be able to:
Discuss the underlying pathology of acute and
chronic rhinosinusitis and nasal polyposis
Describe the management of acute and chronic
rhinosinusitis and nasal polyposis
Rhinosinusitis
Facts:
 14.7% incidence in US population: 31,000,000 cases per year
 Incidence increased by 18% over the past 11 years
 26 million office visits for sinusitis in 1997
 >21 million antibiotic prescriptions in 1997
 Third most common diagnosis for antibiotics
 >70 restricted activity days in 1992
 250,000 surgeries per year
Survey IMS Health 2001
Germany, 7/2000-6/2001
Acute sinusitis
Diagnosis: 6.3 million
Prescriptions: 8.5 million
Chronic sinusitis
Diagnosis: 2.6 million
Prescriptions: 3.4 million
Nasal polyposis:
Diagnosis: 221 000
USA, 1997
Prevalence of sinusitis: 14.7%
Prescriptions of antibiotics for
sinusitis
985
1992
5.8 million
13 million
Work loss (days)
1986
50 million
1992
73 million
1.
2.
3.
4.
5.
6.
7.
8.
9.
Maxillary sinus
Ethmoidal bulla
Ethmoidal cells
Frontal sinus
Uncinate process
Middle turbinate
Inferior turbinate
Nasal septum
Ostiomeatal complex
Infections induce changes in sinus
mucosa
The ostiomeatal complex
Ventilation
and
Drainage
B
Key
MT
B: bulla
ethmoidalis
IT: inferior
turbinate
MT: middle
turbinate
MS: maxillary sinus
MS
IT
Inflammation
and
Remodeling
Anatomy & physiology
RADIOGRAPHIC ANATOMY OF THE PARANASAL SINUSES
Coronal
Anterior
Axial
Posterior
Frontal sinuses
Ethmoid sinus
Sphenoid sinus
Maxillary sinus
Posterior ethmoid
Anterior ethmoid
Sphenoid sinus
Anatomy and physiology
MUCOSAL IMMUNITY
Anatomical and mechanical factors: Epithelial barrier
Mucus/mucociliary clearance
Mucosal immune system:
Innate immunity:
Rapid, nonspecific
Antimicrobial peptides: Defensins
Receptors: Toll-like receptors
Cells: Macrophages, neutrophils,
dendritic cells, NK cells, mast cells
Adaptive immunity: Antigen-presenting cells
Specific,
memory
T-lymphocytes
B-lymphocytes => IgA
Aetiology of rhinosinusitis



Allergy
 Seasonal
 Perennial
Infection
 Acute
 Chronic: specific e.g. Bacterial, fungal
or nonspecific
 Possible host defense deficency
Structural
 Ostiomeatal complex:
 Deviated nasal septum
 Hypertrophic turbinates
After International Consensus Report on the diagnosis and
management of rhinitis. Allergy Suppl 19,49,1994

Others
 Dental, periapical abcess
 Underlying diseases, cystic
fibrosis
 Occupational irritants and
allergens
 Drug induced, rhinitis
medicmentosa
 Irritants induced rhinitis
 Atrophic rhinitis
Anatomy and physiology
COMMON COLD
BACTERIAL SUPERINFECTION
Strep pneu./Haemo inf./Morax catar.
Increasing symptoms after 5 DAYS
No resolution after 10 DAYS
ACUTE rhinosinusitis
MULTIFACTORIAL ETIOLOGY
CHRONIC rhinosinusitis
EAACI Position Paper on Rhinosinusitis and Nasal
Polyps, Allergy 2005: 60: 583-601
Underlying conditions

Sinusitis and Immunodeficiencies
Humoral immunodeficencies
frequently associated with sinusitis
Congenital immunodeficencies
Selective IgA deficency, Common variable IgG immunodeficency,
Agammaglobulinemia, specific antibody deficency, (rarely IgG Subclass
deficency)
Acquired immunodeficencies
Immunosupressive agents, HIV

