1. Disease Profile.
Nasal polyps are common benign diseases of the nose, referring to the inflammatory tissue that protrudes into the nasal sinuses due to edema. Pediatric nasal polyps are found in the maxillary sinus, septal sinus, middle turbinate and middle nasal tract, among which children are most commonly affected by polyps in the posterior nostril of the maxillary sinus that protrude into the nasopharynx. The disease is thought to be closely associated with bronchial asthma, aspirin intolerance, allergic rhinitis, and cystic fibrosis. The incidence of pediatric nasal polyps is lower than that of adults and rarely occurs in young children, but the recurrence rate is higher than that of adults. It is currently believed that nasal polyps in children up to the age of ten years are highly susceptible to recurrence after surgery, but recurrence decreases significantly after the age of ten years.
2. Disease classification.
The classification of nasal polyps is still clinically confusing, and in the annual meeting of Nanchang Otolaryngology in 2008, nasal polyps were classified as sinusitis diseases in [1] and divided into two categories: 1, sinusitis without nasal polyps. 2, sinusitis with nasal polyps. Some scholars list posterior maxillary sinus polyps separately, mainly because they contain a large amount of mucus and few eosinophils, as they are usually called. It is now more uniformly accepted that nasal polyps are inflammatory tissues protruding from the mucosa of the nasal cavity and sinuses due to edema, but very little vascular tissue is present in polyp tissue. This includes polyps rich in eosinophils, polyps in the posterior nostril of the maxillary sinus that contain a large number of mucus cells, and nasal polyps with poorly defined borders that are prone to recurrent episodes. But does not include bleeding necrotic polyps.
3.Causes of pathogenesis.
The etiology of nasal polyps is still unclear, there are many relevant doctrines, which can be broadly divided into the following three categories.
(1) microenvironmental theory of the middle nasal tract: refers to the anatomical structure of the middle nasal tract abnormalities, dysfunction and other causes of the middle nasal tract natural defense function
Weakened, creating conditions for the formation of nasal polyps. Especially in children, the nasal structures are in the stage of perfect development, such as deviated nasal septum, narrow middle nasal tract, poor cilia function, etc. are the main causes of nasal polyps in children.
2) Nasal mucosal metaplasia theory: a large number of mast cells and eosinophils can be examined in the nasal polyp tissue.
IgE is also increased in body fluids, indicating that local allergic reactions are related to their causes. Ma Ruiqin et al [2] (1992) determined immunological indicators on nasal polyp homogenates and concluded that there is an association with type I and type III allergic reactions. It has also been suggested to be related to the activation of B-cell hypersensitivity by certain bacteria, such as the nasal commensal Staphylococcus aureus.
(3) Inflammatory theory: At present, it is certain that nasal polyps are related to inflammation, and histological studies show that nearly 90% or more of nasal
The histological study shows that more than 90% of nasal polyps have a large number of eosinophil infiltration, which is actually an eosinophilic inflammation. This is related to interleukin 5 (IL-5) mediated, chemotaxis.
4. Pathogenesis.
The abnormal environment of the middle nasal tract makes the site susceptible to increase, and under the stimulation of long-term inflammatory factors, the body releases interleukin-5 (IL-5), so that eosinophils converge, differentiate, mature, and produce toxic factors and various cytokines, so that vascular permeability increases, plasma exudation, tissue edema, followed by epithelial cell proliferation, blood vessels and glands grow into, forming polyps. This is the general mechanism of nasal polyp formation. Pathologically, nasal polyps contain a large number of plasma cells, eosinophils, lymphocytes and mast cells in the tissue.
5.Clinical manifestations
Nasal polyps tend to occur bilaterally, and are more common in adults. In contrast, posterior maxillary sinus polyps are unilateral and often originate from the anterior inner wall of the maxillary sinus and protrude toward the posterior nostril, and are more common in children. Common symptoms and complications are.
1) Nasal congestion: nasal congestion, poor nasal airflow, occlusive nasal sounds in speech, and snoring in sleep are the most common initial symptoms of nasal polyps in children.
2）Increased nasal mucus: excessive mucus is also a common symptom, the secretion is sticky or mucopurulent, the amount can be more or less, but often cannot be clean.
(3) Olfactory dysfunction: The obstruction of long-term nasal polyps affects the sense of smell in the olfactory region of the upper nasal tract, and over time, olfactory dysfunction will occur. Some patients will have headache.
(4) Other complications: For the posterior nasal polyp of maxillary sinus protruding into the nasopharynx, because it often obstructs the eustachian tube, there will be symptoms of secretory otitis media, hearing loss, low frequency tinnitus, etc.; severe bilateral nasal polyps can also cause facial changes, nasal dorsal collapse, forming a “frog nose”; long-term nasal polyps patients may also cause asthma. The clinical term for nasal polyps, asthma and aspirin intolerance is “triad”; nasal polyps can also cause hyperplastic sinus disease (HSD), which aggravates the symptoms of the nose.
6.Differential diagnosis
Since the widespread development and use of nasal endoscopy in clinical practice, the diagnosis is not difficult. In the case of polyps from the middle turbinate, the borders are indistinct, diffuse, hard and pink in color. Posterior maxillary sinus polyps also require nasopharyngoscopy to clarify the size of the polyp. A coronal and horizontal CT examination of the nasal sinuses should also be performed before surgery to understand the sinus lesions and the anatomical relationship between the polyp and the nasal sinuses.
Nasal polyps often need to be differentiated from the following nasal diseases.
