The web site for people with sinus problems
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Chronic Sinusitis with Polyps and Fungal Sinusitis: two common reasons for sinus Surgery. |
So, here are some of the common reasons for sinus surgery in the United States.
1. Chronic Sinusitis with Nasal Polyps (keep reading below)
2. Fungal Sinusitis
Chronic Sinusitis with Nasal Polyps:
In the Michigan area, and probably for the US in general, chronic sinusitis with Nasal polyps accounts for a large portion of the surgery being performed. There are several questions about sinusitis with polyps that patients frequently ask. So lets deal with them first. These questions are:
(1) What is a polyp?
(2) Why do polyps form?
(3) How can I tell if I have polyps?
(4) What are the symptoms? and
(5) What can be done, besides surgery, to reduce or eliminate the polyps?
What is a polyp? Nasal and sinus polyps can be defined very scientifically by the types of tissues and cells and the microscopic appearance of the tissues, but for simplicities sake, we’ll describe polyps by their appearance. Polyps arise when the tissue lining the nose, called mucosa, becomes very inflamed and swollen. The normal mucosa, which is pink, moist and 1-2 millimeters thick, can become swollen with fluids and proteins until it resembles a fluid filled sac. Initally a polyp can be translucent, meaning you can see some light right through it. As polyps get older, they become more fibrous and solid, and less “fluid filled” in appearance. These older, or mature, polyps are more dense and almost opaque. If I were to describe the texture of an average polyp, it say it was like inside of a green grape (after the skin was peeled off).
We don’t understand all of the reasons polyps form, or the mechanisms of polyp formation in great detail, but we understand some of the processes by which polyps form. And there are different things that stimulate polyps to form. The common denominator for polyp formation is some sort of inflammatory process or allergic process that triggers the polyp to grow. So patients with severe allergies may have polyps grow in the nose, and patients with an inflammatory disease (not necessarily due to allergies) in the nose and sinuses may have polyps grow in the nose and sinus. So, you may wonder, why don’t we eliminate the cause of the inflammation or allergic reaction. Good point ! This is just what most allergists and ENT doctors try to do when evaluating patients with polyps. Usually patients will have an allergy history taken. This identifies some patients with allergies. Other patients may have allergies, but a doctor cannot determine it from just questioning the patient about their history. (More on allergy histories later) Other patients may have no allergies triggering their polyp growth, either by history or by allergy testing. Many of these patients have some “intrinsic” problem causing their polyps, that is some “imbalance” of the inflammatory system of the body that triggers this growth of polyps. It turns out that many of the patients with this “intrinsic problem” with inflammation causing polyps are the same patients that have inflammation of the lungs and bronchi, commonly known as asthma. When scientists measure the amount of inflammation in the lungs, nose, sinueses or even the bloodstream in these patients, there is a common pattern of “activated” inflammatory cells. This is the intrinsic type of inflammation. It is not necessarily caused by allergies. There may be something causing this “intrinsic inflammation” that scientists are not aware of yet. Many researchers are working on identifying these disorders of inflammation that cause asthma (and probably cause the polyps too). Some of the triggers have been identified, and some causes can be pinpointed, but its likely that there are a lot of different ways this inflammatory system can become “out of balance”, rather than just one cause. So, we’ll need to wait and see what researchers find. In the meantime, what can you do?
How can I tell if I have polyps? What are the symptoms?
Well, polyps come in different size and shapes, and symptoms from polyps will vary from patient to patient, depending on the size of the polyps, and the patients other medical conditions. Generally, as polyps swell or get larger the polyps start to fill the nose and cause nasal blockage or obstruction. Some patients call that “congestion”, but I find that many patients describe “congestion” in many different ways (for instance some say congestion is "fullness of the head" or a different sound to their voice), so I’ll stick to “obstruction” or “blockage” to describe what polyps typically cause.
As the polyps start to fill more than about 50% of the nose, patients begin to notice the obstruction. On bad days, the polyps may swell a little more and cause more obstruction, and on good days they may shrink a bit and cause less symptoms. There are probably many things that cause polyps to swell. If a person with polyps and allergies, a “bad allergy day” will frequently cause the polyps to swell more and cause more symptoms. Likewise, treating a patient’s allergies will often cause the polyps to shrink (at least some) and may give some relief from the blockage.
As polyps get larger, say for instance filling 75% to 90% of the nasal cavity, patiens really start to complain of nasal obstruction, and this often motivates them to seek medical care. We’ll talk about treatment in a moment.