Sinusitis and cystic fibrosis
Classification: chronic rhinosinusitis
with and without nasal polyps
2 OR MORE MAJOR SYMPTOMS

nasal blockage

anosmia/hyposmia

purulent nasal discharge/post-nasal drip

facial pain/pressure
AND EITHER

endoscopic findings of polyps

mucopurulent discharge

edema or obstruction
OR

CT scan abnormality: mucosal changes within ostiomeatal complex or sinus
cavity
EAACI Position Paper on Rhinosinusitis and
Nasal Polyps, Allergy 2005: 60: 583-601
Classification: chronic rhinosinusitis
with and without nasal polyps
DURATION
ACUTE/intermittent < 12 weeks
complete resolution of symptoms
CHRONIC / persistent > 12 weeks
incomplete resolution of symptoms
EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy
2005: 60: 583-601
Symptoms associated with rhinosinusitis
Major symptoms:
Minor symptoms:
Facial pain/pressure
Facial congestion/fullness
Nasal obstruction/blockage
Nasal discharge/purulence/postnasal drip
Hyposmia/Anosmia
Fever
Headache
Fever
Halitosis
Fatigue
Dental pain
Cough
Ear pain/fullness
Microbiology
Normal sinuses: Free of growth
Acute rhinosinusitis:
Viral
Bacterial (Strept. Pneumoniae,H. Influenzae, M. Catharralis)
Chronic rhinosinusitis:
Anaerobes: Propionibacterium, Bacteriodes, Peptococcus
Aerobes: Staphylococcus, Corynebacterium, Pseudomonas
Fungi (Aspergillus fumigatus, Curvularia, Dreschelaria)
Dental sinusitis: Microaerophilic strept. species
Nasal
polyps
Imaging of sinsuses
MRI: only recommended in tumor diagnosis
CT sinuses: current standard imaging
- Acute rhinosinusitis: only for possible complications
- Chronic sinusitis: only after 4+ weeks of treatment!
Septal
deviation
Chronic
Sinusitis
Dental
sinusitis
Nasal
polyps
The signs and symptoms of acute
sinusitis
(>10 days and < 12 weeks):

Prerequisite symptoms
 Persistent upper respiratory
infection (>10 days)
 Persistent muco-purulent nasal or
posterior pharyngeal discharge
 Cough

Supporting symptoms













Congestion
Facial pain/pressure
Post-nasal drip
Fever
Headache
Anosmia, hyposmia
Facial tenderness
Periorbital edema
Ear pain, pressure
Halitosis
Upper dental pain
Fatigue
Sore throat
Diagnosis of acute bacterial sinusitis
(ABS)
A diagnosis of ABS is suggested when
Symptoms of a viral URI
or
Have not improved after
10 days
International Rhinosinusitis Advisory Board. ENT J 1997;76(suppl):1;
Lanza and Kennedy. Otolaryngol Head Neck Surg 1997;117:S1.
Have worsened after 5
to 7 days
Association between viral and bacterial
sinusitis infections

Viral infections
 Self-limiting
 2 to 3 acute viral respiratory infections per year (6-8 in children)
 >80% symptoms resolve in 7-8 days
 Often inciting event for development of sinusitis and other
respiratory tract infections
 0.5%–2% of cases complicated by acute bacterial infection (>20
million cases)
Brook. Primary Care 1998;25:633; Gwaltney. Clin Infect Dis 1996;23:1209;
Gwaltney et al. N Engl J Med 1994;330:25.
Acute bacterial rhinosinusitis (ABRS)
Copyright permission for reproduction pending
Sinus and Allergy Health Partnership, 2000
Therapy





