Polyposis allergic rhinitis

Polypous allergic rhinitis is a manifestation of a general body allergy and, as a rule, enters into the concept of polypous rhinosinusitis. Polyposis allergic rhinitis is divided into the following clinical forms:

• multiple;
• solitary (single polyp of the nose);
• deforming;
• bilateral or one-sided.

[1], [2], [3], [4], [5], [6]

Causes of polyposis allergic rhinitis

The causes and pathogenesis of polypous allergic rhinitis are reflected in the concept of SV Ryazantsev (1990), according to which for the formation of polyps in the nasal cavity it is necessary to combine two conditions: the presence of disturbances in biological processes in the body and the influence of environmental factors. The first condition is the beginning of the emergence of practically healthy people under the influence of congenital or acquired biological changes in the immune, endocrine and autonomic nervous system of certain pathomorphological and pathophysiological processes developing in the whole organism, manifested in the sinusonasal system characteristic of allergic rhinosinusitis pathomorphological changes. The reasons for the development of this pathological condition can be both exoallergenic and auto-allergy, which is characterized by a violation of the immunological tolerance of the organism to its own tissues of the nasal mucosa.

When considering the pathological process of polypology, two important factors should be considered:

• mechanism of polyp origin and development;
• its specific localization.

R.Virkhov considered the polyp as a myxomatous tumor, but further studies showed that this view of an outstanding pathomorphologist turned out to be erroneous and that the nasal polyp is nothing but a product of the interstitial edema of the connective tissue of the submucosal layer of the nasal mucosa that leads to benign degeneration of this layer. Histological studies of Leroux and Delarue showed that polyps are a product of degenerative connective tissue and glandular apparatus of the nasal mucosa, and the most recent studies (SV Ryazantsev, TI Shustova, MB Samotokin, NM Khmelnitskaya, N.Naumenko, E.Shkabarova, E.V. Bezrukova, 2002-2003) showed that the stroma of the polynomial tissue contains elements of the VNS, the functional state of which depends on the permeability of cell membranes and the homeostasis of the morphological structures of the nasal mucosa.

The nasal polyp shell has the form of an epithelial cover of the nasal mucosa, which in some cases can maintain a normal structure. In other cases, it is thinned, and the cylindrical ciliate epithelium is metaplastic into a multilayered epithelium. The latter phenomenon occurs especially often in places that are injured or inflamed. At the same time, sclerosis develops in the connective tissue of the submucosal layer of the polyp shell and its fibrous degeneration. Depending on the predominance of any of these processes, the polyp can acquire various aspects (pevedoangiomatous, pseudo-edema), which sometimes resemble fibroma, angiomas, papillomas, adenomas in appearance.

[7], [8], [9], [10], [11], [12], [13], [14]

Symptoms of polyposis allergic rhinitis

The above clinical forms of polypous allergic rhinitis are rarely found in isolated form, most often they go one to the other, and in the direction of weighting the clinical course. They are observed, as a rule, in adults and very rarely in children. The unresolved nasal polyposis that occurs in childhood leads to a deforming form of this disease. Bilateral polyposis of the nose often indicates a so-called primary allergic process of atopic nature, while inflammatory changes in the paranasal sinuses may occur again. Unilateral development of polyps most often indicates the presence of a primary inflammatory process in the cells of the trellis or maxillary sinus. In this case, the polypous formations arise respectively in either the olfactory gap or in the anterior parts of the middle nasal passage. In the presence of polytopic frontal polyps can prolapse into the anterior parts of the middle nasal passage. Polyposis changes in the maxillary sinus cause the appearance of polyps in the posterior part of the middle nasal passage and prolapse into the nasopharynx. Analogous localization of the polyp can be observed in diseases of the posterior cells of the trellis and the sphenoid sinus.

The growth of polyps occurs gradually at different rates. Sometimes their number is impressive, and the size can reach the size of a chicken egg. In this case, they may fall out on the threshold of the nose or appear in the nasopharynx at the level of the soft palate.

Large polyps injured in the common nasal passage may ulcerate and cause nasal bleeding. In some cases, with intense sneezing or blowing, such polyps can tear off and fall out.