1) Benign and malignant nasal tumors: Malignant tumors are rare in children, and tissue biopsy can confirm the diagnosis. Benign tumors are common in children, such as nasopharyngeal fibrovascular tumor and involute papilloma, the latter can also rely on pathological biopsy for a clear diagnosis, while the former is mainly based on clinical examination, CT, angiography, etc. Diagnosis is contraindicated biopsy, which can easily lead to hemorrhage.
2) Hemorrhagic necrotic polyp: This disease is mainly caused by a history of long-term nasal bleeding, and the examination reveals new organisms in the nasal cavity and sinuses as dark red necrotic tissue that bleeds easily when touched.
3) Chordoma: It is a tumor formed in the nasal cavity during the embryonic period when the chord was not absorbed, and can be diagnosed by CT and MRI imaging, and can be confirmed by tissue biopsy.
4) Meningeal bulge: It is a common congenital disease in infants and children. When there is a congenital defect in the sieve plate, the meninges and brain tissue protrude into the nasal cavity, forming a mass similar to a polyp. CT or MRI can be used for diagnosis.
7.Disease treatment
The onset of nasal polyps is related to a variety of factors and is highly prone to recurrence, especially in children, where the recurrence rate is higher than that of adults. Therefore, comprehensive treatment is currently advocated, and recurrence is inevitable with a single surgical treatment without focusing on perioperative related treatment.
(1) Drug therapy: mainly glucocorticoid therapy, due to the use of hormones, there is a certain impact on children, should be reasonable and standardized. (1) Smaller nasal polyps: If the polyps are small and located in the middle or common nasal tract, nasal spray hormone can be used twice a day for about 4 weeks, and if the polyps become smaller or even disappear, the nasal spray hormone can be discontinued after reducing the dosage. (2) Initial larger polyps: maxillary sinus polyps with larger polyps that have reached the front of the inferior turbinate or have protruded into the posterior nostril, while using nasal spray hormone twice daily, oral prednisone is also needed, once daily before 8:00 a.m., for 7 days, after which the dosage should be reduced, not more than 2 weeks, and discontinued. Antibiotics are used appropriately to fight inflammation and prevent infection. The total amount of nasal spray hormone in children should not be used continuously for more than 3 months, and those who are ineffective should consider surgical treatment. (3) After nasal polyp surgery: nasal spray hormone treatment is still needed. Generally, nasal spray hormone is used continuously for 12 weeks after surgery, with regular review, after which the dosage should be gradually reduced and then discontinued to avoid the rebound phenomenon.
2) Surgical treatment.
For children whose drug conservative treatment is ineffective, surgical treatment should be considered. Currently, the mainstream is nasal endoscopic polyp removal surgery, which should open the maxillary sinus opening and open the septal sinus to reconstruct the middle nasal tract structure while thoroughly removing the polyp tissue, and should reduce the damage to the nasal mucosa to prevent recurrence.
For maxillary sinus polyps and posterior maxillary sinus nasal polyp, which are common in children, in the past 2 years, our department has used urology to effectively dilate the maxillary sinus opening with a balloon catheter and then remove the polyps in the maxillary sinus and in the nasal cavity. The procedure is simple and well suited to the own anatomical characteristics of the nasal-nasal tract complex in children, with minimal bleeding during surgery, little operating time after skilled operation, and quick postoperative recovery without common complications of traditional FESS surgery such as middle nasal tract stenosis or adhesions of the middle turbinate and lateral nasal cavity wall. Also, if recurrence occurs, it is an effective, simple and safe new method for the treatment of maxillary sinusitis, maxillary sinus polyps and posterior maxillary sinus polyps in children because there is less damage to the structure of the middle nasal tract, reserving a larger surgical space for reoperation [3]. Traditionally, it is believed [4] that balloon dilatation is contraindicated for occupying lesions, but for polyps of the maxillary sinus, after our clinical surgery and scientific research statistics in the last 2 years, good results were achieved [5], of course, for nasal polyps of the combined septal sinuses, balloon dilatation has its limitations and is not advocated.
It is worth mentioning that postoperative follow-up management should be strictly performed, as the disease is highly recurrent in children and postoperative follow-up should not be less than 1 year at least. The postoperative nasal spray hormone (e.g., coleus, endosulfan or ryanodine) should be used continuously for three months and then gradually reduced, with the maintenance amount used for more than 6 months. Appropriate use of postoperative antibiotics and mucus promoters is necessary. Many children with recurrence are mostly not well managed in the perioperative period, in addition to their own factors, and this point needs special attention.
8.Prognosis of disease
Nasal polyps in children are very prone to recurrence, which has been clinically proven. However, the proportion of recurrences tends to decrease after the age of 10 years. For children with combined bronchial asthma and aspirin intolerance, the recurrence rate is high. Bronchial asthma may decrease, or at least remain unchanged, after surgery. In contrast, polyps originating in the middle nasal tract, maxillary sinus, and posterior maxillary sinus nostrils generally have a better prognosis after surgery as well as after postoperative regulation of van therapy.
9.Disease prevention
As the onset of nasal polyps and allergic reactions and long-term nasal inflammation, so should strengthen the exercise, enhance physical fitness. A balanced diet is also important, for children with allergic rhinitis, they should also avoid allergenic foods and other allergens, and should actively treat allergic diseases, such as asthma and allergic rhinitis. After surgery, the child should have a regular follow-up visit for nasal clearance until the nasal mucosa is completely healed.