What is Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)?

Symptoms of chronic rhinosinusitis with nasal polyps

People with chronic rhinosinusitis with nasal polyps experience the following symptoms:

• Facial pressure or pain
• Decreased or absent sense of smell (hyposmia/anosmia)
• Nasal congestion
• Runny nose
• Sore throat
• Postnasal drip (mucus flow into the back of the throat)
• Headaches
• Pain in the upper teeth
• Snoring

People with chronic rhinosinusitis without nasal polyps may experience the same symptoms. But CRSwNP is associated with more severe symptoms.

Symptoms can be triggered by anything that irritates the nasal passages. The irritation causes the nasal polyps to swell, leading to nasal congestion. Common triggers include:

• Tobacco smoke

• Chemicals and other irritants

• Allergens such as pollen, mold or dust

• Strong smells

• Aspirin or other non-steroidal anti-inflammatory drugs (NSAID)

 

How common is CRSwNP?

Nearly 30 million adults in the United States live with acute sinusitis (sinus infection). And while a sinus infection is no fun to deal with, acute symptoms last for 4 weeks or less.

Globally 5-12% of people live with chronic sinusitis. They experience all the difficult symptoms as acute sinusitis – sinus pain and facial pressure, nasal congestion, runny nose – for 12 weeks or more. About 25-30% of people with chronic sinusitis also have nasal polyps.

What age group is most impacted by CRSwNP? The age range of diagnosis is between 50 and 60 years. CRSwNP is more common in men (62%) than women (38%). However, studies suggest women are more likely to have more severe sinus disease.

What causes CRSwNP?

The exact cause of CRwNP is unknown. But several factors could play a role in developing CRSwNP.

The sinuses are made up of the following: the ethmoid sinuses, maxillary sinuses, frontal sinuses, and sphenoid sinuses. These sinuses and the nasal cavity have a mucus layer, followed by a mucosal barrier. In normal circumstances, this mucosal barrier protects people from inhaling germs and irritants. But in people with CRSwNP, the barrier breaks down. This leads to more inhalation of germs and irritants. It begins a chain inflammatory reaction that leads to remodeling of the sinuses and nasal tissue, which includes the formation of nasal polyps.

Additionally, some bacteria and fungus alter the tissue barrier. This includes Staphylococcus aureus. One study found 63% of people with CRSwNP have staphylococcus aureus in their nasal passages. This number is close to 90% of people with CRSwNP, asthma, and aspirin-exacerbated respiratory disease (AERD).

How do comorbidities play a role? Comorbidities are diseases that are found simultaneously in a single person. Certain health conditions are associated with CRSwNP. These include asthma, AERD, immune deficiencies, gastroesophageal reflux disease (GERD), and some allergies.

So while there is no known cause of CRSwNP, medical science has an understanding of risk factors. These factors may explain who is at risk for developing chronic rhinosinusitis with nasal polyps.

How is chronic rhinosinusitis with nasal polyps diagnosed?

In CRSwNP, there is often an overlap in symptoms with allergic rhinitis and nonallergic rhinitis. People with allergic rhinitis (“hay fever”) have nasal symptoms triggered by allergens. People with nonallergic rhinitis experience symptoms with no known trigger. Since all three conditions have overlapping symptoms, it is important to see a board-certified allergist or ear, nose, and throat (ENT) doctor to get a definitive diagnosis.

Your healthcare provider will take a detailed history of your symptoms and perform a physical exam. Based on those findings, additional tests may be performed:

• Sinus CT scan – a picture of your sinuses and nasal cavity. A sinus CT scan helps look at the severity of sinus disease.
• Nasal endoscopy – a tiny camera is inserted into your nasal passages to search for nasal polyps. A biopsy of the nasal polyp tissue may also be performed.
• Allergy testing – allergy testing may be done to rule out any allergies that could be triggering symptoms.

The presence of nasal polyps does not always indicate CRSwNP. Conditions like cystic fibrosis or Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis) may also cause the development of nasal polyps. Providing a detailed history of symptoms can help differentiate whether you have CRSwNP or another condition.

Chronic rhinosinusitis with nasal polyps treatment

CRSwNP treatment focuses on both the sinus symptoms and the nasal polyps. Corticosteroid nasal sprays are considered the first line of treatment.

• Corticosteroid nasal sprays: these are designed to reduce inflammation and swelling in the nasal passages. Over-the-counter and prescription versions are available. Mometasone is commonly prescribed corticosteroid nasal spray that is indicated for the treatment of nasal polyps. Mometasone also treats allergic rhinitis brought on by seasonal allergies. If your nasal polyps are too large, however, corticosteroid nasal sprays may not work well and may cause burning, stinging or bleeding.
• Fluticasone with Exhalation Delivery System (EDS)™: this corticosteroid medication treats nasal polyps as well as common allergy symptoms such as runny nose or sneezing. It comes in a breath-powered device (brand name Xhance®). It uses the force of your breath to deliver the medication more deeply into the nose to treat the polyps. A surgeon can also insert stents that deliver corticosteroids directly into the nasal cavity.
• Short course of oral corticosteroids: these can help shrink nasal polyps. However, they should be used with caution. Long-term use of oral corticosteroids can cause severe side effects. Side effects may include weight gain, diabetes, high blood pressure, thinning of the skin, bone loss, eye cataracts or bone loss, among other side effects. It’s important to minimize use of oral corticosteroids as much as possible.
• Biologics: These injectable medications target the source of symptoms – the underlying inflammation – rather than the symptoms themselves. Three are available to treat CRSwNP: dupilumab (Dupixent®), omalizumab (Xolair®) and mepolizumab (Nucala®).
• Surgery: If medications are not reducing the size of nasal polyps, surgery is another option. It works by using an endoscope with a magnifying lens or camera and tiny instruments to remove the polyps. Surgery can open up the sinuses and make nasal medications work better.

