Chronic polyposis rhinosinusitis.

An inflammatory process with the formation of polyps in the nose and sinuses with recurrent growth indicates the development of Chronic rhinosinusitis with nasal polyps (CRSwNP). Polyps appear again and again, despite conservative therapy and surgical treatment. The pathologic process spreads to the microcircular bed, secretory glandular structures. Polyposis growths are formed mainly from edematous tissues infiltrated with neutrophils and eosinophils. Other lymphadenoid structures also take part in the reaction. Treatment measures are complex, aimed at improving the quality of life of patients and preventing recurrences.

Epidemiology

The prevalence of chronic polyposis rhinosinusitis with present clinical manifestations is 1-5%.CRSwNP is a middle-aged disease with an average age of onset of 42 years and a typical age of diagnosis of 40-60 years. [1] According to statistics, this pathology is found in 2-4% of the European population, but the incidence of subclinical course of the disease is much higher and is estimated at about 30% of the general population.

A 2015 study by Stevens and colleagues of patients with CRSwNP who underwent sinus surgery at a tertiary care center found that women with CRSwNP have a more severe disease than men. [2] There are relatively few statistics on incidence in childhood. Children under ten years of age are known to have chronic polyposis rhinosinusitis much less frequently than adolescents and adult patients. According to some information, nasal polyps occur in no more than 0.1% of the pediatric population.

Members of the female sex are somewhat less often. More often the pathology is found in middle-aged men.

The most common symptom of the disease with which patients go to doctors is nasal congestion.

Causes of the chronic polyposis rhinosinusitis.

Chronic polyposis rhinosinusitis refers to multifactorial diseases that do not have a unified theory of origin. However, there are local and systemic pathology, when the pathological process affects only the mucous tissues of the sinuses, or is combined with diseases such as cystic fibrosis, bronchial asthma, Kartagener's syndrome, intolerance to non-steroidal anti-inflammatory drugs and so on. The share of hereditary predisposition to the development of polyposis rhinosinusitis cannot be excluded.

The role of atopy in CRSwNP has been the focus of numerous studies. Although the percentage of patients with allergic rhinitis and nasal polyps is similar to that in the general population (0.5-4.5%) 1, 51-86% of patients with CRSwNP are sensitized to at least one aeroallergen. [3] No study to date has established a relationship between sensitization to one specific aeroallergen and the development of CRSwNP, but sinus disease may worsen during allergen season. [4]

The association between asthma and CRSwNP has been defined in more detail. The vast majority of asthmatics (~88%) have at least some radiologic evidence of sinus inflammation. More specifically, CRSwNP is estimated to occur in 7% of all asthmatics, whereas asthma is reported in 26-48% of patients with CRSwNP. [5]

Histologically, nasal cavity polyps consist of a diseased, often metaplasic epithelium, which is located on a thickened basal membrane, as well as a swelling stroma, which has part of the glands and vessels, and lacks nerve endings. Typical polyposis stroma is represented by fibroblasts forming a supporting base, false cysts and cell elements, mainly eosinophils, localized near glands and vessels, as well as under the covering epithelial tissue.

Presumably, at the beginning of the growth formation due to recurrent infectious processes, there is a permanent swelling of the mucosal tissue, provoked by the disorder of intracellular fluid transport. Over time, the basal epithelial membrane ruptures, prolapse and granulations are formed.

Risk factors

Factors influencing the formation of inflammatory process of mucosal tissues and the occurrence of chronic polyposis rhinosinusitis:

• Internal factors:
  • Hereditary predisposition;
  • male gender and middle age;
  • presence of bronchial asthma;
  • intolerance to non-steroidal anti-inflammatory drugs;
  • arachidonic acid metabolism failure;
  • immunodeficiency states;
  • hypovitaminosis D;
  • metabolic disorders, obesity;
  • obstructive sleep apnea syndrome;
  • gastroesophageal reflux;
  • anatomical anomalies of the nasal cavity.
• External factors:
  • Infectious pathologies;
  • bacterial carrier (e.g., staphylococcal);
  • viral, coronavirus infections, including those of a transient nature;
  • fungal diseases;
  • allergens (drug, plant, industrial, etc.);
  • occupational factors (dusty rooms, exposure to chemicals, metals, mold or rust, regular contact with animals or poisons, etc.).

