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Nasal Polyposis, Mucocele, Nose Swelling, Taken Prednisolone, Ass-intolerant, Histamine Intolerant
Question: Hello Dr. Bhatti,
I am medical doctor myself but I have a very hard problem with my 18 year old son. He had to be operated 8 times because of nasal polyposis,mucoceles with destructions of the os frontale and orbita and he got a lot of complications. He is ass-intolerant and histamin-intolerant and has a lot of allergies, especially against candida and other fungus.
Asthma bronchiale is leaving since he knows the histamin-intolerance and is living with his diet.
He is suffering of very bad mucosa-swelling of his nose and of his left eye-lid every two weeks, we still don`t know the reason, and only 150 mg of prednisolone for 2 days can help him. Do you have any idea where to look for any reason or how to help him?
Do you know anything about hpv infection and nasal polyposis?
Who could be a specialist for this problem? Until now nobody could really help him to prevent the next polyposis and mucosa swelling.
Since one year he is not able to visit school.
I would be glad if you should have any ideas what to do now.
Thank you very much
Dr. Heike Goede
I am medical doctor myself but I have a very hard problem with my 18 year old son. He had to be operated 8 times because of nasal polyposis,mucoceles with destructions of the os frontale and orbita and he got a lot of complications. He is ass-intolerant and histamin-intolerant and has a lot of allergies, especially against candida and other fungus.
Asthma bronchiale is leaving since he knows the histamin-intolerance and is living with his diet.
He is suffering of very bad mucosa-swelling of his nose and of his left eye-lid every two weeks, we still don`t know the reason, and only 150 mg of prednisolone for 2 days can help him. Do you have any idea where to look for any reason or how to help him?
Do you know anything about hpv infection and nasal polyposis?
Who could be a specialist for this problem? Until now nobody could really help him to prevent the next polyposis and mucosa swelling.
Since one year he is not able to visit school.
I would be glad if you should have any ideas what to do now.
Thank you very much
Dr. Heike Goede
Dear Dr. Heike Goede,
Thank you for your query.
1. Your son has the signs and symptoms of Samter's triad, namely: Nasal polyposis, Asthma and Asprin and NSAID hypersensitivity in addition to histamine intolerance. Such patients have a history of multiple surgeries and recurrence.
2. There is an underlying chronic inflammatory process in the nasal and sinus mucosa which causes the recurrence of nasal polyposis. This is mediated by many chemicals; to name a few: histamine, prostaglandins, proteoglycans, proteases, leukotirenes, interleukins (cytokines) and so on. Once released, only a few of these chemical mediators can be counteracted. Has he received any anti-leukotriene such as montelukast, zafirlukast or zileuton?
3. An ideal treatment combination includes an anti-histamine like levocetrizine or rupatidine, an anti-leukotriene, a steroid nasal spray, saline nasal washes and steam inhalation.
4. Nasal polyposis is invariably accompanied by fungal infections and thick mucoid pus. AFRS (Allergic Fungal Rhino Sinusitis) is one end of the spectrum where the fungus is present only in the sinuses but still provokes an allergic reaction in the body.
5. His repeated episodes of nasal and left eyelid swelling may be related to the repeated surgeries that he has undergone. Has he had any CT PNS (Para Nasal Sinuses) Scans done recently and in the past. You may upload them onto a free filesharing site such as WWW.WWWW.WW or WWW.WWWW.WW and share a link here or email the link or some images (and photos of the swelling ) to YYYY@YYYY with 'Attn: Dr. Sumit Bhatti' as the subject line. Destruction or breaching of bony barriers such as the lamina papyracea can cause this. A CSF leak (CSF Rhinorrhea) may also cause bad mucosal swelling and reactions in the nasal cavity. Damage to the lacrimal apparatus can also give rise to lid edema and epiphora.
6. Have you attempted aspirin desensitization? What diet plan does he follow?
7. HPV infections are usually transient and they may show up on immuniohistochemistry and PCR (Polymerase Chain Reaction) studies of nasal polyp tissue. However the association has been traditionally with Inverted Papilloma (Ringertz or Transitional Cell Carcinoma) and certain sino-nasal malignancies which are frequently positive for HPV-6, 11, 16, 18 and 57 DNA.
