Introduction

Nasal polyps present have been a characteristic form of chronic persistent inflammation that is associated with severe and chronic allergic rhinitis hypercreativity reactions, chronic sinusitis, and other chronic inflammatory indeterminate etiologies (Schleimer, 2017; Shamji et al., 2019). Genetical and environmental eosinophilic polyps that are also considered to be responsive and are primarily enhanced sinonasal severity (Stevens et al., 2015; Bochner & Stevens, 2021). Confirming the diagnosis of nasal polyps requires endoscopic investigations or complex radiological investigations (Akdis et al., 2015).

The current management is still controversial and depends upon understanding the complex pathophysiological and etiological factors. There have been several theories that proposed the initial process regarding polyps’ formation (Cayé-Thomasen et al., 2004; Schleimer, 2017). However, currently available medications are mostly based upon clinical experience that describes these pathophysiological and etiological hypotheses (Ta, 2019).

This review provides a wide view on the current evidence-based diagnosis and management abilities in Nasal polyp’s conditions, to fully be able to help and aid ENT clinicians to provide good medical compliance throughout the medication process.

MATERIALS AND METHODS

This review was classified and collected from eligible publicized only English written extracts, articles, and advanced clinical trials. These electronic research engines were included: PubMed and Google Scholar database. The keywords “Nasal” and ‘Polyps ‘including words used in MeSH(( (( ‘Diagnosis’ [Mesh])) ,((‘Management’ [Mesh])) , (( ‘ Guidelines' [Mesh])) , (( ‘Treatment' [Mesh])) ,((“Biologics” [Mesh])) were used together in integral combinations. This review discussed the first step for diagnosing and treating nasal polyps. All details involving this topic including medical definitions, pathological and physiological classifications, and guidance for treatment were included in this review.

Review

Nasal polyps formation

The different patterns of inflammations in the nasal mucosa have a great impact on the development of nasal polyps in patients with chronic rhinosinusitis issues. Chronic rhinosinusitis is characterized by recurrent nasal congestions, posterior or anterior rhinorrhea, hyposomia, facial pain for 12 weeks or more (Orlandi et al., 2016; Fokkens et al., 2019; Takabayashi & Schleimer, 2020). Nasal polyps are jelly-cyst-like lesions that originate from the surrounding paranasal sinus cavity and the middle nasal meatus. More intense histological features are found to be edematous pseudo cystic stroma that contains plasma proteins such as albumin and low amounts of collagen production and clear features of fibrosis (Takabayashi et al., 2013; Takabayashi & Schleimer, 2020).

Etiology of nasal polyps

In treating nasal polyps, understanding the causes of these polyps is crucial for achieving effective and appropriate management. Nasal polyps alone are never considered an ultimate diagnosis. The causes of nasal polyps are not fully known or explained and are usually described in endoscopic pathological associations. However, Nasals polyps etiological hypotheses are clarified into several classifications (Table 1) (Ta, 2019).

Table 1. Categorical classifications for nasal polyps for explaining nasal polyps’ pathological associations: (Ta, 2019)

Examination findings and clinical investigations

Since nasal polyps are associated with chronic rhinosinusitis, patients are suspected to present with chronic nasal congestion, decreased or gradual loss of smell, and rhinorrhea (cardinal symptoms of chronic rhinosinusitis). Positive findings are detected using anterior rhinoscopy or other radiological CT scans [American Academy of Otolaryngology-Head and Neck diagnostic criteria for chronic rhinosinusitis] (Table 2) (Rosenfeld et al., 2015). The presence of other comorbid conditions such as asthma and allergic rhinitis may promote the existence of nasal polyps (Feng et al., 2012).

Table 2. Chronic Rhinosinusitis Diagnostic Criteria of the American Academy of Otolaryngology (Rosenfeld et al., 2015).

The investigation for localized nasal polyps must also include microbiological samples, biopsies for further histopathological assessment, particularly for elderly individuals and patients with a high risk of sinonasal malignancies (Feng et al., 2012). Intracranial complications in chronic rhinosinusitis are also suspected and require urgent workup for diagnostic and therapeutic assessment.  It is important to refer patients to an otolaryngologist soon after revealing neoplasms, to prevent further complications (Rosenfeld et al., 2015; Sedaghat, 2017).

Treatment and management

The treatment of nasal polyps depends on the different phenotypes and endotypes analyzed to determine the preferable management [Chronic rhinosinusitis pathophysiology is believed to be associated with T-helper 2 eosinophils, Immunoglobulin E, and high presence of interleukin IL-5, with the dominant presence of cationic eosinophilic protein concentration at the nasal polyp.] (Table 3) (Van Zele et al., 2006; Akdis et al., 2015; Ta, 2019). Treating nasal polyps is directed to relieve symptoms and upgrade therapeutic management to provide the best results of care. Since nasal polyps are associated with chronic rhinosinusitis, non-surgical treatment is dedicated to receiving intranasal corticosteroids, performing nasal saline irrigations, receive short- and long-term oral antibiotics to prevent further infections (Rosenfeld et al., 2015).

 The main goal of non-surgical treatment is to enhance sinus drainage and improve mucociliary clearance, eliminate local infections and provide a suitable pathway for topical medications. Otolaryngologists should be informed if patients were not responding to medical treatment and other patients with common comorbidities such as patients who are suffering from asthma or other systemic comorbidities (e.g., Granulomatous diseases, cystic fibrosis, vasculitis, and immunodeficiency) that is involved in the formation of chronic rhinosinusitis (Rosenfeld et al., 2015; Ta, 2019).

Table 3. Phenotypes and endotypes of Nasal polyps in chronic rhinosinusitis: (Ta, 2019)