Decongestives/pain
Saline washes
Antibiotics (oral, IV)
Corticosteroids (local, oral)
Surgery:
Adenoidectomy (child)
Endoscopic sinus surgery (adult)
acute
chronic
Strength of evidence for treatment of
acute rhinosinusitis
Therapy
Level
antibiotic
Ia (49 studies)
A
yes: after 5-10days,
or in severe cases
topical corticosteroid
1b (1 study)
A
yes
addition of topical steroid to
antibiotic
Ib (5 studies)
A
yes
oral steroid
no evidence
(1 study)
D
no
addition of oral antihistamine
in allergic patients
Ib (1 study)
B
no
nasal douche
no evidence
(3 studies)
D
no
decongestion
no evidence
(3 studies)
D
Yes as symptomatic
relief
mucolytics
no evidence
(3 studies)
D
no
EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005:
60: 583-601
Recommendation
Relevance
An update on acute rhinosinusitis
management: antibiotics in adults
Cochrane Review Antibiotics for acute maxillary sinusitis

7330 subjects in 32 studies (10 double blind)
 antibiotic vs. control (n=5)
 newer, non-penicillin antibiotic vs. penicillin class (n=10)
 amoxicillin-clavulanate vs. other extended spectrum antibiotics (n=10)

Confirmed radiographically or by aspiration, current evidence is limited
but supports penicillin or amoxicillin for 7 to 14 days. Clinicians should
weight the moderate benefits of antibiotic treatment against the potential
for adverse effects
Williams Jr JW, The Cochrane Library 2003
Evidence for treatment of rhinosinusitis with
topical corticosteroids plus antibiotics - 1
Study
Drug
Antibiotic
Number
Effect
X-ray
Meltzer, 2000
(340)
Momet.
furuate
amox/clav
407
Significant effect in
congestion, facial
pain, headache and
rhinorrhea. No
significant effect in
postnasal drip
No statistical
difference in
CT outcome
Nayak, 2002
(341)
Momet.
furuate
amox/clav
967
Total symptom
Score (TSS) was
improved
(nasal congestion,
facial pain,
rhinorrhea
and postnasal drip)
No statistical
difference in
CT outcome
Evidence for treatment of rhinosinusitis with
topical corticosteroids plus antibiotics - 2
Study
Drug
Antibiotic
Number
Effect
X-ray
Dolor,
2001
(342)
FP
cefurox
95
Significant effect.
Effect measured
As clinical
success
depending on
Patient’s
self-judgment of
symptomatic
improvement
Not done
Evidence for treatment of rhinosinusitis with
topical corticosteroids plus antibiotics - 3
Study
Drug
Antibiotic
Number
Effect
X-ray
Barlan,
1997 (343)
Bud
amox/clav
89
children
Improvement in
cough and nasal
secretion seen at
the end of the
second week of
treatment in the
BUD group
Not done
Meltzer,
1993 (344)
Flunisol.
amox/clav
180
Significant
sympt: overall
score for global
assessment of
efficacy was
greater in the
group with
flunisolide
No effect
on x-ray
Copyright permission for reproduction pending
J Allergy Clin Immunol. 2005 Dec;116(6):1289-95.
Community-acquired
acute sinusitis
Inflammatory component:
Topical corticosteroids
Symptomatic treatment
If unsuccessful,
prolonged,
or primary signs
Primary signs
of bacterial infection:
Localized severe headache
Pus in the middle meatus
Complications (orbital, skin, etc.)
Infectious bacterial component:
Antibiotic treatment
If unsuccessful on
several trials,
or complications
Surgical intervention
Considerations in antibiotic selection
Pharmacokinetics (PK)/
Pharmacodynamics (PD)
Medication
Allergy
Activity Against Likely Pathogen
Ease of Dosing
Considerations
in Antibiotic
Selection
Cost/ Formulary
Status
Adverse Effects
Resistance Patterns
Adapted from Kennedy et al. Ann Otol Rhinol Laryngol Suppl 1995;167:22;
Sinus & Allergy Health Partnership. Otolaryngol Head Neck Surg.
2000;123:S1.
Conditions for effective antibiotic
treatment