When polyps fill the entire nose, then patients are miserable. They can’t breath through their nose at all. They mouth breath during the day and at night. During the day it becomes difficult to eat when the polyps fill both nasal cavities, because one must chew with their mouth open in order to breath while eating. Moms golden rule “don’t chew with your mouth open” becomes impossible.
At night, patients can’t breathe through their nose, so they mouth breathe while sleeping. This is bothersome because the patient’s mouth dries during the night, within a couple of hours, and patients wake up frequently to drink water. Also, when patients sleep with their mouth open, their tongue falls back into their throat a bit and they tend to snore more, and some become severe snorers. Patients who already snore some may develop sleep apnea (more on sleep apnea later). Sleep apnea is when the throat is so narrow that patients stop “moving air”, despite the chest moving, for more than 10 seconds. Some patients may not have complete “stoppage” of air (apnea), but may get just a small amount of air with each attempted breath. This is called “hypopnea”. Either Apneas or Hypopneas are not normal. When a patient has more than 10 apnea or hypopneas each hour, they meet the criteria to be called suffering from “sleep apnea”. So, sometimes nasal polyps can make snoring severe enough to tip a “snorer” over to “sleep apnea”. Sleep apnea can vary in degree from mild (10-20 apneas or hypopneas per hour) to moderate (20-40 apneas or hypopneas per hour) to severe 40 or more per hour. Sleep apnea has substantial effect on patients. As it becomes moderate to severe, patients not only don’t sleep well (tossing and turning because they wake up short of breath), but also at highter risk other problems, including heart disease, heart attack, stroke, memory, and concentration problems. If you think this may be an issue for someone you know, you should discuss it with your primary care doctor or ENT doctor, lung doctor, allergist, cardiologist (and some other medical specialists). The test needed to diagnose this is called a sleep study, and it will identify the presence or severity of the sleep apnea.
I cant taste anything very well
Patients with medium to large polyps will usually complain of loss of sense of smell and taste. Why?
Well, the sense of smell occurs at the very top of the nasal cavity in an area of tissue called “olfactory epithelium”. If you think about your nose as a tall thin triangle, you can imagine that lots of air will pass through the lower (wider) portion of this triangle, but less air will pass though the top of the triangle (where the sense of smell occurs). The slow passage of air in the top of the nose allows for people to smell odors.
When there are polyps filling about 50% of the nose or more, the air is blocked and does not reach the area where these smell nerves are located. When air and odors can’t get to the nerve endings, then a person cannot smell well, or may not smell anything at all. So what? People with normal smell say: “that would be great, I couldn’t smell diapers or skunks”. Well, unfortunately, its not that simple. Because most of what we enjoy about eating is not about “taste”, its about the sense of smell that goes with eating food. Most people don’t realize that the tongue can only taste four things: sweet, sour, salty, and bitter. Everything else about the wonderful taste of foods is really related to the sense of smell. So as polyps obstruct airflow or otherwise limit the sense of smell, patients with polyps complain bitterly about losing their sense of taste. They complain about foods having little taste, that they can’t enjoy eating, that cooking isn’t “fun” any more, and that they need to salt foods to help with flavoring. Others are justifiably concerned that they can’t smell smoke, natural gas from stoves that might leak, food that has spoiled, or personal odors that they want emphasize (perfumes) or mask (body odor). Its quite bothersome to patients, and this sometimes drives them to the doctor for medical and/ or surgical care of their polyps.
3. What can be done, before surgery, to reduce or eliminate the polyps?
So you have polyps and want to know how to shrink them, to avoid surgery. Well, the treatment for polyps depends on what is causing them, so its very important to get a thorough evaluation of the polyps in order to “go for” the best treatment. We can’t give you medical recommendations here and now, because we don’t know whats causing the polyps in your particular case, but there are some general treatments that may be common to all types of polyps so we’ll go over some of the treatments that your doctor may prescribe for you. Specifically, we’ll talk about steroid sprays and steroid pills.
Steroid Sprays
Who gets them?
Steroid sprays are typically prescribed for most types of nasal polyps. They are commonly used for mild polyps that are caused by allergic rhinitis (say, for instance, polyps caused by allergies to cats, dust, molds, pollens, trees, grasses, and/or molds). They are also used for patients with medium and large polyps. Generally speaking, steroid sprays are helpful to shrink polyps or may just slow the natural growth of polyps. More on treatment of polyps later in the text.
How do they work?
How are they best given?
Are there any problems with them? We'll talk more on this later. This section is under development.
Oral steroid pills.
