The treatment of nasal polyps is a complex issue. Patients are often torn back and forth between whether they should have surgery or use medication. But the reality is that neither treatment is satisfactory for all patients. Especially when some patients have a recurrence of polyps within six months or even three months after surgery, it is not only difficult for patients to accept, but also embarrassing for doctors. How can a small nasal polyp be so difficult to treat?
The reason for this outcome is that nasal polyps are a heterogeneous disease, which means that patients with nasal polyps are a diverse group. Although the same nasal cavity is full of polyps. The clinical features, co-morbidities, treatment modalities, and outcomes of nasal polyps are completely different for different causes, races, and lifestyles. For such a mixed group, “one size does not fit all” and “one key for one lock” is necessary. Therefore, the clinical typing of nasal polyps and the treatment plan under the typing have been the focus and frontier of research in the international arena.
Happily, the rhinology research team at Beijing Tongren Hospital has summarized the clinical characteristics and treatment process of patients with nasal polyps over the past five years and incorporated these data into a multifactorial cluster analysis (a medical statistical method that allows individuals with the same intrinsic pattern to be grouped together without interference from subjective human factors), and found that based on the histopathological characteristics of nasal polyps, Chinese patients with nasal polyps can be There are five types of nasal polyps: lymphocytic, plasma cell, neutrophilic, mixed, and eosinophilic. Lymphocytic and plasma cell types rarely recur after surgery, neutrophilic and mixed types partially recur, while eosinophilic nasal polyps mostly recur after surgery. Why do polyps with different immune cell dominant types have different outcomes? Before understanding nasal polyps, let us understand what immune cells are present inside the normal nasal mucosa: the lamina propria of healthy nasal mucosa is mainly composed of lymphocytes and plasma cells (Figure 1), who are the second line of defense of the mucosal immune system (the first one is the epithelial barrier), with occasional neutrophils (indicating the presence of infection) and basically no eosinophils (if there are any, indicating allergy or eosinophilia hyperplasia). Based on this, surgical treatment of lymphocytic and plasmacytic nasal polyps, which are very similar to normal mucosa, has the best outcome and rarely recurs; neutrophilic nasal polyps are often indicative of infection and should be treated with antibiotics along with surgery, otherwise the outcome is compromised; eosinophilic polyps are the most problematic, as we mentioned in our previous article, if the eosinophil percentage of all inflammatory When the ratio of eosinophils in nasal polyps exceeds 27%, the risk of recurrence within two years will be more than 95% (American Journal of Rhinology and Metaplasia, 2015, Corresponding author: Luo Zhang and Chengshuo Wang). In contrast, mixed polyps are mixed with various factors instead various features are atypical. This study was published in the European Journal of Rhinology in 2016 (RHINOLOGY, ranked first in the field of rhinology). It was also the first time that Chinese scholars proposed the clinical staging of nasal polyps in the international arena. (Figures 2-3) Figure 1. The lamina propria of healthy nasal mucosa is mainly composed of lymphocytes (shown in boxes) and plasma cells (shown in circles).
Figure 2. our latest clinical typing study of nasal polyps published in RHINOLOGY 2016.
Figure 3. nasal polyps can be classified into 5 categories by cluster analysis (cluster analysis).
Figure 4. Two of the more difficult nasal polyps: the mixed type and the hypereosinophilic type.
The significance of this study is that nasal polyps can be treated in a truly individualized way. In the future, it is recommended that a small piece of polyp tissue be clamped and sent to pathology for analysis at the time of initial consultation, and that treatment strategy be determined based on the pathological findings (which immune cells are predominant). Some nasal polyps should be treated with surgery (e.g., lymphocytic and plasma cell type) because the surgical results are mostly good and recurrence is rare; some nasal polyps should be treated with intensive antibiotic therapy (e.g., neutrophil-dominant type); and some nasal polyps should be treated with special caution, such as hypereosinophilic polyps. Because this type of nasal polyp is often not just a localized nasal problem, but a nasal manifestation in the context of systemic hypereosinophilic inflammation, these patients often have elevated peripheral blood eosinophils (often above 5%), often combined with bronchial asthma, and are easily misdiagnosed as allergic disease or coexisting with it. This type of disease is like a car parked on a slope, which will continue to move downward under the influence of gravity (systemic hypereosinophilic inflammatory state) (the polyps grow larger and larger, the symptoms get worse and worse). Medication is like a strong hand holding the “downhill car” from the bottom up to keep it from going down. If the downward “gravity” (inflammation) is balanced by the upward thrust (medication), the case is a stable and controlled one, where the symptoms are mild, the polyp stops growing, and surgery is not necessary. If the downward “gravitational force” (inflammation) is too heavy or the upward force (medication) is too small, causing the “downward spiral” to slow down, the symptoms will worsen and the polyp will grow, and when the polyp has grown large enough to cause severe symptoms, then There is no choice but to perform surgery to remove the polyps and open the sinuses. At this point, the patient’s symptoms improve significantly, which is equivalent to the extreme way of surgery to send the “downhill car” back to the top of the mountain again. However, do not forget that the “gravity” (systemic inflammatory state) still exists, if not given after surgery to counteract the thrust (medication), will repeat the same mistake, slowly downward until the polyp recurrence, which is how most of the so-called “refractory sinusitis nasal polyps” that are not good treatment! “This is the truth! Therefore, for hypereosinophilic nasal polyps, the core of the treatment is to fight the systemic hypereosinophilic inflammation through drugs, and surgery is only an adjunct to the drug treatment system, which is a last resort when the polyp growth is irreversible and seriously affects life, and drug treatment cannot improve. For this type of nasal polyp, it must be regarded as a “systemic chronic disease” such as diabetes and hypertension! The ultimate goal of treatment is not “cure”, but “control”.
It is believed that in the near future, through the progress of clinical and basic research, and through the continuous efforts of medical scientists, more precise methods will be found to treat all types of nasal polyps.