Single, (solitary) or choanal, the polyp was first described by the German otorhinolaryngologist Killian in 1906. This form of polyposis rhinitis is characterized by the one-sidedness of the process and the fact that the polyp only occurs in adults and in a single specimen, the starting point of its growth is the maxillary sinus, in which primarily develops polypous degeneration of the nasal mucosa. As a rule, with hoanalyum polyp, there are always polypous growths in the corresponding maxillary sinus.

The clinical manifestations of the choana polyp have features. A typical manifestation in this form of the nose polyp is the valve mechanism, which makes it difficult to exhale through the corresponding half of the nose. With large sizes of the choanal polyp, when it falls into the nasopharynx and even into the upper parts of the pharynx, it begins to interfere with the function of the soft palate, which affects the voice function (closed nasal), and also causes a vomiting reflex due to irritation of the posterior pharyngeal wall. At the same time, the blocking function of the soft palate may be violated (if the liquid is swallowed, the latter enters the nasal cavity), and also the function of the corresponding auditory tube. Hence - the tying of the tympanic membrane on the side of the obturated choana, a decrease in hearing on this side, complications in the form of tubotitis. Sometimes there are solitary polyps, originating from the sphenoid sinus or from the edge of the choana. In the latter case, their growth can be directed both to the nasal cavity and to the nasopharynx. In the latter case, this polyp has a significant density and is classified by some authors as a benign nasopharyngeal fibrosis with a growth point from the fibrous Hoana tissue, the morphological structure of the mucous membrane of which differs from that of the nasal mucosa.

Severe polyposis of the nose occurs in young people who did not receive timely and effective treatment.

The evolution of polypous allergic rhinitis is characterized by a slow and prolonged (years and decades) course with characteristic recurrent relapses that occur even after a seemingly radically effected operation. Nevertheless, the prolonged course of the polypous process, which lasts for a lifetime, never leads to malignant polyps.

Complications are divided into local and general. Local complications include infectious-allergic sinusitis, from mono-, hemi- to pancinusitis, as well as similar diseases of the auditory tube and middle ear.

The most frequent complications appear at a distance, and primarily in the bronchopulmonary system, manifested by asthmatic crises or exacerbations of bronchial asthma, if that preceded the onset of polyposis of the nose. In addition, with polyposis of the nose may occur violations of the digestive system, manifested by bloating, aerophagia, dyspepsia. It should be assumed that both bronchopulmonary and gastrointestinal "complications" of the polyposis of the nose, as well as the polyposis itself, are the corresponding syndromes of the general allergy of the organism, and their local manifestation is due to a lower tolerance of this organ to allergens.

Diagnosis of polyposis allergic rhinitis

Diagnosis of polyposis of the nose in typical cases does not cause difficulties and is based on the clinical manifestations of this disease described above. However, to clarify its etiology (the nature of the allergen), it is necessary to carefully collect the history and appropriate allergological examination. In addition, all patients, even with small polyps, should conduct an x-ray examination of the paranasal sinuses to exclude polyposis sinusitis.

More carefully, differential diagnosis should be carried out, since the occurrence of polyps can be caused by some infectious inflammatory process, localized in the paranasal sinuses. Polynous allergic rhinitis should also be differentiated from benign tumors such as adenoma on the leg, myxoma, perihoanal polyp, angioma, angiofibroma of the nasopharynx, etc. Differential diagnosis of nasal polyposis with malignant tumors is important, as the latter are often accompanied by the formation of polyps that can mask the tumor , therefore in all cases, obtained operatively or by biopsy, the material is sent for histological examination.

The prognosis for the usual course of polypous allergic rhinitis and timely and adequate local and general treatment is favorable. However, in the presence of polypsic rhinosinusitis, he becomes cautious due to possible complications from the latter.

[15], [16], [17], [18]

Treatment of polypous allergic rhinitis

Polyps of the nose are only a manifestation of a common disease, the etiology and pathogenesis of which are so complex that the treatment of polypous allergic rhinitis as such reduces only to the palliative removal of polyps, and then only for certain indications. The basic treatment is the control of allergies in the areas described above, mainly the identification of the cause of allergy, its elimination, the elimination of foci of infection and other risk factors, the use of antihistamine, steroid and other medications, both local and general use.