8. If you suspect a CSF Rhinorrhea or a Naso-Orbital CSF leak, you should get a CT Cisternography / MRI done. If you suspect a lacrimal problem, get a Dacryocystogram (DCG) done.
Hope I have answered your query. Awaiting your reply.
Regards.
Thank you for your query.
1. Your son has the signs and symptoms of Samter's triad, namely: Nasal polyposis, Asthma and Asprin and NSAID hypersensitivity in addition to histamine intolerance. Such patients have a history of multiple surgeries and recurrence.
2. There is an underlying chronic inflammatory process in the nasal and sinus mucosa which causes the recurrence of nasal polyposis. This is mediated by many chemicals; to name a few: histamine, prostaglandins, proteoglycans, proteases, leukotirenes, interleukins (cytokines) and so on. Once released, only a few of these chemical mediators can be counteracted. Has he received any anti-leukotriene such as montelukast, zafirlukast or zileuton?
3. An ideal treatment combination includes an anti-histamine like levocetrizine or rupatidine, an anti-leukotriene, a steroid nasal spray, saline nasal washes and steam inhalation.
4. Nasal polyposis is invariably accompanied by fungal infections and thick mucoid pus. AFRS (Allergic Fungal Rhino Sinusitis) is one end of the spectrum where the fungus is present only in the sinuses but still provokes an allergic reaction in the body.
5. His repeated episodes of nasal and left eyelid swelling may be related to the repeated surgeries that he has undergone. Has he had any CT PNS (Para Nasal Sinuses) Scans done recently and in the past. You may upload them onto a free filesharing site such as WWW.WWWW.WW or WWW.WWWW.WW and share a link here or email the link or some images (and photos of the swelling ) to YYYY@YYYY with 'Attn: Dr. Sumit Bhatti' as the subject line. Destruction or breaching of bony barriers such as the lamina papyracea can cause this. A CSF leak (CSF Rhinorrhea) may also cause bad mucosal swelling and reactions in the nasal cavity. Damage to the lacrimal apparatus can also give rise to lid edema and epiphora.
6. Have you attempted aspirin desensitization? What diet plan does he follow?
7. HPV infections are usually transient and they may show up on immuniohistochemistry and PCR (Polymerase Chain Reaction) studies of nasal polyp tissue. However the association has been traditionally with Inverted Papilloma (Ringertz or Transitional Cell Carcinoma) and certain sino-nasal malignancies which are frequently positive for HPV-6, 11, 16, 18 and 57 DNA.
8. If you suspect a CSF Rhinorrhea or a Naso-Orbital CSF leak, you should get a CT Cisternography / MRI done. If you suspect a lacrimal problem, get a Dacryocystogram (DCG) done.
Hope I have answered your query. Awaiting your reply.
Regards.
Above answer was peer-reviewed by :
Dr. Prasad
Dear Dr. Bhatti,
thank you very much for your answer.
ad 3) My son took muntelukast for about 1,5 years, but the polyposis could not be stopped. He had to endure 3 operations whilst taking montelukast, but he did not always take it on a regular basis.
He took mometason spray four times a day. Salin nasal washes and steam inhalations made him feel bad in his nose, he felt worse, so we stopped it.
ad 4) My son took Telfast(fexofenadinhydrochlorid) 180 mg per day but it could not change his actual or chronical problems.
ad 5) This seems to be very important from my point of view:
Two weeks ago he had an allergy test (prick-test) with very impressive results:
There was a high reaction to aspergillus fumigatus, candida albicans, penicillinum notatum, pullularia pullulans, serpula lacrimans, ustilago titrici and cat epithels.
The nasal provocation of season-pollinosis was positive.
The rast-test was different, there we could not see the same result.
What do you think, is mor important for his desease, the result of the rast-test or the prick-test?
Very impressive was his reaction after the allergy-test: Before he felt quite good and he had only very little lid-swelling. A few hours after the test he felt quite weak and his eyelid started swelling more and more until he got an exophtalmus. The symptoms continued to deteriorate for 5 days. Fexofenatadin could not change anything until I gave him prednisolon 150 and Ebastel (ebastin) 2 x 20 mg. Now, after 10 days the symptoms are better and he "only" has a lidswelling.
