Polyposis allergic rhinitis

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

• multiple;
• solitary (single nasal polyp);
• deforming;
• double-sided or single-sided.

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Causes of polypous allergic rhinitis

The causes and pathogenesis of polypous allergic rhinitis are reflected in the concept of S.V. Ryazantsev (1990), according to which the formation of polyps in the nasal cavity requires a combination of two conditions: the presence of disturbances in biological processes in the body and the impact of environmental factors. The first condition begins with the occurrence in 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 sinus-nasal system by pathomorphological changes characteristic of allergic rhinosinusitis. The causes of the development of this pathological condition can be both exoallergens and autoallergy, characterized by a violation of the immunological tolerance of the body to its own tissues of the nasal mucosa.

When considering the pathomorphological process of polyp formation, two important factors should be taken into account:

• mechanism of occurrence and development of polyps;
• its specific localization.

R. Virchow considered the polyp to be a myxomatous tumor, but further research showed that this view of the outstanding pathologist was erroneous and that the nasal polyp is nothing more than a product of interstitial edema of the connective tissue of the submucosal layer of the nasal mucosa, which leads to benign degeneration of this layer. Histological studies by Leroux and Delarue have shown that polyps are a product of degeneration of connective tissue and glandular apparatus of the nasal mucosa, and the most recent studies (S.V. Ryazantsev, T.I. Shustova, M.B. Samotkin, N.M. Khmelnitskaya, N.P. Naumenko, E.V. Shkabarova, E.V. Bezrukova, 2002-2003) have shown that the stroma of polynous tissue contains elements of the autonomic nervous system, the functional state of which determines the permeability of cell membranes and homeostasis of the morphological structures of the nasal mucosa.

The nasal polyp membrane has the appearance of the epithelial covering of the nasal mucosa, which in some cases can retain a normal structure. In other cases, it is thinned, and the cylindrical ciliated epithelium is metaplastic into a multilayered squamous epithelium. The latter phenomenon is especially common in areas subject to injury or inflammation. At the same time, sclerosis of the connective tissue of the submucosal layer of the polyp membrane and its fibrous degeneration develop. Depending on the prevalence of any of the above processes, the polyp can acquire various aspects (peeudoangiomatous, pseudoedematous), which sometimes resemble fibromas, angiomas, papillomas, and adenomas in appearance.

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Symptoms of polypous allergic rhinitis

The above clinical forms of polypous allergic rhinitis are rarely found in isolation, most often they pass into one another, and in the direction of worsening clinical course. They are usually observed in adults and very rarely in children. Untreated nasal polyposis that occurs in childhood leads to a deforming form of this disease. Bilateral nasal polyposis most often indicates the so-called primary allergic process of an atopic nature, while inflammatory changes in the paranasal sinuses can occur secondarily. Unilateral development of polyps most often indicates the presence of a primary inflammatory process in the cells of the ethmoid bone or maxillary sinus. In this case, polypous formations occur, respectively, either in the olfactory fissure or in the anterior sections of the middle nasal passage. In the presence of polypous frontal sinusitis, polyps can prolapse into the anterior sections of the middle nasal passage. Polypous changes in the maxillary sinus cause polyps to appear in the posterior part of the middle nasal passage and prolapse into the nasopharynx. Similar localization of the polyp can be observed in diseases of the posterior cells of the ethmoid bone and sphenoid sinus.

Polyps grow gradually at different speeds. Sometimes their number is impressive, and their size can reach the size of a chicken egg. In this case, they can fall out into the vestibule of the nose or appear in the nasopharynx at the level of the soft palate.

Large polyps trapped in the common nasal passage may ulcerate and cause nosebleeds. In some cases, with intense sneezing or blowing of the nose, such polyps may break off and fall out.

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

Clinical manifestations of choanal polyp have their own peculiarities. A typical manifestation of this form of nasal polyp is a valve mechanism, which makes it difficult to exhale through the corresponding half of the nose. With large sizes of 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 nasality), and also causes the appearance of a gag reflex due to irritation of the back wall of the pharynx. At the same time, the locking function of the soft palate can be impaired (when swallowing liquid, the latter gets into the nasal cavity), as well as the function of the corresponding auditory tube. Hence - retraction of the eardrum on the side of the obstructed choana, hearing loss on this side, complications in the form of tubootitis. Sometimes solitary polyps are found, originating from the sphenoid sinus or from the edge of the choana. In the latter case, their growth can be directed both into the nasal cavity and to the side of the nasopharynx. In the latter case, the said polyp is characterized by significant density and is classified by some authors as a benign fibrous tumor of the nasopharynx with a growth point from the fibrous tissue of the choana, the morphological structure of the mucous membrane of which differs from the structure of the nasal mucosa.

Severe nasal polyposis occurs in young people who have not received timely and effective treatment.

The evolution of polypous allergic rhinitis is characterized by a slow and long (years and decades) course with characteristic constant relapses that occur even after a seemingly radical operation. However, the long course of the polypous process, sometimes lasting a lifetime, never leads to malignancy of the polyps.