Appropriate spectrum
Appropriate penetrance and local activity
Minor side-effects
Good tolerance
Liklihood of no resistence
Affordable
Available
Antibiotic therapy for sinusitis 2007
Penicillin
Macrolide
Amoxicillin
Amoxicillin/clavulanate
Erythromycin/sulfisoxazole
Clarithromycin
Azithromycin
Cephalosporin
Cefuroxime
Cefopodoxime
Cefixime
Cefprozil
Cefdinir
Miscellaneous
Ketolides
Quinalones
Metronidazole
Trimethoprin/sulfamethoxazole
Clindamycin
Recommended antibiotic choices - 2007
First choice:
Amoxicillin/clavulante or cephalosporin
Good second choice: Clarithromycin
Back-ups:
Quinalones
Use metronidazole plus one of the above or clindamycin when gram
negative is suspected
Topical mupiricin very useful in select cases
An update on acute rhinosinusitis management:
Antibiotics in acute rhinosinusitis?





Don’t treat viral common cold with antibiotics
Use symptomatic treatment in mild acute rhinosinusitis
 saline
 decongestant
 NSAID
Use topical steroids in acute and chronic sinusitis (evidence)
Reserve antibiotics for severe acute presumably bacterial
rhinosinusitis
Prescribe antibiotics based on local resistance patterns
Sinusitis - conclusions





Sinusitis is common and over-looked
Causes are complex
Treatment requires appreciation of causes and careful follow-up
Medical management is effective in most cases
Functional endoscopic surgery is helpful in resistant sinusitis after
adequate medical management
Definitions and classification
CLINICAL DEFINITION OF RHINOSINUSITIS/NASAL POLYPS
2 OR MORE MAJOR SYMPTOMS
 nasal blockage
 smell dysfunction
 nasal discharge/post-nasal drip
 facial pain/pressure
AND EITHER

endoscopic findings of polyps

mucopurulent discharge

edema or obstruction
OR
 CT scan abnormality: mucosal changes within ostiomeatal complex or sinus cavity
EAACI Position Paper on Rhinosinusitis and Nasal
Polyps, Allergy 2005: 60: 583-601
The signs and symptoms
of chronic sinusitis
(symptoms persisting >12 weeks):
Prerequisite symptoms
 Purulent nasal and posterior
pharyngeal discharge
 Plus:
 Facial pain/pressure
 Persistent nasal obstruction
 Cough/post-nasal drip/throat
clearing
Supporting symptoms

Hyposmia, anosmia

Sore throat

Malaise

Fever

Headache, facial pressure,
dental pain

Halitosis

Sleep disturbance

Fatigue
Diagnosis of chronic rhinosinusitis
Symptoms suggestive of chronic rhinosinusitis
Initial evaluation:
 Medical history: major, minor symptoms
 General examination
 Evaluation of underlying disease and co-morbidities
 Anterior rhinoscopy,
 Nasal endoscopy
 CT scan (not in an acute episode)
Special indications (differential diagnosis
and underlying disease)







Allergy tests
Microbiology (eventually
sinus puncture)
Challenge test for aspirin
sensitivity
Nasal cytology (eosinophils,
neutrophils)
MRI (if tumor or fungus
suspected)
Ciliary function studies
Biopsy






Biopsy
Blood examinations
(Wegener’s, immunodeficencies)
Sweat chloride test
Electron microscopy of cilia
Genetic analyses
Consultations of other
specialities (ophthalmologist,
neurologist etc.)
Differential diagnosis of chronic
rhinosinusitis - 1








Infectious rhinitis: viral upper respiratory tract infection
Allergic rhinitis: seasonal, perennial, occupational
Nonallergic rhinitis: “Vasomotor rhinitis”, NARES,
aspirin- exacerbated respiratory disease
Rhinitis medicamentosa
Rhinitis secondary to pregnancy, hypothyroidism
Anatomical abnormalities: severe septal deviation,
foreign body
Nasal polyps
Inverted papilloma, benign and malignant tumors
Claus Bachert, Allergy: principles and practice.
Differential diagnosis of chronic
rhinosinusitis - 2








Cerebrospinal fluid leak, meningoencephaloceles
Mucoceles
Wegener‘s granulomatosis
Cocaine abuse
Atrophic rhinitis
Specific or tropic infections
Fungal sinus disease
Ophthalmologic or neurologic diseases
Claus Bachert, Allergy: principles and practice.
Chronic rhinosinusitis: why?