Antibiotics are sometimes prescribed to treat an infection due to CRSwNP. Leukotriene modifiers like montelukast may also provide some benefit in reducing nasal polyps. These should be used cautiously given the risk of side effects, including mood and mental health concerns.

Are there chronic rhinosinusitis with nasal polyps treatment guidelines?

Treatment guidelines for CRSwNP were published in 2014 in the Annals of Asthma, Allergy, and Immunology. These help to provide consistent guidance for the management and treatment of CRSwNP.

What can healthcare professionals do to be most helpful to people dealing with CRSwNP?

Healthcare professionals can provide treatment options, prescribe medication and recommend lifestyle changes such as avoiding triggers. It’s also important they show empathy for a patient group that faces difficult challenges. Think about it – people with CRSwNP deal with chronic headaches, facial pressure, fatigue, congestion and runny nose. Symptoms may also cause sleep disturbances that can impact mood. It’s one thing to deal with rhinosinusitis for a few weeks during an acute infection, but dealing with CRSwNP for months at a time is especially hard. It can impact your ability to take part in daily activities and overall quality of life. Healthcare professionals who are understanding and empathetic can build trust in their patients.

What if my CRSwNP does not respond to standard steroid therapies?

If CRSwNP does not respond to first-line treatments, there is hope. Your doctor may suggest an injectable biologic medication. These medications treat the source of symptoms – the underlying inflammation – rather than the symptoms themselves. They may prevent the need for oral c0rticosteroids or sinus surgery in people with nasal polyps.

Current approved biologics for the treatment of nasal polyps include:

• Dupixent® (dupilumab) – this can be injected at home every two weeks
• Xolair® (omalizumab) – this is initially injected in the doctor’s office, but after three doses may be injected at home. It is administered every 2-4 weeks.
• Nucala® (mepolizumab) – this is initially injected in the doctor’s office but can be injected at home afterward. It is administered once every four weeks.

What is the role of the pharmacist in CRSwNP?

Pharmacists are a valuable part of your healthcare team. They have knowledge of the latest medications and treatments and can collaborate with the prescribing physician. Pharmacists may be able to assist you with insurance coverage for medications and copays. They are also trained in educating patients on their medications. They can show you how to administer them and review potential side effects.

What about chronic rhinosinusitis with nasal polyps surgery?

If your nasal polyps are too large or there are too many of them, your doctor may recommend sinus surgery. Sinus surgery removes the polyps in your nose and sometimes makes the sinus opening bigger. Surgery does not cure CRSwNP, but when removing these benign growths it can lead to improved breathing. Sometimes nasal polyps come back after surgery, so patients may need to continue taking medications after surgery.

Questions to ask your doctor

Preparing for your doctor appointment is important. You may need to share your health history and current symptoms as well as provide a list of medications you take.

Don’t forget that a doctor appointment is also your opportunity to ask questions. Some questions you may want to ask about CRSwNP:

• What is causing my symptoms?
• What can I do at home to help my symptoms and reduce chronic inflammation?
• What are treatment options?
• How long should I expect to wait to see improvement of symptoms once I start treatment?
• Should I consider surgery for my nasal polyps?
• Are there any side effects to worry about from treatment?
• When should I follow up or consider seeing a specialist?
• What lifestyle changes should I consider to help prevent CRSwNP?

 

Managing chronic rhinosinusitis with nasal polyps

While CRSwNP requires treatment from a healthcare provider, there are some lifestyle changes that can help prevent symptoms. These include:

• Get adequate rest.
• Keep your sinuses moist with a saline spray.
• Drink lots of fluids – this also helps keep sinuses moist.
• Use warm compresses on the nose.
• Take steam showers to moisten and soften mucus flow.
• Rinse out nasal passages. (You can do this with a neti pot.)
• Avoid triggers.
• Make sure chronic conditions such as asthma, allergies or gastroesophageal reflux disease (GERD) are also well managed.

 

Are chronic rhinosinusitis with nasal polyps and asthma related?

It is common for people with CRSwNP to also have asthma. Studies suggest up to 67% of people with CRSwNP also have asthma. Both conditions see higher levels of eosinophils (white blood cells that help fight disease) and immunoglobulin E (IgE). This indicates a level of immune dysfunction. People with asthma who also have CRSwNP often have more severe asthma.