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

The most common complications are those that arise at a distance, and primarily in the bronchopulmonary system, manifested by asthmatic crises or exacerbations of bronchial asthma, if such preceded the occurrence of nasal polyposis. In addition, with nasal polyposis, there may be disturbances in the functions of the digestive organs, manifested by bloating, aerophagia, and dyspeptic phenomena. It should be assumed that both bronchopulmonary and gastrointestinal "complications" of nasal polyposis, as well as polyposis itself, are corresponding syndromes of general allergy of the body, and their local manifestation is due to the reduced tolerance of this organ to allergens.

Diagnosis of polypous allergic rhinitis

Diagnosis of nasal polyposis 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), a thorough anamnesis and appropriate allergological examination should be carried out. In addition, all patients, even with small polyps, should undergo an X-ray examination of the paranasal sinuses to exclude polypous sinusitis.

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

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

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Treatment of polypous allergic rhinitis

Nasal polyps are only a manifestation of a general disease, the etiology and pathogenesis of which are so complex that the treatment of polypous allergic rhinitis as such is reduced to palliative removal of polyps, and only for certain indications. Basic treatment is the fight against allergies in the directions described above, mainly identifying the cause of the allergy, eliminating it, eliminating foci of infection and other risk factors, using antihistamines, steroids and other medications for both local and general use.

Surgical treatment of polypous allergic rhinitis includes various methods of polyp removal, which are determined mainly by the size of the polyps and the degree of impairment of nasal breathing and olfaction. In the case of small polyps resulting from degeneration of the nasal mucosa in the area of the middle nasal passage, not causing any functional impairment, their removal is not indicated. In this case, local and general antiallergic treatment should be used. In the presence of signs of neurovegetative rhinitis, short-term use of decongestants is acceptable. If polyps are detected in the area of the respiratory slit, one should assume the presence of polypous ethmoiditis and conduct a more in-depth examination of the patient. In the presence of polypous ethmoiditis, surgical intervention may include opening the ethmoid labyrinth and removing polypous masses from its cells, but this does not guarantee the exclusion of a relapse.

An indication for surgical intervention is the presence of large polyps filling the common nasal passage and causing difficulty in nasal breathing and olfaction (mechanical anosmia). And in this case, one should not strive for radical removal of polypous masses, limiting oneself only to the largest and most accessible for effective capture with the appropriate instrument. The main and only goal of such a gentle method of polyp removal 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, in addition to nasal polypotomy, surgical sanitation of the corresponding paranasal sinuses is also indicated. However, in the presence of general allergy, even such radical treatment without the use of systemic antiallergic therapy does not exclude relapses of both polypous allergic rhinitis and purulent sinusitis.

The technique of polypotomy involves the use of special instruments that allow the removal of both solitary polyps and small grape-like vegetations. Before the polyp removal procedure, premedication may be used, such as sedatives and general anesthetics, as well as parenteral administration of diphenhydramine (intramuscularly 3-5 ml of a 1% solution) and atropine sulfate (subcutaneously 1 ml of a 0.1% solution). On the eve of the operation, it is advisable to prescribe a sleeping pill and a cleansing enema; on the day of the operation, food intake is excluded. 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 surgery. The anesthetics usually used are 5% (10%) cocaine hydrochloride solution, 1% (3%) dicaine solution or 10% lidocaine solution, released in an aerosol dispenser. One dose of aerosol contains 4.8 mg of active substance. To anesthetize the nasal mucosa, 2-3 doses are sufficient, however, it should be borne in mind that nasal polyps, as a rule, are an obstacle to the penetration of aerosol to the nasal mucosa, therefore it is advisable to lubricate the nasal mucosa with an anesthetic substance using a nasal lubricant (cotton wool) at the initial stage of the operation and only after removing the bulk of the polyps use lidocaine spray (1-2 doses). To reduce the absorption of the anesthetic substance, prolong its anesthetic effect and reduce bleeding, an adrenaline solution is usually added to its solutions (for example, 3-5 drops of 0.1% adrenaline hydrochloride solution per 5 ml of cocaine solution).

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

To do this, the loop is inserted into the common nasal passage with a plane parallel to the nasal septum, then at the lower pole of the polyp it is turned 90° and with the help of small vibration movements it is put on the polyp so that it reaches the base of the polyp, i.e. its stalk. Here the loop is tightened, and with a light tearing movement the polyp is removed from the nasal cavity. Some authors prefer to use a cutting loop to cut off the stalk of the polyp, which significantly reduces bleeding both during the operation and in the postoperative period. In cases where the polyp is difficult to access due to its "inconvenient" location, the shape of the loop is changed accordingly by bending it or other surgical instruments are used that are appropriate for the given case.

As a rule, regardless of the prevalence of nasal polyposis, the operation is attempted to be completed in a single intervention. However, often, when removing visible polyps, conditions are created for the prolapse of deeper polyps either in the deep sections of the internal nose, or in the maxillary sinus or ethmoid labyrinth. In this case, on the second day or after a few days, newly appeared polyps can be seen in the nasal cavity. After their removal, this can be repeated several times, which indicates the presence of a "reservoir" of polyps, usually in the maxillary sinus or in the cells of the ethmoid labyrinth. The pathognomonic sign of the latter is the presence of the so-called concha bullosa - a sharply enlarged bone base of the middle nasal concha, which is part of the ethmoid labyrinth.

The surgical intervention is completed by anterior loop tamponade according to V.I. Voyachek with gauze tampons soaked in vaseline oil and a broad-spectrum antibiotic solution. The tampons are removed after 24-48 hours.