Chronic inflamed (eosinophilic) mucosa
 Possible superimposed infections
 Bacteria
 Fungi
Superantigens
Biofilms
Osteitis
Chronic rhinosinusitis
with and without nasal polyps
Chronic
Rhinosinusitis
Nasal Polyps
The spectrum of sinus disease
Rhinosinusitis
Nasal Polyps
- Eosinophils +
Chronic rhinosinusitis
with and without nasal polyps
Chronic
Sinusitis
Nasal
Polyposis
Facial pain/pressure
Yes
Sometimes
Facial congestion/fullness
Yes
Yes
Nasal obstruction/blockage
Yes
Yes
Nasal discharge/purulence/postnasal drip
Yes
Yes
Anosmia
Sometimes
Yes
Blood eosinophils
Sometimes
Often
Yes
Often
Rarely
10% of cases
Asthma
Aspirin exacerbated respiratory disease
Chronic sinusitis - without nasal polyps
Prevalence of 14.7% in the
normal population
Th1 type Inflammation with

increased IFN 

increased TGF and
remodeling
Pathogenic role of infections
is unclear
Nasal polyposis
Prevalence approx. 2- 4%
Asthma in approx. 40-65%
Aspirin sensitivity in 10-15%
Mixed cellular infiltrate with
prominent eosinophilia in 90%
Inflammation with
 local IgE production
 increased IL-5, eotaxin,
cys-LTs and ECP
Superantigens or superallergens





Bacterial Superantigens
 Staph aureus enterotoxins: SEA, SEB, SEC, SED, SEE, TSST-1
 Strep. pyogenes,
 Mycoplasma arthritidis,
 Yersinia pseudotuberculosis ……
T-Cell
Highly potent immune stimulators
Interact with T-cell R
TCR V V
and MHC class II
MHC II
20% of all T-cells are
activated by SEA
APC
SAg
S. aureus colonization and IgE antibodies to
S. aureus enterotoxin mix in mucosal tissue
Copyright permission for reproduction pending
T. Van Zele, P. Gevaert et al. JACI 2004
Nasal polyposis: aetiology and pathogenesis
Epithelial damage (barrier
dysfunction)
chronic microbial trigger
B
T
Hyper IgE 
Cytokines 
Polyclonal IgE
Albumin
Superantigens
Eosinophils 
( apoptosis)
IL-5
Chemokines
Eotaxin
S. Aureus enterotoxins: disease modifiers
ECP
Recommended approach to the treatment of
chronic rhinosinusitis 2007





Hydration (6 - 8 glasses of water per day)
Antibiotics X 14-21+ days (until asymptomatic +7 days) Choices:
cephalosporin, amoxicillin/clavulanate, clarithromycin, quinalone
Long-acting nasal decongestant, BID X 7 days (oxymetazoline)
Nasal saline applied with nasal irrigation device, BID
Topical nasal CCS:

