Sinus411.org

The web site for people with sinus problems

Chronic sinusitis with nasal polyps is a condition of inflammation of the sinuses which lasts more than 12 weeks, and when examined by doctors, there is evidence of polyps in the nose or sinuses.  

Whether there are polyps or no polyps turns out to be an important distinction or important classification, because usually the treatments are different when there are polyps versus when there are no polyps.  

  The decision to proceed with surgery is very dependent on the patient’s symptoms and the impact on the patient’s lifestyle.  Therefore, the threshold where patients elect to perform surgery is quite variable.  However, there are some general guidelines.

 First, the presence of nasal polyps alone is not necessarily an indication of surgery, since patients with this disease will almost always have some degree on nasal polyps. 

Common factors that your physician may consider in discussing surgery may be:

• The degree of nasal obstruction the patient has and how bothered the patient is by the symptoms. (i.e., are they snoring, not sleeping or continuously mouth breathing?)
• Whether the patient’s sinus problems and sinusitis is causing exacerbation of their asthma.  Patients that are requiring substantial amounts of oral steroid medications may be able to reduce their asthma medication requirements with successful surgery.   This is usually due to the fact that the surgery removes the tissues and cells that promote inflammation in the whole body (and make asthma worse).   One type of cell that causes this body-wide inflammation is called at the eosinophil.  Some surgeons that treat patients with polyps describes the operation of polypectomy as an eosinophil -ectomy, alluding to the fact that patients get better, at least partially, because these inflammatory eosinophils have been removed.

• The frequency and severity of symptoms of infectious (ie bacterial or fungal) sinusitis that a patient may have.  True bacterial sinus infections in patients with severe polyps are often difficult to clear because the sinuses do not drain well, the pus and bacteria are “stunned but not killed and cleared from the sinuses, and the infected cavities become quickly reinfected once antibiotics are stopped.  Having said that, it is also uncommon for surgeons to find “pus” in the sinuses when we do operate on patients with only chronic sinusitis and severe nasal polyps.  Usually, we only find lots of swollen tissues (polyps) and very old, thick, allergic mucin.  Its surprisingly unusual to find pus in the sinuses, that is rare to find a bacterial infection.  It does occur, but not commonly.  

• Chronic headaches or other signs of potential complications due to polyps and sinus disease.  Your sinus specialist is qualified to assess these more unusual reasons for surgery.  Since many patients with polyps usually have low grade headaches or pressure over the sinuses, patients that complain of severe pain are also evaluated to determine if they simply have polyps and another common headache syndrome such as migraines.  Reading the section on migraines may be helpful.

Other considerations:

 

Many patients with severe nasal polyps produce a thick, yellow, rubbery mucus that is allergic to send commonly referred to as "allergic mucin".  Patients who have experienced allergic mucin describe it as almost as rubber cement in its consistency.

When we evaluate patients at the Michigan sinus Center, we try to determine whether a patient has this allergic mucin (which is quite unusual in the typical population) or whether the patient has yellow-green nasal discharge that is more like the mucous we all get when we experience a particularly bad cold or a routine type of sinus infection.  So, we ask patients if they have the yellow, rubber cement type of allergic mucin or the more routine infected type of mucus that one might imagine in a preschooler with a "snotty nose".

 Although this distinction is a bit graphic, we find that patients are easily able to identify which type of discharge they are experiencing.  And it's important from a diagnostic and treatment standpoint to try to understand which type of discharge a patient with polyps (or without polyps) is experiencing.  We find that patient with polyps and the thick, rubbery, allergic mucin respond incredibly well to a burst and taper of oral steroids (such as prednisone).  The polyps shrink, the amount of yellow, rubbery, allergic mucin diminishes dramatically, and the patients often have substantial improvement.  When patients have polyps and allergic mucin (but no "snotty nosed mucus"), the improvement with oral steroids is typically much much greater than the patient would experience with antibiotics alone.  Patients typically say they get dramatic responses with oral prednisone and about 10% of that type of dramatic response when they take antibiotics alone.  Of course, when patient take antibiotics and steroids together, it's difficult to ascertain which drug is providing the greatest amount of relief, but our experience has been that patients with allergic mucin as the primary nasal discharge reap most of the benefits from prednisone and minimal benefits from antibiotics.

 Patients with polyps and allergic mucin do occasionally get a bacterial infections and then complain of having both types of nasal discharge..  These patients often times have a dramatic exacerbation of their asthma, sometimes develop a very productive cough, and worse wheezing.  When a patient with allergic mucin also develops on infectious type of nasal discharge, the patient often develops a very dramatic increase in an amount of coughed up secretions, coughing, and sometimes wheezing for asthma attacks.  These patients should of course be evaluated by a doctor who can address their asthma exacerbation.  From a nasal standpoint, these patients often benefit from a burst of prednisone and a course of antibiotics.  The choice of antibiotics is a complicated decision, and sometimes either simple, inexpensive, first-line antibiotics are used, but sometimes more broad-spectrum antibiotics are necessary.

We think it's important to note that patients with severe polyps (especially those with asthma and aspirin sensitivity)  often have CT scans that show the sinuses and much of the nasal cavity to be completely full of polyps and thick secretions.  When we operate on these patients, we almost never find signs of a bacterial infection, but typically only find thick, rubbery secretions.  When we call for the secretions, they rarely grow out bacteria.  In fact, and it appears that the secretions are probably full of such toxic chemicals that bacterial infections do not typically take hold in these sinuses.  This confirms our clinical impression that antibiotics are far less useful in patients with nasal polyps and allergic mucin, and that oral prednisone is much more effective.

 

Please also read the POLYPS AND FUNGUS section of this web site. its important.