Understanding Risk Factors, Treatment of Nasal Polyps in Children

Although rarely reported in childhood, nasal polyps—benign inflammatory masses that cause chronic nasal obstruction—have been cited as potential risk factors for the development of systemic diseases, such as cystic fibrosis and immunodeficiencies.

With growing interest in nasal polyps due to new therapeutic options, namely biological agents, authors of a review published in Children sought to examine diagnostic and therapeutic approaches in pediatric populations.

They outlined recent data on nasal polyps in childhood, with a particular focus on multiple nasal polyps, and provided suggestions for personalized approaches to both the diagnosis and management of nasal polyps in children.

In first discussing its epidemiology, researchers note that nasal polyps are typically associated with underlying chronic rhinosinusitis (CRS), with other reported symptoms including posterior nasal drip, headache, snoring, and rhinorrhea. The current gold standard diagnostic test is nasal endoscopy, both in adults and children, in which computed tomography was cited to be potentially useful for surgical planning and scoring the severity of CRS.

“Nasal polyp suspicion should be raised in all children with chronic nasal obstruction regardless of whether it is unilateral or bilateral or intermittent or constant,” said the authors. “In adults, an altered sense of smell and taste is also commonly reported, while in children, such disorders cannot always be assessed due to both the limited feasibility of available diagnostic tools and the delayed awareness of olfactory impairment.”

They next discussed current comprehension of CRS with nasal polyps (CRSwNP), in which inflammation was highlighted to play a key role in the pathogenesis of the condition. Specifically, 3 different types of inflammatory patterns have been detected in adults with CRS:

• Type 1 inflammation, originally directed toward intracellular pathogens, and characterized by a predominance of interferon (IFN)-γ and tumor necrosis factor (TNF)–alpha secretion
• Type 2 inflammation, targeting extracellular parasites, and characterized by a predominance of interleukin (IL)-4, IL-5, and IL-13 secretion
• Type 3 inflammation, targeting extracellular bacteria and fungi, and dominated by IL-22 and IL-17 secretion
  

These inflammatory properties of CRS have been associated with the development of several comorbid conditions among patients with CRSwNP, including asthma, nonsteroidal anti-inflammatory drug–exacerbated respiratory disease, and allergic rhinitis (AR), although associations with AR remain controversial.

Risk of chronic diseases as a potential cause and comorbidity in children with CRSwNP was also noted, particularly cystic fibrosis, primary ciliary dyskinesia, and immunologic disorders.

Regarding treatment, first-line therapy includes nasal irrigation with saline and intranasal corticosteroids both in pediatric and adult patients with CRS with or without nasal polyps, with antibiotics and systemic steroids used only in cases of exacerbation. Efficacy of topical corticosteroids has also been shown in adult patients, but remains uncertain in children.

“Even if no randomized controlled trial has been performed to date to support the efficacy of intranasal steroids in children affected by CRS, the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 supports their use in light of their anti-inflammatory effects and excellent safety profile in childhood,” the authors noted.

Among younger children refractory to appropriate medical therapy, adenoidectomy is considered the first-line surgical intervention, followed by functional endoscopic sinus surgery aimed at reestablishing adequate sinus ventilation and secretion drainage. Biologics (dupilumab, omalizumab, and mepolizumab) have also exhibited promise in the treatment of children with CRSwNP, but also suffer from a lack of clinical studies.

Researchers concluded that a multidisciplinary approach is highly suggested to appropriately manage children with CRS and NPs.

Reference

Di Cicco ME, Bizzoco F, Morelli E, et al. Nasal polyps in children: the early origins of a challenging adulthood condition. Children (Basel). 2021;8(11):997. doi:10.3390/children8110997