Article Tan Yihe “Ming Pao”
Affected by the COVID-19 and flu viruses, many people suffer from upper respiratory tract infections one after another and suffer from nasal congestion for a long time.
When the nasal cavity and sinuses are infected by viruses or bacteria for a long time, it will lead to chronic sinus inflammation. Patients will continue to have nasal congestion and facial pain. Some patients even develop nasal polyps due to nasal mucosal growth, causing backflow of nasal water and loss of sense of smell.
(Hong Kong News) Sinusitis and nasal polyps are common nasal diseases. Dr. Cuixin Huang, Honorary Clinical Assistant Professor of the Department of Otorhinolaryngology and Head and Neck Surgery, CUHK, pointed out that when the nasal passages and sinus surface mucosa are infected by bacteria or Viral infection can lead to chronic sinus inflammation; the mucous membrane is stimulated by inflammation for a long time, which can cause edema, and then produce a benign lump nasal polyp, which is “translucent, soft, like a small grape.”
80% of chronic sinusitis have nasal polyps
Another cause of nasal polyps is that the autoimmune system is overactive, and the type 2 immune response goes wrong, which is called “type 2 inflammation”, and causes a variety of allergic diseases, such as eczema and asthma (see more for details).
Li Xi, director of the Rheumatology and Clinical Immunology Department of the Department of Internal Medicine of the University of Hong Kong, and a specialist in the Department of Immunology and Allergy, pointed out that type 2 inflammation causes continuous inflammation of the sinuses, induces mucosal hyperplasia, and forms nasal polyps. However, even if the polyps are removed, most patients will relapse. According to international data, 12% of adults suffer from chronic sinusitis, and 8 of them also have nasal polyps.
If the treatment of sinusitis and nasal polyps is delayed, the patient will not only suffer from nasal congestion, runny nose, impaired sense of smell, facial pain and headache. Huang Cuixin said that nasal polyps will also block the sinus outlet, causing sinusitis, sinusitis and nasal polyps interact , obstruct the upper airway, and can cause sleep apnea in severe cases.
Mr. Chen, who works in logistics, has experienced suffering three times in the past 20 years, and has to undergo general anesthesia for endoscopic sinus surgery again and again. He tried to sleep with difficulty breathing every night, and was forced to get up and sit up in the middle of the night.
“When it is the most serious, it will be difficult to breathe, even after spraying anti-allergic drugs,
But the effect of the medicine wears off after 4 to 5 hours.
I woke up at 3 or 4 in the morning with severe nasal congestion and runny nose.
Basically, before the operation, I couldn’t sleep for a long time every day.
After waking up, I have to go out of the living room to sleep, just sit down, close my eyes and rest. “
Enlarged polyps affect the olfactory nerve
The 65-year-old Mr. Chen began to suffer from sinusitis and nasal polyps as early as 2004. Because the nasal cavity was full of polyps, he underwent endoscopic surgery for the first time. In 2018, the disease relapsed, and he had a long runny nose, which hindered his breathing. He had to undergo general anesthesia again for minimally invasive surgery to remove the polyps.
After 3 years, he had a lot of snot again, “it was pale yellow in color, and he had to use one or two packs of tissues a day to wring his nose, and his family members also found it annoying, so they asked, do we need to use so much?” Mr. Chen is also troubled by his sense of smell, because when the polyp grows bigger and affects the olfactory nerve, he doesn’t even know that there is a strange smell coming from around him: “I can’t smell white flower oil, and I can’t smell burnt things.”
“The doctor said that if I don’t have surgery, it will affect the optic nerve.” Mr. Chen himself suffers from asthma, and the blood test results also found that his nasal polyps are related to allergic reactions. Therefore, he accepted the suggestion and had surgery to remove the polyps in January this year Meat, followed by subcutaneous injections of biologics every 2 to 4 weeks.
At present, doctors use nasal endoscopy, nasal computer scan and other methods to confirm the hyperplasia of intranasal tissue and rule out sinus tumors. In terms of treatment, the doctor will decide whether the patient needs to use drugs or surgery according to the size of the nasal polyps, the area affected and the severity of the symptoms.
Surgical treatment is a palliative, not a permanent cure
Medications include nasal steroid sprays, oral antihistamines to treat sensitivity, antibiotics to control serious infections, and high concentrations of oral steroids.