Do you think the fungus could be the reason for the acute problems?
In the hospital labaratory they found one time after the operation candida albicans. This has never been treated. Do you think it would be good for him to treat the (unknown) fungus with (for example) itraconazol?
I did not give him itraconazol so far since I am not sure that he can take it with his ASS-intolerance and to prevent reactions to the medicament, but I think perhaps it would make sense to treat also the unknown fungus infections, would you agree?
ad 6) We did several ct and mrt. There we found the lack of the lamina papyracea and the destruction of the orbita roof.
It is planned to do a reconstruction, but I am not sure if it is the right decision, because he has had so many operations and this big operation is quite XXXXXXX
Until now neither the ophtalmologists nor the ent-specialists came to the idea to look there. Could there be any possibility to do "a small operation" for the lacrimal aparatous?
ad 7) We did a ASS-desensisitation for about one year, he had no symptoms at that time. Then we stopped it because he became tired to take so many medicaments and we did not know how many problems would come.
It is planned to do a ASS-desensitation again after the next operation.
ad7) HPV: Would you think it could be good for him to give him a vaccination with gardasil?
Dear Dr. Bhatti, thank you very much for your very helpful answers, I have been desperately trying to get some in-depth knowledge.
With kind regards,
Heike Goede
thank you very much for your answer.
ad 3) My son took muntelukast for about 1,5 years, but the polyposis could not be stopped. He had to endure 3 operations whilst taking montelukast, but he did not always take it on a regular basis.
He took mometason spray four times a day. Salin nasal washes and steam inhalations made him feel bad in his nose, he felt worse, so we stopped it.
ad 4) My son took Telfast(fexofenadinhydrochlorid) 180 mg per day but it could not change his actual or chronical problems.
ad 5) This seems to be very important from my point of view:
Two weeks ago he had an allergy test (prick-test) with very impressive results:
There was a high reaction to aspergillus fumigatus, candida albicans, penicillinum notatum, pullularia pullulans, serpula lacrimans, ustilago titrici and cat epithels.
The nasal provocation of season-pollinosis was positive.
The rast-test was different, there we could not see the same result.
What do you think, is mor important for his desease, the result of the rast-test or the prick-test?
Very impressive was his reaction after the allergy-test: Before he felt quite good and he had only very little lid-swelling. A few hours after the test he felt quite weak and his eyelid started swelling more and more until he got an exophtalmus. The symptoms continued to deteriorate for 5 days. Fexofenatadin could not change anything until I gave him prednisolon 150 and Ebastel (ebastin) 2 x 20 mg. Now, after 10 days the symptoms are better and he "only" has a lidswelling.
Do you think the fungus could be the reason for the acute problems?
In the hospital labaratory they found one time after the operation candida albicans. This has never been treated. Do you think it would be good for him to treat the (unknown) fungus with (for example) itraconazol?
I did not give him itraconazol so far since I am not sure that he can take it with his ASS-intolerance and to prevent reactions to the medicament, but I think perhaps it would make sense to treat also the unknown fungus infections, would you agree?
ad 6) We did several ct and mrt. There we found the lack of the lamina papyracea and the destruction of the orbita roof.
It is planned to do a reconstruction, but I am not sure if it is the right decision, because he has had so many operations and this big operation is quite XXXXXXX
Until now neither the ophtalmologists nor the ent-specialists came to the idea to look there. Could there be any possibility to do "a small operation" for the lacrimal aparatous?
ad 7) We did a ASS-desensisitation for about one year, he had no symptoms at that time. Then we stopped it because he became tired to take so many medicaments and we did not know how many problems would come.
It is planned to do a ASS-desensitation again after the next operation.
ad7) HPV: Would you think it could be good for him to give him a vaccination with gardasil?
Dear Dr. Bhatti, thank you very much for your very helpful answers, I have been desperately trying to get some in-depth knowledge.
With kind regards,
Heike Goede
Dear Dr. Heike Goede,
Thank you for writing back.
1. The fungi and antigens tested above are ubiquitous. It will be difficult to avoid these. A RAST will pick up the specific IgE antibodies in the blood and Skin Prick Testing is an antigen challenge by exposure. Both have to be evaluated in the clinical picture and context. Both tests are useful in deciding exclusion and avoidance. In RAST immunoassay, levels of allergen specific IgE are important.
