Chronic Rhinosinusitis with Nasal Polyps

Chronic rhinosinusitis with nasal polyps is a long-lasting inflammatory condition where soft, noncancerous growths develop in the nose and sinuses, causing symptoms like nasal congestion, loss of smell, facial pressure, and postnasal drip that can significantly impact daily life and sleep quality.

Table of contents

• What is Chronic Rhinosinusitis with Nasal Polyps?
• Who Gets This Condition?
• Symptoms
• Underlying Causes and Inflammation
• How Doctors Diagnose This Condition
• Triggers and Things to Avoid
• Treatment Options
• Impact on Quality of Life
• Related Health Conditions

What is Chronic Rhinosinusitis with Nasal Polyps?

Chronic rhinosinusitis with nasal polyps, often shortened to CRSwNP, is a condition that combines two problems: long-lasting inflammation of the nasal passages and sinuses, along with soft tissue growths called nasal polyps (noncancerous lumps that form inside the nose or sinuses)^[1].

The “chronic” part of the name means the condition lasts a long time—at least 12 consecutive weeks—even with treatment^[7]. Rhinosinusitis refers to inflammation and swelling of both the nose (rhino) and the sinuses (the hollow spaces inside the bones of your face)^[8].

Nasal polyps in this condition are typically benign growths that appear on both sides of the nose. They usually start in the ethmoid sinus (a sinus located between your eyes) and can range in size from small teardrops to larger grape-like clusters^[3][4]. When they grow large enough, these polyps can block your nasal passages and sinuses, making it hard to breathe through your nose^[4].

Who Gets This Condition?

Nasal polyps affect approximately 1 to 4% of the general population^[3][19]. Among all people with chronic rhinosinusitis, only about 25 to 30% develop nasal polyps^[3].

This condition is more common in certain groups of people. Men are twice as likely as women to develop nasal polyps^[4]. The average age when people first develop CRSwNP is 42 years old, and most people are diagnosed between ages 40 and 60^[2][3]. However, anyone can get nasal polyps, and the overall risk increases as you get older^[4].

Symptoms

Small nasal polyps might not cause any symptoms at all^[4][8]. However, as polyps grow larger or occur in groups, they can lead to several uncomfortable problems.

The most common symptoms include a stuffy or runny nose, loss or decreased sense of smell, facial pressure or pain, and postnasal drip (mucus that runs down the back of your nose into your throat)^[2]. Many people also experience pain in their upper teeth, snoring, and headaches^[2].

When nasal polyps grow large enough to block your nasal passages and sinuses completely, they can cause more serious problems. These include frequent asthma attacks (sudden worsening of asthma symptoms) in people who already have asthma, repeated sinus infections, sleep problems including sleep apnea (pauses in breathing during sleep), and difficulty breathing even in people without asthma^[4].

One of the most debilitating symptoms is anosmia (complete loss of smell)^[19]. This can affect not only your enjoyment of food but also your safety, as it limits your ability to detect dangers like smoke or gas leaks^[5].

Underlying Causes and Inflammation

Doctors know that inflammation causes nasal polyps, but they don’t fully understand why some people develop polyps from inflammation while others don’t^[4].

CRSwNP is driven by a specific type of immune response called type 2 inflammation (a pattern of immune system activity involving certain proteins and cells). This inflammation starts in the epithelium (the thin layer of tissue lining your nasal passages and sinuses), which acts as the first point of contact for everyday irritants like dust and pollen^[5].

When the epithelium encounters these irritants, it releases special signaling proteins called cytokines (molecules that cells use to communicate with each other), including thymic stromal lymphopoietin (TSLP), IL-25, and IL-33^[5]. These cytokines can trigger multiple inflammatory pathways that lead to polyp formation and chronic symptoms^[5].

The condition also involves elevated levels of eosinophils (a type of white blood cell that normally fights infections but can cause inflammation when present in high numbers)^[6]. Because surgery doesn’t eliminate this underlying inflammation, nasal polyps can grow back after removal^[6].

Several risk factors can increase your chance of developing nasal polyps. These include having asthma, allergic rhinitis (hay fever caused by allergies), chronic sinus infections, or cystic fibrosis (a genetic disease affecting mucus production)^[4]. Some people also have increased sensitivity to certain nonsteroidal anti-inflammatory drugs like aspirin and ibuprofen^[4].

Genetics may also play a role, as certain gene changes may affect how your nasal tissues react to inflammation^[4].

How Doctors Diagnose This Condition

To diagnose chronic rhinosinusitis with nasal polyps, doctors look for at least two of four main symptoms—facial pain or pressure, reduced or absent sense of smell, nasal drainage, and nasal obstruction—that last for at least 12 weeks. But symptoms alone aren’t enough; doctors also need objective evidence from either a physical exam or imaging tests^[7].

During a physical exam, your doctor will ask about your symptoms and medical history, then look inside your nose. The most common way to see nasal polyps is through nasal endoscopy (a procedure where a thin tube with a tiny camera is inserted into your nose)^[2]. This is usually done right in the allergist’s or ear, nose, and throat (ENT) specialist’s office^[2].

Your doctor might also order imaging tests. A CT scan (computed tomography, which uses X-rays to create detailed images) is the preferred imaging method to confirm the diagnosis and show the size and location of polyps, including those deep in the sinuses^[7]. An MRI (magnetic resonance imaging, which uses magnets and radio waves to create images) might also be used^[4].

Your allergist might do allergy testing to see if allergies are making your condition worse^[2]. This can be done through skin tests, where tiny drops of substances that cause allergies are pricked into your skin, or through blood tests^[12].