2 sprays BID, until symptoms resolved

Reduce to lowest effective dose, to maintain remission

Aim towards the eye and away from the nasal septum
Next recommended approaches






Switch antibiotics
CT scan; limited cut, coronal plane
 Treat bacterial rhinitis
 rarely MRI – fungal or possible tumors
Add metronidazole or clindamycin (especially with foul smell)
Consider fungal Rx (itraconazole, amphotericin)
Oral CCS (Daily followed by QOD)
Topical antibiotics (tobramycin, mupirocin nasal ointment)
Evidence-based treatment of CRS
Therapy
Level
Grade of
Recommend.
Relevance
oral antibiotic therapy
short term < 2 weeks
III (4)
C
no
oral antibiotic therapy
long term ~ 12 weeks
III (6)
C
yes
topical steroids
without significant
systemic absorption
II (2)
B
yes
oral steroid
no data
available
-
no
nasal douche
III
C
yes, for
symptom
relief
decongestion topical/oral
no data in
single-use
-
no
Evidence-based treatment of CRS
Therapy
Level
Grade of
Recommend.
Relevance
mucolytics
systemic antimycotics
IV (1)
VI
D
D
no
no
topical antimycotics
III
D
no
oral antihistamine
in allergic patients
Ib (1)
B
no
allergic therapy
in allergic patients
Studies include
patients with
NP
D
yes
allergen avoidance
in allergic patients
Studies include
patients with
NP
D
yes
proton pump inhibitors
III (3)
D
no
Evidence-based long-term antibiotics in CRS
Study
Drug
Number
Time/Dose
Effect on
symptoms
Evidence
Hashiba et al,
1996(379)
clarithromycin
45
400mg/d
for 8 to 12
weeks
clinical
improvement in
71%
III
Nishi et al,
1995 (381)
clarithromycin
32
400mg/d
pre- and postTherapy
assesment of
nasal clearance
III
Gahdhi et al,
1993 (382)
Prophylatic
antibiosis
details not
mentioned
26
Not
mentioned
19/26 decrease
Of acute
exacerbation by
50%
7/26 decrease of
acute
exacerbation by
less than 50%
III
Evidence-based long-term antibiotics in CRS
Study
Drug
Number
Time/Dose
Effect on
symptoms
Evidence
Ichimura et
al, 1996
(18)
roxithromycin
20
150mg/d
for at least
8 weeks
clinical
improvement
and polypshrinkage in
52%
III
Roxithromycin
and azelastine
20
1mg /d
Clinical
improvement
and polyp
shrinkage in
68%
Strength of evidence for treatment of
CRS/NP
Intervention
Topical
Systemic
Antibiotics Oral short term < 2w
Oral long term >12w
Antimycotics Topical / Systemic
Antihistamines
Anti-leukotrienes
Nasal saline douche
Decongestants
Allergen avoidance
Chronic rhinosinusitis
A
Corticosteroids
/
C
C
D
D
/
C 
D
D
Nasal polyps
A
C 
D
C 
D
B
C
D
D
D
Treatment options for polyposis






Treat underlying sinusitis
High dose nasal CCS
Oral CCS
Chronic/prophylactic antibiotics, systemic and/or topical
Anti-fungal, systemic and/or topical
Anti-IL5
Nasal corticosteroid spray in nasal polyposis
Copyright permission for reproduction pending
Lund V, et al. Arch Otolaryngol Head Neck Surg 1994; 124: 513-8
Nasal corticosteroid drops in nasal polyps
Copyright permission for reproduction pending
Aukema, Mulder,
Fokkens; JACI 2005
Budesonide use, 2007

Dilute budesonide solution (Pulmicort Respules), 500-1000 ug in 2-4 Oz
saline and irrigate the sinuses BID

Have head positioned to the side so that gravity helps get washings into
the sinuses; turn head as if to put the ear on knee