Pathogenesis

Currently, the following assumptions are known regarding the pathogenesis of chronic polyposis rhinosinusitis:

• Eosinophilic inflammatory process. Eosinophil cells play a major role in the development of the inflammatory response in polyposis rhinosinusitis. It is known that in polyposis tissues there is an increase in the presence of interleukin-5, eosinophil cationic protein, eotaxin, and albumin. All these components activate the migration of eonsinophils, prolong apoptosis, resulting in the development of an eosinophilic inflammatory reaction. What exactly becomes the trigger mechanism of this process is unknown.
• IgE-dependent allergic reaction (the theory is theoretical and has not yet been confirmed). Patients with chronic polyposis rhinosinusitis are prone to pollen allergy and allergic rhinitis.
• Interleukin (IL)-17A, a cytokine produced predominantly by Th17 cells, plays a crucial role in the development of allergic reactions, inflammation and autoimmunity. [6], [7], [8], [9]
• Disorder of arachidonic acid metabolism. Salicylates, inhibiting cyclooxygenase, activate the alternative metabolic channel of arachidonic acid, which is transformed into leukotrienes under the influence of 5-lipooxygenase. Arachidonic acid breakdown products play the role of strong proinflammatory mediators: they have the ability to trigger the migration of eosinophils into the mucosal tissue of the respiratory tract, where the development of inflammatory reaction is forced.
• Bacterial involvement. The role of bacterial pathogens in the development of chronic polyposis rhinosinusitis is currently under active study. It is known that every second patient has the presence of specific IgE to exotoxin of Staphylococcus aureus. It is likely that infectious agents participate in the pathogenetic mechanism, but not as common allergens, but as potent antigens that support the eosinophilic inflammatory response. Staphylococcus aureus enterotoxin is presumed to cause the formation and further growth of polyps, and even the co-development of bronchial asthma. The involvement of bacteria is also indicated by the detection of specific "neutrophilic" growths and polyposis purulent rhinosinusitis.
• Fungal invasion. Mycelium particles are ubiquitous in the respiratory system, so they are found both in healthy people and in patients with a predisposition to the occurrence of polyposis rhinosinusitis. In the second group of individuals, eosinophils are activated, under the influence of T-lymphocytes migrate to the mucous secretion present in the sinuses. Eosinophils attack fungal particles, releasing toxic proteins, which leads to the formation of thick mucin in the lumen of the sinuses, damaging the mucosal tissue, provoking an inflammatory reaction and subsequently - polyposis growth. Presumably, mycelium particles can trigger and sustain inflammation and polyp growth in the sinuses of people with a predisposition to the disease. However, this theory has not yet been sufficiently confirmed.
• ACUTE RESPIRATORY INFECTIONS. There is clinical evidence that viruses often favor the reappearance and intensive growth of polyps, even in supposedly stable remission.
• Hereditary predisposition. As a confirmation of this theory is a clear link between the occurrence of polyps and such genetic pathologies as Kartagener's syndrome and cystic fibrosis. Scientists have not yet been able to identify a specific gene responsible for the formation of the problem, such works are few.
• Pathologies of the sinuses themselves (presence of an additional sinus cavity, cystic neoplasms, etc.).

As a cause of local polyposis rhinosinusitis, various anatomical defects (deviated nasal septum, irregular structure of the nasal concha or hook-shaped process) are considered to be capable of causing a disorder of air conduction. When changing the direction of the main air flow, there is a regular irritation of the corresponding zones of mucous tissues. Bacteria, viruses and antigens in the air contribute to the transformation of damaged areas, processes of cellular infiltration are triggered, hypertrophy and blockage of the ostiomeatal formation occurs.

Since chronic polyposis sinusitis is a polyetiologic disease, the pathologic influence of all kinds of biological abnormalities, congenital or acquired, present in the body as a whole, or in individual organs, cells or subcellular structures is not excluded. Thus, a certain contribution can make a violation of the autonomic nervous system - in particular, excessive activity of the parasympathetic department. Predisposition to the development of the disease may not manifest itself until the moment of exposure to any provoking factor: infection, allergens, mechanical damage, chemical damage, etc.

As an independent pathogenesis pathway, chronic purulent-inflammatory reaction in the appendicular sinuses is considered. Here, chronic polyposis rhinosinusitis becomes a secondary pathology and mainly develops in the sinus, in which purulent inflammation is present. As for the diffuse process, it is accompanied by a gradual spread to the mucosal tissues of all the adventitious sinuses. This type of disease refers to systemic forms, it is associated with violations on the part of immune defense and failure of the general reactivity of the body.