In children with nasal polyps, doctors may test for cystic fibrosis using a sweat test (a test that measures salt levels in sweat)^[12]. Blood tests can also check for conditions linked to nasal polyps, such as allergies or immune system problems^[12].

Triggers and Things to Avoid

Several things can irritate your nasal passages and make nasal polyps swell, making your symptoms worse. Avoiding these triggers may help reduce symptoms^[2].

Common triggers include tobacco smoke, incense, aspirin and nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen sodium, chemical fumes, and dust or debris^[2].

In addition to avoiding triggers, there are simple things you can try at home to improve mucus flow and help you breathe better. You can use a saline (saltwater) spray that you can buy or make without a prescription^[2]. Another option is to rinse out your nasal passages with a device such as a neti pot (a container designed to pour saltwater through your nostrils). These devices come with directions for mixing salt with water that should be distilled, sterile, or boiled and then cooled. Be sure to rinse and dry the neti pot thoroughly after each use^[2].

Treatment Options

Treatment for CRSwNP aims to reduce inflammation, shrink or eliminate polyps, and relieve symptoms. The approach depends on the size and number of your polyps and how severe your symptoms are.

First-Line Medical Treatments

The first treatments doctors typically recommend are nasal saline irrigation and intranasal corticosteroid sprays (steroid medicines sprayed directly into the nose to reduce inflammation)^[7]. Research shows these treatments improve symptoms in people with chronic rhinosinusitis^[7].

Several corticosteroid nasal sprays are available over the counter or by prescription. These can be sprayed once or twice daily in each nostril. Examples include fluticasone, budesonide, mometasone, and beclomethasone^[2][12]. These medications are easy to use and inexpensive, though they can cause burning, stinging, or bleeding in the nose and may not work well if your polyps are large^[2].

Short-Term Treatments

For more severe symptoms or larger polyps, doctors may prescribe short courses of oral corticosteroids (steroid pills or shots taken by mouth or injection) for up to three weeks^[7][13]. These can provide temporary relief and help shrink polyps, but they can cause serious side effects when used long term, so they’re used sparingly^[12].

Antibiotics given for up to three weeks may be considered if you have an acute flare-up or superimposed infection, though their role in treating chronic symptoms is limited^[7].

Biologic Medications

For people whose disease isn’t controlled with standard treatments, newer medications called biologics (medicines made from living cells that target specific parts of the immune system) offer an alternative^[2]. These are given by injection and work by blocking specific inflammatory pathways that cause nasal polyps^[15].

Three biologics have been approved by the U.S. Food and Drug Administration for treating CRSwNP: dupilumab, mepolizumab, and omalizumab^[15]. These medications target type 2 inflammation through different approaches. When added to standard care, they can reduce nasal congestion, improve sense of smell, shrink polyp size, and significantly reduce the need for oral steroids or surgery^[14][16].

Research comparing these biologics shows that dupilumab may be more effective at decreasing nasal polyp size and nasal congestion compared to the other options, though all three have similar safety profiles^[9].

Surgery

If medical treatments don’t provide relief, endoscopic sinus surgery (a procedure where surgeons use small instruments and cameras inserted through the nostrils to remove polyps and improve sinus drainage) may be recommended^[7]. This surgery can be effective, but polyps may grow back in some people^[2]. In fact, approximately 40% of patients who have surgery experience polyp recurrence within a few years^[5].

Working with Specialists

You may see more than one type of doctor for CRSwNP, such as an allergist and an ENT specialist (also called an otolaryngologist). Sometimes these doctors work together to provide the best care^[2]. If you don’t respond to first-line medical therapy, you should be referred to an otolaryngologist. Selected patients with a history suggesting other related conditions may also benefit from referral to an allergist or pulmonologist^[7].

Impact on Quality of Life

CRSwNP can significantly impact your daily life, affecting both physical and emotional well-being^[5]. The condition can make you feel like you have a cold that never goes away, which slowly wears you down^[19].

Common symptoms like loss of smell can affect not just your enjoyment of food but also important safety concerns, as you may not be able to detect hazards like fire or smoke^[5]. One in five patients report being diagnosed with depression at some point in their lives^[19].

Many people with CRSwNP report difficulties in being taken seriously by healthcare professionals, as the social and psychological aspects of the condition are sometimes underestimated^[19]. The condition affects sleep quality, work productivity, and relationships, as the constant symptoms never provide a break^[19].

Research shows that the greatest impact of chronic rhinosinusitis is decreased quality of life through burdensome chronic symptoms and repeated flare-ups^[7]. However, when symptoms are well controlled, people may experience the world with greater vitality and reclaim small joys that CRSwNP can interfere with^[20].

Related Health Conditions

Many people with nasal polyps also have asthma. Inflamed sinuses from nasal polyps can make asthma worse^[2]. Your allergist can work with you to control both conditions, and in many cases, treating nasal polyps can improve asthma control^[2]. In people with asthma, having CRSwNP is associated with poor asthma control, as well as more asthma-related emergency department visits and increased need for systemic corticosteroids^[7].

CRSwNP frequently occurs alongside allergic rhinitis^[3]. The condition can also be associated with several other health problems. Ongoing sinus infections linked to nasal polyps can result in rare but serious complications, including bone infection, abscesses that can spread to the eye area and brain, and meningitis (infection of the tissues around the brain and spinal cord)^[4].

People with cystic fibrosis almost always develop chronic rhinosinusitis, and the bacterial flora from their sinuses can serve as a reservoir for seeding lung infections^[7].