Huang Cuixin pointed out that if the drug effect is not satisfactory, the doctor will recommend minimally invasive surgery with “functional endoscope” to remove polyps, foreign bodies, cysts and other diseased tissues in the nasal cavity and sinuses. The surgical procedure takes about 2 to 3 hours, requires general anesthesia, and generally requires hospitalization for 3 days and 2 nights.
She said that past patients may relapse after receiving medical and surgical treatment. Until 2021, the US Food and Drug Administration (FDA) approved the first biological agent that can be used to treat chronic sinusitis with nasal polyps. This drug mainly inhibits interleukins IL-4 and IL-13 in the body, thereby alleviating Inflammation and allergic reactions.
The drug was approved by the Hong Kong Department of Health in August last year to treat such patients.
Li Xi added that surgery alone to treat sinusitis and nasal polyps caused by type 2 inflammation is a temporary solution, not the root cause. “After the polyp was removed, the nasal cavity was unblocked, and the pain was not so painful, but it did not reduce inflammation, and it did not help the sense of smell. Only by using biological agents that specifically target inflammation can the chance of recurrence be reduced, and the existing nasal polyp may even shrink.”
At present, there are 3 biological agents approved for use in patients with sinusitis and nasal polyps in the world, targeting different interleukins (IL) or immunoglobulin E (IgE), and 2 of them have been registered in Hong Kong in the past year.
He said that the three drugs are also quite safe, and the side effects are mainly needle-point reactions. Doctors will recommend appropriate drugs for different patients.
After the first injection, the polyp shrinks and there is a sense of smell
The University of Hong Kong is currently conducting a study on the treatment of nasal polyps with biological agents, and more than 10 patients have participated. Among them, 60% to 70% of the patients had recurrence of nasal polyps, and some patients had undergone three or four surgical excisions, and they had been injected with biological agents for at least half a year.
Li Xi said that after the first injection, there was improvement within a few days, from complete loss of smell to no smell at all. The polyp also shrank, and the effect was obvious within a month or two. “As for whether or when patients will relapse once the drug is stopped? He pointed out that there are no relevant figures locally, but according to foreign experience, all patients will relapse after stopping the drug.
In fact, public hospitals have not yet listed biological agents as a routine treatment for sinusitis with nasal polyps. If patients want injections, they mainly use them in private clinics or hospitals. However, the monthly drug cost of biologics is estimated to be about 10,000 to 15,000 yuan (approximately RM5,000 to 7,500).
“The biggest worry is the affordability of patients.” Huang Cuixin said. Mr. Chen is currently using biological agents subsidized by pharmaceutical companies for a period of six months. After undergoing surgery with biological agents, the curative effect is remarkable, and there has been no sign of recurrence since the beginning of the year.
Mr. Chen was overjoyed at the recovery of his sense of smell, “When I took a bath, I smelled the scent of shower gel. It smells so good! I haven’t smelled it for a long time.”
Type II immune response gone wrong Can cause eczema allergic asthma
The immune system is the body’s defense mechanism. When it detects the invasion of pathogens or harmful substances such as viruses, bacteria, and parasites, it will fight back.
Li Xi, Director of the Rheumatology and Clinical Immunology Department of the Department of Internal Medicine of the University of Hong Kong, pointed out that if the immune system goes wrong and becomes overactive, it may attack the body and cause autoimmune diseases. It can cause comorbidities such as eczema, allergic asthma, nasal allergies, food allergies, and drug allergies.
Immune response kills pathogen
He explained that the immune system has different weapons. Type 1, type 2 and type 3 immune responses can kill different pathogens respectively; if the type 1 immune response goes wrong, rheumatoid arthritis and various inflammations will appear; Inflammation can produce different infections such as mold and suppuration.
Although patients with eczema, sinusitis, and asthma may seek medical advice from dermatologists, otolaryngologists, or respiratory doctors, from the perspective of immunology, some patients may be involved in the same pathology, which is caused by type II inflammation: “appears in There are nasal allergies and sinusitis in the nose; asthma in the lungs; atopic dermatitis, eczema in the skin.” Since biologics are targeted drugs that can specifically address type II inflammation, many patients After taking the medicine, her eczema, asthma and sinusitis improved together.
Interdisciplinary care for allergy patients
The University of Hong Kong has set up a clinic with the cooperation of immunology and otolaryngologists. Every Thursday morning, patients with sinusitis and severe nasal allergies will be diagnosed and treated. In addition to biological agents, desensitization treatments will also be used; family doctors, private clinics or public specialists Outpatient clinics can refer patients to them if necessary. He expects that interdisciplinary care for allergy patients will become the future trend.