Symptoms of the chronic polyposis rhinosinusitis.

Chronic polyposis rhinosinusitis is manifested by two or more symptoms, the leading one being nasal congestion and difficulty in nasal breathing. Additional symptoms include nasal discharge, facial pain (pressure sensation in the projection of the affected sinuses), impaired odor perception with a duration of more than 12 weeks. As can be seen, the above symptomatology is nonspecific and can occur in chronic sinusitis without nasal polyposis. Therefore, it is important to perform a diagnosis with CT scan of the sinuses and/or nasal endoscopy.

Patients who develop polyposis rhinosinusitis due to aerodynamic abnormalities voice complaints of nasal breathing problems. During the examination, it is possible to detect a polyposis growth blocking one of the halves of the nose, or a deviated septum in combination with an irregular structure of the shells. There may be no discharge.

The first signs of fungal chronic polyposis rhinosinusitis include headache. Both unilateral and bilateral involvement of the sinuses is possible. Polyposis formations sometimes resemble granulations, which is also noted with the bacterial process. Periostitis is often found.

In patients with impaired arachidonic acid metabolism, nasal polyps are different in appearance, forming a solid polyposis mucous mass (in purulent inflammation, polyps have a denser structure). The appendicular sinuses are filled with viscous, dragging discharge, difficult to separate from the sinus walls.

As a rule, the first symptoms appear when the growths grow and leave the sinuses. The patient has a sharp nasal congestion, which is not eliminated by the use of vasoconstrictors. On average, patients with CRSwNP are thought to have more severe sinonasal symptoms than patients with chronic rhinosinusitis without nasal polyps (CRSsNP). [10], [11] In a cohort of 126 patients with CRS, Banjeri and colleagues found that nasal congestion and hyposmia/anosmia were more significantly associated with CRSwNP, whereas facial pain/pressure was more common in patients with CRSsNP. [12] Additional studies of patients with CRS at selected tertiary care centers found that patients with CRSwNP were more likely to report rhinorrhea, severe nasal congestion, and loss of sense of smell/taste than patients with CRSsNP. [13], [14]

Additional pathologic features include:

• frequent headaches;
• impairment or loss of sensitivity to odors;
• mucus and/or pus discharge;
• sensation of a foreign body in the nasal cavity;
• breathing problems, sometimes swallowing problems;
• sleep disturbance, irritability.

Patients with CRSwNP on average have more extensive paranasal sinus involvement than patients with CRSsNP, as determined by worse CT and sinus endoscopy findings. [15] Even after paranasal sinus surgery, patients with CRSwNP may continue to have worse objective measures of sinus disease than patients with CRSsNP who have also undergone surgery. [16]

Polyposis rhinosinusitis in children

In young children (under 10 years of age) chronic polyposis rhinosinusitis is much less common than in adults (no more than 0.1% of all children). The pathogenetic mechanism of pediatric nasal polyps is poorly understood. Presumably, neoplasms are formed due to chronic inflammatory processes, genetic diseases, which are accompanied by lesions in the mucosal tissues of the respiratory system. Often we are talking about cystic fibrosis, as well as syndromes of primary ciliary dyskinesia.

There is some correlation between polyposis rhinosinusitis and allergic diseases. Thus, in children this combination occurs in more than 30% of cases.

The clinical picture in chronic polyposis rhinosinusitis in children is practically the same as in adults. However, experts note that in children polyps cause a more obvious deterioration in the quality of life and negatively affect the prognosis of other associated pathologies.

The predominant pediatric symptom becomes nasal congestion, often increasing.

In childhood, anthrochoanal polyps are most commonly found in 70-75% of cases. Large solitary masses are diagnosed less frequently.

Stages

In order to objectively assess the degree of chronic polyposis rhinosinusitis, the Lund-Kennedy staging scale is used:

• 0 - no polyps visible;
• 1 Polyposis limited to the middle nasal passage;
• 2 - polyps extend beyond the lower border of the middle nasal shell into the nasal cavity.

The degree of swelling of the mucous membrane is also assessed:

• 0 - no swelling;
• 1 - small, moderate edema;
• 2 - polyposis tissue changes are present.

Presence of abnormal discharge:

• 0 - no discharge;
• 1 - mucous discharge;
• 2 - discharge is thick (dense) and/or purulent.

