Andrew Lichtenstein/Andrew Lichtenstein Dr. Satish Govindaraj, vice chairman of clinical affairs in Mount Sinai’s department of otolaryngology, specializes in treating problems ranging from rhinitis and sinusitis to nasal polyps. THE SPECIALIST
The vice chairman of clinical affairs in the department of otolaryngology at Mount Sinai, Dr. Satish Govindaraj specializes in treating problems ranging from rhinitis and sinusitis to nasal polyps. Ninety percent of his patients have nasal and sinus-based problems.
WHO’S AT RISK
The average American has two to three colds a year, with winter serving as peak cold season — but 1% to 4% of the population suffers from chronic congestion that comes from a completely different sources. “In response to irritants like allergens, cigarette smoke and construction dust, the lining of the nose can develop a hyperactive immune response that causes it to grow nasal polyps,” says Dr. Govindaraj. “Nasal polyps can form on one side of the nose or both, and their classic symptoms are nasal congestion accompanied by a decreased sense of smell, and sometimes taste.”
Why nasal polyps form remains a mystery. “We don’t know the underlying cause — what we do know is that it’s a hyperactive immune response,” says Dr. Govindaraj. “For this reason, removing the polyps alone doesn’t provide a cure. Once you remove the polyps, you still have to treat the lining to calm it down, or else it can start making polyps again.”
Because nasal polyps tend to originate in the back of the nose, they aren’t visible to the naked eye or even to a doctor’s nasal speculum until they have progressed. “It’s usually necessary for the doctor to use an endoscope and camera to get a look at these polyps,” says Dr. Govindaraj. “The polyps look like a cluster of grapes, consisting of tissue that is similar to the lining of the nose, but tends to be more fluid filled and swollen.”
While just about anyone can develop polyps, about 50% of cases occur in patients who also have allergic rhinitis, also known as seasonal allergies. “Polyps tend to affect the middle-aged population, but it can develop anywhere from adolescence onward,” says Dr. Govindaraj. “Doctors have identified a cluster of conditions that are commonly associated with more severe polyps called Samter’s triad: nasal polyps, asthma and aspirin allergy. If you have any of these conditions, it’s worth talking to your doctor about whether you might have the others.” People with cystic fibrosis also have an increased risk of nasal polyps.
What’s the distinction between run-of-the-mill nasal congestion and the red flag of nasal polyps? “When polyps grow in the nose, they eventually block the olfactory cleft, or smell zone,” says Dr. Govindaraj. “So if your nasal congestion is accompanied by loss of smell, it should be evaluated by your primary care physician, allergist, or an ENT.”
The severity of symptoms associated with nasal polyps depends on their size and placement. “Polyps can range from very small and asymptomatic to large polyps that create almost total obstruction, leading to decreased smell and difficulty breathing,” says Dr. Govindaraj. “This condition can be as debilitating as COPD or heart disease, and is a leading cause of what we call quality of life loss. Fortunately, we have highly effective treatments to help patients regain their quality of life.”
SIGNS AND SYMPTOMS
The warning signs of nasal polyps aren’t always obvious. “The most common complaint is nasal congestion, on either one side or both sides,” says Dr. Govindaraj. “As the polyps grow, they can also cause a decrease or loss of smell, post nasal drip, facial pain, or headaches. Sometimes the polyps can block the sinuses and patients can develop a secondary sinus infection and/or fever.”
While polyps themselves aren’t malignant, it’s important to evaluate them completely. “We like to take a small sample of the polyp to make sure it’s not something more serious, like a tumor, especially in the setting of polyps occurring on one side of the nose,” says Dr. Govindaraj.
TRADITIONAL TREATMENT
Untreated nasal polyps can really interfere with quality of life-but doctors now have effective treatment regimens to provide relief. “The first line of treatment is topical steroids, usually delivered by a nasal spray used once or twice a day,” says Dr. Govindaraj. “The steroids decrease both polyp size and nasal congestion.”
In some cases, the polyps are so large that they block the nasal spray and prevent it from working. “For these patients, we can use a short course of oral steroids to shrink the polyps down so that the spray works,” says Dr. Govindaraj. “Patients who have no response to steroids need to be evaluated further, to make sure there isn’t something more serious going on.”
Surgery is another treatment option. “Endoscopic sinus surgery can be used to reduce the polyp load down to a level where medical treatment can keep it at bay,” says Dr. Govindaraj. “One of the biggest misconceptions is that once you have surgery, it’s all done. But medical therapy is still needed to prevent the lining from forming new polyps.”
The efficacy of treatment varies from patient to patient, but the overwhelming majority respond very well. “For the average patient, surgery accompanied by medical therapy has a 90% success rate, with real improvement in quality of life and breathing,” says Dr. Govindaraj. “But it also depends on the patient being compliant with the medical regimen.”
RESEARCH BREAKTHROUGHS
While researchers are still searching to find out why polyps develop in the first place, they are pushing forward with treatment advances. “Our biggest breakthrough is a dissolvable steroid implant,” says Dr. Govindaraj. “Traditionally we delivered steroids to the nose with nasal spray or irrigation, but it was hard to tell how much of the steroids actually reached the polyp. Placing this implant delivers the steroids locally-it’s in clinical trials now for outpatient use.”
QUESTIONS FOR YOUR DOCTOR
If you have chronic congestion, especially with decreased smell, ask: “Could this be polyps?” If you’re receiving treatment for asthma and allergies and you’re not getting better, then ask, if she can refer you to a specialist. “This is a quality of life disease, and it’s not something you have to live with for the rest of your life,” says Dr. Govindaraj. “We’ve had a lot of treatment advances, so there’s a lot we can do to bring polyps under control. We want our patients to come in and say, ‘I feel great.’”
WHAT YOU CAN DO
Get informed.
For trustworthy information about nasal polyps on the web, start with NIH (http://www.nlm.nih.gov/medlineplus/ency/article/001641.htm). You can find additional materials through the ENT department at Mount Sinai (www.mountsinai.org/sinus).
Manage your allergies.
“Avoiding your triggers is one the best things you can do,” says Dr. Govindaraj. If you have known allergies, consider allergy shots.
Comply with medication.
“When it comes to nasal polyps, surgery is really an adjunct to medical treatment,” says Govindaraj. “So it’s essential for patients to take their medications as prescribed.”
BY THE NUMBERS
-1% to 4% of the population have nasal polyps
-More than half of all patients with nasal polyps also have seasonal allergies
-There is a 90% success rate for sinus surgery with continuing medical treatment
-Up to 40% of patients with cystic fibrosis also have nasal polyps