Surgical treatment of polyposis allergic rhinitis includes various methods of removing polyps, which are determined mainly by the size of the polyps and the degree of disruption of nasal breathing and smell. With small polyps that arise as a result of degeneration of the nasal mucosa in the region of the middle nasal passage, which do not cause any functional disorders, their removal is not shown. In this case, local and general antiallergic treatment should be used. If signs of neurovegetative rhinitis are present, short-term use of decongestants is acceptable. When polyps are found in the area of the respiratory tract, one should assume the presence of polyposic etmoiditis and conduct a more in-depth examination of the patient. In the presence of polytopic etmoiditis, surgical intervention may include opening a trellis labyrinth and removing polypous masses from its cells, but this does not guarantee the exclusion of relapse.

Indication for surgery is the presence of large polyps that fill the common nasal passage and cause difficulty in nasal breathing and smell (mechanical anosmia). And in this case, we should not strive for a radical removal of polypous masses, confining ourselves to only the largest and most accessible effective capture by the appropriate tool. The main and only goal of such a sparing method of removing polyps is the restoration of nasal breathing and olfaction.

If polypous allergic rhinitis is a consequence of purulent inflammation of the paranasal sinuses or is itself the cause of the latter, then, apart from the polypotomy of the nose, surgical sanation of the corresponding paranasal sinuses is shown. However, in the presence of general allergy, even such a radical treatment without the use of systemic antiallergic therapy does not exclude relapses and polyposis of allergic rhinitis, and purulent sinusitis.

The technique of polypotomy involves the use of special tools that allow the removal of both solitary polyps and small grovelike vegetations. Before the procedure for the removal of polyps, the use of premedication is possible, for example, the appointment of sedatives and general anesthesia, as well as parenteral administration of diphenhydramine (intramuscularly with 3-5 ml of a 1% solution) and atropine sulfate (subcutaneously 1 ml of 0.1% solution). On the eve of the operation, it is desirable to prescribe a hypnotic and cleansing enema; on the day of surgery - the exclusion of food. The operation is performed under local (superficial) anesthesia, the purpose of which is total anesthesia of the nasal mucosa, which inevitably comes into contact with the surgical instrument during surgical intervention. As an anesthetic, a 5% (10%) solution of cocaine hydrochloride, 1% (3%) solution of dicaine, or 10% lidocaine solution produced in an aerosol dispenser is usually used. One dose of aerosol contains 4.8 mg of active substance. For anesthesia of the nasal mucosa 2-3 doses are sufficient, but it should be borne in mind that the polyps of the nose, as a rule, are an obstacle to the penetration of the aerosol to the nasal mucosa, so it is advisable at the initial stage of the operation to apply lubrication of the nasal mucosa with an anesthetic (cotton towel) and only after removing the bulk of the polyps, apply lidocaine spray (1-2 doses). To reduce the absorption of anesthetic, prolong its anesthetic effect and reduce bleeding, an adrenaline solution is usually added to its solutions (for example, 5 ml of a cocaine solution of 3-5 drops of 0.1% solution of epinephrine hydrochloride).

To remove solitary polyps, the so-called pressing or tearing nasal loop is usually used.

To do this, the loop is inserted into the common nasal plane parallel to the septum of the nose, then at the lower pole of the polyp it is unfolded by 90 ° and, with the help of small vibrational movements, put it on the polyp so that it reaches the base of the polyp, i.e. Its legs. Here, the loop is tightened, and the polyp is extracted from the nasal cavity by a slight tearing motion. Some authors prefer the use of a cutting loop to cut off the leg of the polyp, which drastically reduces bleeding both during surgery and in the postoperative period. In cases where, due to the "inconvenient" location of the polyp, it is difficult to access, the loop shape is changed accordingly by bending it, or other surgical instruments appropriate to the case.

As a rule, regardless of the prevalence of polyposis of the nose, the operation is attempted to complete with a single intervention. However, often with the removal of visible polyps, conditions are created for the prolapse of deeper polyps either in the deep sections of the inner nose, or in the maxillary sinus or trellis labyrinth. In this case, on the second day or a few days later, newly appeared polyps can be seen in the nasal cavity. After removing them, it can repeatedly repeat, which indicates the presence of a "reservoir" of polyps, as a rule, in the maxillary sinus or in the cells of the latticed labyrinth. The pathognomonic sign of the latter is the presence of the so-called concha bullosa - the sharply enlarged bone base of the central nasal cavity, which is part of the trellis labyrinth.

Operative intervention is completed with a front loop tamponade according to VI Voyachek with gauze tampons impregnated with vaseline oil and a broad-spectrum antibiotic solution. Tampons are removed after 24-48 hours.