Forms

In general, chronic rhinosinusitis is divided into polyp-free and polyposis rhinosinusitis. To date, there is no universally accepted classification of chronic polyposis rhinosinusitis directly. But experts distinguish different types of the disease, depending on the clinical and histologic features, as well as on the causes of pathology.

Depending on the histologic structure of polyps, distinguish:

• Allergic polyposis rhinosinusitis (aka -edematous, eosinophilic);
• Polyposis cystic sinusitis, fibrotic inflammatory, neutrophilic;
• glandular rhinosinusitis;
• sinusitis with stromal atypia.

According to the peculiarities of etiopathogenesis, the disease is classified as follows:

• Polyposis resulting from aerodynamic disorders of the paranasal sinuses and nasal cavity;
• polyposis purulent rhinosinusitis developed against the background of chronic purulent inflammatory process in the nose and sinuses;
• fungal polyposis;
• rhinosinusitis due to arachidonic acid metabolism disorders;
• polyposis due to cystic fibrosis, Kartagener's syndrome.

Most experts are of the opinion that chronic polyposis rhinosinusitis is not a single nosological unit, but is a syndrome that includes a number of pathological conditions, ranging from a local lesion of any of the sinuses, and to diffuse pathology, which is found against the background of bronchial asthma, intolerance to nonsteroidal anti-inflammatory drugs, genetically determined diseases.

Additionally highlighted:

• diffuse bilateral form of chronic polyposis rhinosinusitis (characterized by the progression of polyp growth in the nasal cavity and in all sinuses);
• unilateral, solitary form of the disease (in particular, ethmochoanal, anthrochoanal, sphenochoanal rhinosinusitis).

Complications and consequences

The most common complications are frequent nosebleeds, chronic runny nose, deterioration or loss of the sense of smell. In addition, there is often a secondary infection, increasing the risk of pyogenic microflora, which contributes to the development of purulent inflammatory process in the nasal cavity. In complicated cases, the development of septic conditions is not excluded.

Polyps themselves do not pose a threat to the patient's life, but they significantly worsen its quality. The growths in the nasal cavity and sinuses become an ideal place for various microorganisms to settle and accumulate, leading to frequent bacterial infections, nosebleeds, tonsillitis, rhinitis, sinusitis, tracheitis and laryngitis, as well as other diseases that can also have a complicated course.

Nasal polyps are dangerous due to the constant presence of chronic inflammation. Outgrowths prevent the normal function of breathing and excretion of mucous secretions. As a result, problems such as:

• Obstructive sleep apnea (interruptions, breath-holding during sleep);
• recurrences of bronchial asthma;
• frequent infections of the nasal cavity and sinuses.

To avoid adverse consequences, it is necessary to timely consult doctors, undergo all the necessary stages of diagnosis and treatment.

Diagnostics of the chronic polyposis rhinosinusitis.

Diagnostic measures begin with the collection of complaints and anamnesis, as well as objective examination. The obtained information is used to determine further diagnostic tactics.

The specialist clarifies:

• time of onset of initial symptoms (difficulty breathing through the nose, abnormal discharge, head pain, olfactory disturbances);
• if there's a history of rhinosinusitis;
• whether any surgical interventions have been performed on the ENT organs;
• whether the patient has taken any treatment (prescribed by another doctor or self-treatment).

It is obligatory to find out the probability of genetic predisposition to polyposis, review the history of diseases. Special attention should be paid to the presence of genetic diseases, bronchial asthma, endocrinologic disorders, bad habits.

Then the doctor performs anterior and posterior rhinoscopy, endoscopy of the nasal cavity. Attention is paid to the anatomy of the structure, the state of the mucous tissues and ostiomeatal complex. In polyposis rhinosinusitis, polyps are usually detected in the nasal passage or outside it, in the nasal cavity and/or nasopharynx. Swelling of the mucosa, the presence of mucous or purulent secretion is also determined. It is important to find out the stage of development of polyposis.