When treating patients for nasal and sinus polyps, sometimes a physician will prescribe steroid pills which (for most people) will cause a dramatic shrinkage of the polyps. However, the effect is usually temporary. The polyps usually return within a few days or a couple of weeks after stopping the steroid pills. I use a graphic analogy with patients to get the point across, which is the grape-raisin anology. When grapes are dehydrated to form raisins, all of the protein and “meat” of the grape remains, but the water is removed. Similarly, when large polyps are treated with oral steroids, the fluid in the polyp is dramatically reduced, but the inflammatory cells and tissue remains, and within a few days after stopping the steroids, the water returns to the polyps and they often return to about their original size, if nothing else is done to treat the polyps.
Who gets them
How do they work?
How are they best given?
Are there any problems with them?
So, we are back to the topic of “Chronic sinusitis with polyps”. We now know that a polyp is inflamed, edematous or swollen nasal or sinus tissue that often causes symptoms by obstructing airflow and / or obstructing air to the olfactory area (causing decreased sense of smell and complaints of poor ability to taste).
But what is “chronic sinusitis”. Well sinusitis is, simply put, an “itis” or inflammation, of the sinuses. The sinuses are air filled spaces between, below, above, and behind the eyes (see drawing/photo of sinuses). The sinuses are lined with mucosa, a very thin, moist, pink lining usually less than about 1mm thick. If the mucosa becomes inflamed (“itis”), the condition is called “sinusitis”. There are many, many possible causes for inflammation of the sinuses, some of them very common, some not common, and some incredibly rare. So you see “sinusitis” is a sort of generic term for inflammation that could be caused by many different things. Kind of like saying you have “car trouble”. The mechanic you go to will try to find out what sort of “car trouble” you are having: an electrical/ignition problem, fuel problem, a timing problem, an exhaust problem in order to classify the type of car problem and focus on solutions.
Doctors dealing with sinusitis also try to classify the type of problem in order to identify the best solution for that particular type of sinusitis. Of course, classifying the different types of sinusitis is also important for scientists and clinicians to be able to study the disease (and agree on which type of sinusitis anyone is researching or talking about). It turns our that there are several different ways to classify sinusitis. You can classify it by how long its been there (acute or chronic), whether its infectious or not, what type of infectioun it is (viral, bacterial, fungal). Doctors can also classify sinusitis by what the doctors sees on examination (with or without polyps), or what the pathologist sees when he or she examines sinus tissue (from surgery) under the microscope.
The first types of classificationof sinusitis, and perhaps the easiest, is by timing: that is, how long has this problem lasted? If the sinusitis has been less than 4 weeks, it is called acute sinusitis. If its been more than 12 weeks, its called chronic sinusitis, and if its been between 4 and 12 weeks, its called subacute sinusitis. For the most part, patients with acute sinusitis, sometimes referred to as a routine sinus infection, get better. Either on their own or with antibiotics, most all of them improve. However, a small percentage of patients with an acute infection will not completely improve and symptoms will smolder (or be quite evident) for more than 3 months, again fitting the category of what we’d call “chronic sinusitis”, just by its timing. If you have acute sinusitis once a year, you probably just get it treated (or it gets better on its own), and it doesn’t bother you enough to spend the time to read this book. Good for you! But other folks get acute sinus infections one time after another, perhaps every 6-8 weeks. They are frequently calling their doctor for medications, get better with treatment, then have a recurrence of the infection after several weeks. Doctors refer to this type of infection as “recurrent acute sinusitis”, because it completely resolves between the acute infections, then recurs.
Some patients with sinus infections never completely improve between these infections and after treatment. The symptoms may improve to some degree with antibiotics or other treatment, but the nasal and sinus symptoms don’t completely resolve. Doctors classify these patients as having chronic sinusitis when the symptoms last more than 12 weeks. Sometimes there are low grade, smoldering symptoms most of the time, then there is a sudden or acute flare up of symptoms, which may get treated and improve, but the patient still has the low grade symptoms afterwards. These patients are described as having a type of sinusitis called “acute exacerbations of chronic sinusitis”. So now we have described at least one type of classification for sinusitis (acute versus chronic). This will help us complete our definition of chronic sinusitis with polyps:
So chronic sinusitis with polyps is a condition of inflammation of the sinuses which lasts more than 12 weeks and is associated with nasal polyps.
Great, we have described the first type of chronic sinus problems that require sinus surgery, chronic sinusitis with nasal polyps. It gets easier from here, in some respects, because the next type is chronic sinusitis without polyps.