Has resolved polyp resistant to nasal fluticasone sprays
Topical anti-fungal treatment in nasal
polyposis
Copyright permission for reproduction pending
A Richetti et al. 2002 J Laryngology & Otology
Topical anti-fungal treatment in nasal polyposis
Before treatment
42% cured
50
48
40
After treatment
30
Nasal lavages with Amphotericin
B is in 2 DBPC studies:
n
20
27
0% cured
62% cured
- Ebbens F & Fokkens W J Allergy Clin
2006 Nov;118(5):1149-56.
10 Immunol.
13
13
13
5
- Weschta M & Riechelmann H. , Arch Otolaryngol Head Neck Surg. 2006 Jul;132(7):743-7
Stage I
Stage II
Oral
antifungal
is ineffective:
Open
study:terbinafine
- with
4 w Amphotericin B
inOct;115(10):1793-9
74 patients
- Kennedy DW, Laryngoscope.-2005
Stage III
+ nasal GCS
with NP
 48% improvement of NP (>> small polyps)
Long term antibiotic treatment in nasal
polyposis
DBPC study in 90 patients:
 3m low-dose erythromycin, nasal douche, nasal GCS vs. sinus surgery
 50% Improvement of symptoms
 no difference vs sinus surgery
Mupiricin use
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Use mupiricin with
 Recurrent crusting, particularly anterior
 Congestion, headache, green secretions & normal CT – contact
points, spurs
 Polyps
Mupiricin (Bactroban 2%) anteriorly with finger or Q tip, blot nose
Dissolved in saline, irrigate nose and sinuses with sinus rinse, along with
budesonide
Polyp treatments - 2007
Anticipate 25+% improve with sinus Rx + nasal CCS
 Another 25-50% improve with sinus Rx + high dose nasal CCS (FP
drops or MDI, or nasal lavages with budesonide)
 The remainder improve with oral CCS + FP or nasal lavages with
budesonide solution
Overall medical treatment can get close to 100% success
 Mupiricin appears to help prevent regrowth, especially with crusting
 Surgery, properly done, is successful short-term but polyps can and do
recur and repeated surgery gets progressively more difficult and
dangerous!
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Polyps – recommended treatment - 2007
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Treat underlying sinusitis
High dose nasal CCS
 Fluticasone (FP), either nasal drops (EU) or MDI (USA) through nasal
adapter (such as a baby bottle nipple)
 Prednisone 20-30 mg
 Daily x 3-4 weeks, then QOD, then taper to 0
Budesonide solution (Pulmicort Respules) dissolved in sinus lavage
 Wash with the head positioned with ear turned to the knee
Mupiricin ointment topically or dissolved in sinus lavavge
Consider careful surgery if polyps are persistent, resistant or recur
Consider oral or topical anti-fungal treatment
Conclusions - 1
Lack of controlled studies in Chronic Rhinosinusitis/Nasal Polyps!!
Current standard treatment for CRS:
 Nasal douche with saline
 Topical corticosteroids
BUT in NP: reversible effect, no resolution of NP
 Surgery: endoscopic sinus surgery
BUT in NP: high recurrence rate!!
Conclusions - 2
Treat associated diseases: Allergic rhinitis
Combinations?
 Nasal douche
 Topical steroids (drops)
 Antibiotic ointment (mupiricin)
 Long term antibiotics (macrolides or doxycycline)
Future therapies in nasal polyposis
Anti-CCR3?
Anti-IgE?
Eotaxin
IgE
Tacrolimus?
Anti-IL-5?
IL-5
Corticosteroids?
Anti-LTs?
ECP
Antibiotics?
Anti-fungal?
Summary - chronic rhinosinusitis
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CRS is common; nasal polyposis occurs in about 25% CRS
Nasal polyposis is a complex disease to treat and few etiologic answers
are known
Polyposis is nearly always associated with CRS and makes treating
underlying sinusitis more difficult
Treat for sinusitis plus high dose nasal corticosteroids, particularly in
solution. Consider topical antibiotics
Surgery may be beneficial, especially when combined with good medical
care
Nasal polyps recur – this is a chronic, relapsing disease
World Allergy Organization (WAO)
For more information on the World Allergy Organization
(WAO), please visit www.worldallery.org or contact the:
WAO Secretariat
555 East Wells Street, Suite 1100
Milwaukee, WI 53202
United States
Tel: +1 414 276 1791
Fax: +1 414 276 3349
Email: [email protected]