Histologic analyses are mandatory. A typical polyposis outgrowth is represented by damaged, often metaplastic epithelial tissue localized on a compacted basal membrane, as well as edematous stroma with a small number of glands and a scanty vascular network, with a minimal number of nerve endings. In the stroma, fibroblasts are present, on which the supporting framework is based, as well as cellular elements and false cysts. The main cells present are neutrophils, eosinophils, localized near vessels and glands, or immediately under the epithelial tissue. [17]

Instrumental diagnosis, first of all, includes radiologic studies - in particular, computed tomography of the sinuses. CT allows you to find out the intensity of the inflammatory reaction, detect anatomical features. If the operation is supposed to be carried out, then the specialist needs to have comprehensive information about the area of intervention, in order to prevent the development of postoperative complications. Using X-rays, the doctor examines in detail the maxillary, frontal, cuneiform sinuses, anterior and posterior sections of the lattice labyrinth. The condition is evaluated in points on the following scale:

• 0 - sinus pneumatization is present;
• 1 - pneumatization is partially reduced;
• 2 - pneumatization is reduced total.

Additionally, the condition of the ostiomeatal complex on both sides is assessed in points:

• 0 - no pathologic changes;
• 2 - ostiomeatal complex is not defined.

The maximum possible total score in patients with total diffuse polyposis rhinosinusitis is 24 points.

Differential diagnosis

When nasal polyps are detected in children and elderly patients, special attention should be paid to exclude the following conditions:

• in childhood - cystic fibrosis in case of bilateral pathologic process, encephalocele - in case of unilateral process;
• in elderly patients - other benign and malignant neoplasms, which is especially important in unilateral lesions or atypical localization.

Polyposis rhinosinusitis and bronchial asthma in combination represent one of the most complex disease phenotypes, have difficulties in making recommendations for the diagnostic and therapeutic management of patients.

In all patients seeking medical help, a detailed history of life and disease is collected, as well as an obligatory allergologic anamnesis.

In all cases, differential diagnosis with neoplasms of the following types is performed:

• An inverted papilloma is an epithelial tumor with the possibility of malignant degeneration.
• Squamous cell carcinoma is the most common malignant neoplasm of the sinuses.
• Melanoma is a malignant tumor composed of melanocytes of the nasal cavity or paranasal sinuses.
• Esthesioneuroblastoma is a rare type of neoplasm that develops from the olfactory neuroepithelium.
• Hemangiopericytoma is a vascular neoplasm that develops at the base of the skull.
• Nasal glioma is a rare benign tumor of glial tissue. In 40% of cases, it is an intranasal glioma.
• Juvenile nasopharyngeal angiofibroma is a rare benign vascular tumor resembling a polyp.

With unilateral pathologic process, it is necessary to exclude all possible benign and malignant neoplasms. Any tumor is capable of mimicking or coexisting with chronic polyposis rhinosinusitis. All polyposis tissues removed during surgical intervention should be subjected to histomorphologic examination to exclude the possibility of malignancy and metaplasia, with further rational therapy.

Treatment of the chronic polyposis rhinosinusitis.

Treatment measures include gentle surgery, prolonged courses of inhaled glucocorticosteroids, and short courses of systemic corticosteroids. Antifungal therapy and antibiotics are indicated for some patients.

Medical treatment options for patients with CRSwNP remain limited. According to recent US guidelines, both topical corticosteroids and saline nasal lavage are recommended as initial medical therapy for sick patients. [18] Intranasal corticosteroids can reduce the size of nasal polyps, decrease sinonasal symptoms, and improve patients' quality of life. [19], [20] Oral corticosteroids can also reduce polyp size and improve symptoms, but should always be prescribed with caution given their association with serious systemic side effects. [21] Antibiotics may be useful in treating infectious exacerbations of CRSwNP, but clinically significant efficacy ( i.e., polyp reduction) is lacking in large randomized trials.

Drug therapy involves the use of the following groups of drugs and types of treatment:

• Topical glucocorticosteroids (nasal) help to reduce the size of polyps, prevent the development of early recurrences after surgical removal of growths. Side effects in most cases are limited to a feeling of dryness in the nose and nosebleeds. There is no effect on the state of the lens and intraocular pressure. Most often such drugs as Mometasone, Fluticasone, Ciclesonide are used, less often - Budesonide, Beclomethasone, Betamethasone, Dexamethasone, Triamcinolone. The standard dosage is 200-800 mcg.
• Implantation of corticosteroid implants into the lattice labyrinth is indicated in patients with recurrent chronic polyposis rhinosinusitis after sinus surgery. This procedure improves the patency of the nasal passages and prolongs the remission period. Most often it is a self-absorbing implant that releases Mometasone Furoate in a dose of 370 mcg. The duration of action of the implant is 1 month.
• Short-term courses of corticosteroid drugs (from 1 to three weeks) involve oral administration of methylprednisolone in the amount of 1 mg per kg of body weight with a gradual decrease over 2-3 weeks. This approach allows you to reduce the nature of clinical manifestations, improve the condition of the sinuses. Treatment is often combined with antibiotic therapy or inhaled corticosteroids. Example of therapy: Prednisolone orally at 0.5-1 mg/kg per day, for 10-15 days. The dose is gradually reduced, starting on the eighth day, by 5 mg daily until complete withdrawal of the drug. In chronic polyposis rhinosinusitis it is optimal to conduct 1-2 courses of such treatment annually.
• Irrigations of the nasal cavity with physiologic sodium chloride solution or Ringer's solution, often with the addition of sodium hyaluronate, xylitol and xyloglucan also demonstrate a positive therapeutic effect.
• Short or long courses of systemic antibiotics (side effects: intestinal dysfunction, anorexia) are prescribed if indicated.It is noted that macrolides in low doses have an immunomodulatory effect, provide a stable postoperative remission. When prescribing a prolonged course, possible cardiotoxicity of macrolides should be taken into account.
• Topical antibacterial agents are used to rinse the nasal cavity. For example, mupirocin solution has similar efficacy to oral amoxicillin/clavulanate, which has been successfully used against Staphylococcus aureus.
• Antihistamine medications are appropriate for the treatment of patients who have concomitant allergies.

Physical therapy is contraindicated in cystic and polyposis rhinosinusitis.

Biologic therapy for polyposis rhinosinusitis

If the course of chronic polyposis rhinosinusitis cannot be brought under control, biological therapy with monoclonal antibodies is added to the main treatment. In patients with bilateral pathologic process who have already undergone sinus surgery, treatment of polyposis rhinosinusitis with monoclonal antibodies is prescribed if three criteria are met, and if four criteria are met in patients without surgery or if surgery is not possible:

Criteria for biotherapy	Criteria indicators
Clinical manifestations of the T2-inflammatory process. The need for systemic corticosteroid therapy or the presence of contraindications to it. A clear negative impact on quality of life. Marked deterioration of olfactory function. Combination with bronchial asthma.	Tissue eosinophils greater than 10 in the field of view (x400), or blood eosinophils greater than 250 kL/μL, or total IgE greater than 100 IU/mL. More than two courses per year, or long-term low-dose treatment. On a SNOT-22 scale of 40 points or more. Anosmia. Bronchial asthma with the need for regular corticosteroid inhalation therapy.

The results of biotherapy should be evaluated after 4 months and one year after its initiation. If there is no positive response according to the above criteria (at least one of them), this treatment is discontinued.

Criteria for evaluating the results:

• shrinking polyps in size;
• reducing the need for systemic use of corticosteroid drugs;
• improved olfactory function;
• Improved quality of life in general;
• Reducing the impact of background pathologies.

An excellent indicator of biotherapy is said if there is a positive response to all of the above criteria, a moderate indicator is said if there is a positive response to three or four criteria. A response on 1-2 criteria is assessed as weak.

To date, various monoclonal antibodies have been used as therapeutic agents, in particular Dupilumab, [22] Omalizumab, Mepolizumab, [23] Benralizumab, Reslizumab. Dupilumab-based subcutaneous solution - Dupixent for polyposis rhinosinusitis is often the drug of choice. [24] The initial recommended dose for an adult is 300 mg every two weeks. If an injection is missed, the injection should be given as soon as possible and then continued according to the previously prescribed regimen.

Dupilumab	300 mg subcutaneously once every two weeks. After 12 months, the frequency of administration can be changed to once every four weeks.
Omalizumab	Starting at 75 to 600 mg subcutaneously once every 2 to 4 weeks.
Mepolizumab	100 mg subcutaneously once a month.

Herbal treatment

Official medicine does not welcome the use of folk treatment in chronic polyposis rhinosinusitis, which is associated with a high risk of aggravation of the disease and increased intensity of polyp growth. Folk remedies are allowed to use only after consultation with the attending doctor and against the background of the main treatment prescribed by doctors.

Possible phytotherapy recipes:

• Pumpkin seeds (5 tbsp.) grind with 200 ml of sea buckthorn oil, mix well. Take 1 tsp. Daily 15 minutes before the first meal. Frequency of reception: 10 days to take, 5 days break, until a steady improvement in condition. The medicine should be stored in the refrigerator.
• Mix equal parts of chamomile and celandine. Pour 1 tbsp. Of the resulting mixture 200 ml of boiling water, insist under a lid for several hours. Take a remedy for 1 tbsp. L. 30 minutes before each meal. Duration of treatment - 4 weeks, then the reception can be repeated after a 10-day break.
• Put in a pot 1 tbsp. Of juniper berries, pour 200 ml of boiling water and kept on low heat for 10 minutes. Then the remedy is cooled, filtered and drink 50 ml three times a day an hour after meals.

