The Medical Consumer's Advocate
Nasal Polyps
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risks of oral steroids
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risks of surgery
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inverting papilloma
-
physiology of olfaction (the sense of smell)
Q:
I have had nasal polyps for
several years which usually don't bother me except when I
have a cold or hay fever. My ENT doctor recommended
surgery which I declined because of the chance of
recurrence. Recently however, my right eustachian tube
feels blocked and I was given a prescription for
prednisone plus a steroid nasal spray to treat the
polyps. Would prednisone for two weeks plus the nasal
spray be better than surgery to relieve the polyps, or is
surgery still the best treatment? Also, what is the best
treatment for the blocked eustachian tube?
A:
Polyps are weird creatures,
really. They are always related to chronic inflammation
(sometimes from allergies, sometimes from chronic sinusitis)
which is why it makes some sense to treat with steroids (which are
the most potent anti-inflammatory agents available). Nasal
steroid sprays, by themselves, rarely if ever shrink polyps,
which is why some doctors resort to oral steroids.
Is surgery better or worse than being on oral steroids? With both
treatments, there is a high probability of recurrence IF the underlying
problem (i.e., allergy or chronic sinusitis) is not addressed. I am usually
a very conservative guy, but this is one instance where I think surgical
treatment may be safer than medical treatment. Although a short course of
oral steroids is relatively safe, the key word is "relatively." A short
course of steroids is safe relative to being on steroids for a long time.
There is an incredibly long list of potential complications due to steroid
use. (Please note: these are not the "bulk you up" steroids that you hear
about in the press. In medicine, we differentiate between "anabolic
steroids," which are the drugs that athletes abuse to add muscle bulk, and "catabolic
steroids" -- more commonly called corticosteroids -- which are anti-inflammatory drugs. Guess
what: they're both potentially dangerous classes of drugs.)
Don't get me wrong, steroids can be life-saving for many
medical problems. But your polyps, no matter how
uncomfortable they may make you feel, are not going to kill
you. Given that fact, you should weigh the risks of therapy
carefully.
Steroids often cause side effects such as water weight gain, increased
appetite, insomnia, mania or depression. They can also cause
serious problems with virtually every organ system in the
body. Brain: temporary psychosis. Eyes: cataracts and glaucoma. Stomach:
ulcers. Diabetes in individuals who are "borderline
diabetic," and out-of-control diabetes in diabetics.
Bone: osteoporosis, and also a really nasty problem called
"aseptic necrosis of the femoral head" (the ball
joint of the hip dies and must be surgically replaced with an
artificial joint). And this is a partial list.
Most of these serious side effects occur
primarily with long term use, but have been known
to occur with short term use also. I know of one case of bilateral
aseptic necrosis of the femoral heads due to a brief course
of steroids (about 2 weeks... and it was given to treat
polyps).
The main risks of surgery are: risks from anesthesia,
bleeding, and the chance that the polyps will recur.
Depending upon how aggressive your doctor wishes to treat the
polyps (i.e., does he want to clean out your sinuses as well)
there are also risks to your eyes and brain, since these are in the neighborhood, after all. Fortunately, such serious
complications are rare. Talk to your doctor in detail
about the risks of surgery if you decide to take this option.
Mind you, this is a
very controversial topic, and MANY excellent ear, nose and
throat docs treat polyps with steroids and reserve surgery
only for people who do not respond to steroids. The usual
argument is, "If I can buy the patient 6 to 12 months of
relief from their polyps, it is worth the risks of
steroids." So my answer to your question is, ultimately,
very wishy-washy. Talk to your doctor about the two options.
Do what feels right to you. Both treatments are considered
acceptable, so you will have to do what seems right to you.
Make sure you are doing something to discover (and, of
course, treat) the root cause of the polyps.
One last comment. If you only have polyps on ONE SIDE,
this is a whole different ballgame. In this case, we worry
about whether the patient has a cancer that merely LOOKS like
a polyp. We also worry about whether the patient has
something called "inverting papilloma." This
polyp-like tumor can spread aggressively. Although it is not
a cancer, a small percentage of these tumors can become
cancerous. The only way to know if a polyp is actually an
inverting papilloma or cancer is to biopsy it! In each case,
the tumor must be aggressively removed to prevent recurrence.
Best treatment for a blocked Eustachian tube: figure out
why it's blocked, and fix that problem. Basically the same
way we (try to) get rid of polyps: deal with the underlying
problem. Bacterial rhinitis, chronic sinusitis and allergy
are all possible explanations. If all else fails, your ENT
can, under local anesthesia, cut a small hole in your ear
drum and place a tiny plastic tube which will allow air to
pass into your middle ear space. Really not a bad operation.
If you haven't already read my bit on Eustachian tube
dysfunction, please do, as this may answer any other
questions you might have on this topic.
Q: Thank you for
your response to my email. My gut feeling is to stay away
from the prednisone with all the possible side effects,
and look at surgery which my first ENT doctor recommended
when my polyps were first diagnosed in 1990. I usually
can tolerate them, but with occasional sinus problems and
now this Eustachian tube problem I might just try the
surgery which I hear is a lot safer these days. One of my
fears was permanently losing my sense of smell (I lost it
for almost a year after my polyps first started), and
worried that surgery would destroy it completely.
Hopefully whatever I do I'll be rid of them for good.
Feel free to use my letter on your webpage, and many
thanks again for writing back.
A: It is possible that surgery could eliminate
your sense of smell (many things are possible), but it is
actually a lot more likely that it will improve your sense of
smell or leave it unchanged.
Here's the basic physiology of the
situation: the olfactory receptors are located very high in
the nasal cavity. These are chemical receptors:
"smells" are, ultimately, vaporized molecules from
the "smelly object". These gas phase molecules have
to be able to reach the olfactory receptors for you to be
able to smell them. If there is no air flow to this part of
the nose, then you can't smell anything. The polyps cause a
physical obstruction to air flow. Take the obstruction away,
and you may be able to smell again. Sinus surgery IS safer
nowadays, assuming that your ENT is well trained. If he/she
has a good reputation, you should do fine.