That’s right. If you have nasal polyps, you will receive very little sympathy from family and friends. You see, it’s not bleeding, broken, or cancer. And you won’t die of nasal polyps. And your partner will complain of snoring and spitting mucus, your workmates will just think you’ve got one long continuous cold or allergy, and your friends will wonder why you are often just too tired to go out. But you deserve all the sympathy they can muster.
What are these dreadful things? Polyps are lumps or masses of greasy, lumpy flesh that protrude from the wet lining of the nose and sinuses, called the mucosa. They have nothing to do with polyps in the bowel. About 2% of the population are afflicted. There are three main symptoms. They fill the inside of the nose and block it completely. Polyps secrete slimy mucus which runs down the back of the throat. And the worst symptom for most people? Loss of sense of smell, and, with it, taste. This last symptom is the one most people complain of. It can affect your personal life (smelling perfume), dining (obviously), safety (early warning of fire), and occupation (I have seen several miners from Central Australia who cannot go back into the mines because they cannot smell gas). You can see many images courtesy of Google here.
There are lots of other symptoms in various degrees. Pain in the face and jaw, fatigue, frequent sinus infections due to blockage of the sinus drainage system, bad breath and depression. Nasal polyps are also linked with adult-onset asthma and/or aspirin allergy (or allergy to other similar anti-inflammatories) in a large minority.
Is there a link to allergy? Probably not. Somewhere between 30% and 60% of people with polyps are allergic to a range of inhalants such as dust mite and mould, but in many no allergy can be proved.
Treatment? Currently, pretty unsatisfactory for most. Intranasal corticosteroid sprays, often in higher doses than needed for hay fever, help some. If severe then surgical polypectomy can provide relief. The recurrence rate after surgery ranges from 20% to 80%, depending on the paper you read. After two polypectomies, most ENT surgeons would advise daily steroid sprays indefinitely to reduce the chance of recurrence. Short courses of oral steroids can give excellent relief and briefly restore a sense of smell, but are not a long-term proposition due to adverse effects. While antibiotics are often needed to control infection, there is renewed interest in using certain antibiotic families in a lower dose for a longer time, such as 6-8 weeks. These antibiotics have an anti-inflammatory action and can reduce swelling. There are a few good scientific trials that demonstrate a small effect in a minority with montelukast, a non-steroid tablet used mainly in asthma. We have published one such trial, but I have to admit, for the majority, there is no improvement.
What about treating allergy to inhalants in those who have both allergy and polyps? Well, there is no evidence that allergy shots (injection allergen immunotherapy) or allergy drops (sublingual allergen immunotherapy) shrink polyps or reduce their recurrence after surgery or oral steroids. But this allergy treatment has a high chance of reducing allergy symptoms, which can also cause blocked nose and mucus, and we find that can be helpful. But it is not a cure.
As mentioned, a significant minority will be allergic to anti-inflammatories, such as aspirin. If allergic, such patients can develop severe sinus congestion or asthma on ingestion of the drug. So-called aspirin desensitisation may be useful in some, but it is not easy. A skilled unit supervises the program, with very low doses of aspirin initially, and if the patient reaches a good daily dose of aspirin, then up to 70% improve, but have to stay on daily doses of aspirin (much higher than used to thin the blood) to maintain improvement. There are adverse effects. Pretty well all the randomised scientific studies on this procedure have come out of the Scripps Clinic in La Jolla, where I was fortunate to visit in 1993. In our city of Melbourne, Australia, we have one unit with a lot of experience and allergists will refer to that unit. But, you know, it’s not useful for most people with polyps.
I haven’t mentioned the usual stuff, saline sprays, irrigations.
Is there research on this disease? Yes, but limited. It just doesn’t rate high on an institutions research agenda. While a lot is published about the biochemistry of polyps, we still don’t really know the cause.
So, back to the sympathy that is not offered. I feel both family and physician should be proactive in bringing up the subject, talking about the effects of this disease in that person’s life, and making sure that depression is not significant. A good start is to say “you know, I bet you don’t get much sympathy for this problem”. The management of nasal polyps may not have the adrenaline of the emergency department, and it won’t save a life. It’s about long-term management with every support needed to maintain quality of life. And that’s often harder to do than a lot of acute medicine.