Surgical treatment

Surgical intervention consists of functional endoscopic surgery to remove polyps, correct anatomical defects (deviated septum, hypertrophy of the nasal shells, etc.), inspection and correction of the size of the sinus cavity, opening and removal of the cells of the lattice labyrinth, which are affected by pathological growths.

Polyps are removed in accordance with the principles of minimally invasive surgery, with minimal damage to mucous tissues. The nasal septum is operated with preservation of its supporting function. If an additional maxillary sinus connection is detected, it is connected to the main one.

If we are talking about polyposis purulent rhinosinusitis, the intervention involves restoring communication with the nasal cavity, creating conditions for normal air exchange in the sinuses, removal of growths and pus. In this case, the mucous tissue of the sinuses is not removed, regardless of the presence of edema. Before proceeding to surgery, the doctor finds out the microbiological features of the inflammatory process, determines the type of pathogen and its sensitivity to antibacterial drugs.

A similar approach is used for fungal polyposis sinusitis. In this case, it is sometimes necessary to perform a microgaymorotomy through the anterior wall or through the lower nasal canal. The main condition for eliminating the fungal process in the sinuses is the restoration of aeration.

In patients with cystic fibrosis, Kartagener's syndrome polyps are removed regularly, because in all cases there is a re-growth of formations.

Prevention

There is no specific prevention of the development of chronic polyposis rhinosinusitis. It is recommended to avoid the influence of risk factors, systematically visit doctors for preventive examinations, timely treat any otolaryngologic diseases.

Patients with pre-existing polyposis should make every effort to prevent recurrence of polyp growth. Visits to the doctor are planned according to an individual schedule and include regular examination of the nasal cavity, removal of secretions and accumulations, local treatment with antiseptics. For a long period of time, local therapy with corticosteroids is prescribed. If the patient underwent surgical intervention, then in the future to visit the doctor should be every three months. With previous purulent or fungal lesions of the sinuses, the doctor is visited at least once every six months.

If chronic polyposis rhinosinusitis is combined with bronchial asthma or intolerance to non-steroidal anti-inflammatory drugs, intranasal administration of corticosteroids is prescribed for a long period of time (several years or for life). If the growth of polyps can not be stopped by medication, then repeated intervention is performed, preventing the intensive growth of formations and blocking nasal breathing.

Under favorable circumstances, corticosteroid therapy may be temporarily suspended for the summer period, with resumption in early fall, which is associated with a high risk of starting polyp re-growth.

Forecast

The main goal of treatment is to prolong the asymptomatic period of the disease and improve the patient's quality of life. Most patients have to undergo repeated and multiple endoscopic surgeries, daily intranasal administration of local corticosteroids (often for life, at regular intervals).

Patients are systematically monitored by an otolaryngologist (every 2-3 months). The treatment prognosis depends not only on the surgical intervention performed, the qualifications of the attending physician, but also on the patient's compliance with medical recommendations.

It is important to realize that the removal of nasal polyps does not eliminate the root cause of their appearance, so after a certain period of time, the growths may reappear. To reduce the likelihood of recurrence, it is necessary to follow the recommendations of the doctor, and after surgical intervention to undergo a prolonged course of drug therapy.

Polyposis rhinosinusitis and the army

If a conscript is diagnosed with polyps of the nose and sinuses, he can be assigned such categories of eligibility:

• fit for military service;
• restricted.

Restrictions on service are possible if chronic polyposis sinusitis is officially confirmed, including a CT scan. In addition, at the time of enlistment, the patient must be on the dispensary register for at least six months.

If the conscript had a surgical operation to remove the growths, and at the same time the formation of recurrences did not occur, and there is no danger to health, the category "fit for military service" is assigned.

If there is documentary evidence of regular recurrence of neoplasms, respiratory problems, if there are complications of rhinosinusitis, then we can talk about restrictions on fitness, less often - about unfit for service.

In most cases, chronic polyposis rhinosinusitis in the acute phase becomes an indication for deferment from mobilization and compulsory service.