2. I would like to introduce you to the concept of Food Intolerance, which is IgG mediated and it's extension to inhaled antigens. As long standing allergies mature, IgG levels are important. There are two tests available in UK known as Food Detective and Food Print.
3. I would also like to introduce you to the concept of Biofilm formation in his nasal passages and sinuses. There may be associated allergic, fungal and mucus related conditions. The simplest example of Biofilm is the sludge or slime seen in drainage pipes or the moss seen along water channels. The Biofilm represents colonies of different types of bacteria, fungi living together like a 'city' with different micro organisms taking up different tasks or "profession's" like we do in our communities. Some of them secrete a matrix that protects them all. Due to close proximity, these organisms share genetic material and may be genetically distinct from those that are grown in lab cultures. Hence they do not respond to the same antifungals and antibiotics that they show sensitivity to in lab studies.
He should wash his sinuses with a solution of normal saline with a pinch of salt and baking soda added to it. This alkaline nasal douche will help break up the Biofilm and allow penetration by other medicines. You may add a few drops of anti-dandruff shampoo which contain undecylenic acid, which is a natural fungicide, besides some brand contain ant-fungals such as ketaconazole. If Mometasone does not suit him, he may discontinue and replace it with a milder steroid such as fluticasone or ciclesonide. Steroids should be given under antibiotic cover. Surgical debridement, removal and disruption of the Biofilm may require surgery.
4. Instead of Itraconazole, I recommend that he takes an even broader spectrum anti-fungal such as Posaconazole (or Voriconazole).
5. Probably the bony defects allow the allergy to spill out of the nasal passages into the orbit. You may delay the repair and reconstruction till you have ruled out CSF leaks and lacrimal problems.
6. There is no harm in vaccinating him with Gardasil. There is always a small risk with all vaccines. You should attempt aspirin desensitization again.
7. You should also try rupatidine and levocetrizine instead of fexofenadine. Patients who feel worse after steam inhalation are those who have significant nasal obstruction. Do you have access to rhinomanometry and nasal nitic oxide measurement?
8. Prof. Dr. H. Stammberger at the Medical University of Graz is one of the world's foremost specialists in sinus surgery and nasal polyposis. Graz, Austria is about 300 miles east of Konstanz. You should consult him (if you have not already done so). Do you have details of all the eight surgeries?
Hope I have answered your questions. If I have missed out on any or if you have any follow up queries I will be available to answer them.
Regards.
Thank you for writing back.
1. The fungi and antigens tested above are ubiquitous. It will be difficult to avoid these. A RAST will pick up the specific IgE antibodies in the blood and Skin Prick Testing is an antigen challenge by exposure. Both have to be evaluated in the clinical picture and context. Both tests are useful in deciding exclusion and avoidance. In RAST immunoassay, levels of allergen specific IgE are important.
2. I would like to introduce you to the concept of Food Intolerance, which is IgG mediated and it's extension to inhaled antigens. As long standing allergies mature, IgG levels are important. There are two tests available in UK known as Food Detective and Food Print.
3. I would also like to introduce you to the concept of Biofilm formation in his nasal passages and sinuses. There may be associated allergic, fungal and mucus related conditions. The simplest example of Biofilm is the sludge or slime seen in drainage pipes or the moss seen along water channels. The Biofilm represents colonies of different types of bacteria, fungi living together like a 'city' with different micro organisms taking up different tasks or "profession's" like we do in our communities. Some of them secrete a matrix that protects them all. Due to close proximity, these organisms share genetic material and may be genetically distinct from those that are grown in lab cultures. Hence they do not respond to the same antifungals and antibiotics that they show sensitivity to in lab studies.
He should wash his sinuses with a solution of normal saline with a pinch of salt and baking soda added to it. This alkaline nasal douche will help break up the Biofilm and allow penetration by other medicines. You may add a few drops of anti-dandruff shampoo which contain undecylenic acid, which is a natural fungicide, besides some brand contain ant-fungals such as ketaconazole. If Mometasone does not suit him, he may discontinue and replace it with a milder steroid such as fluticasone or ciclesonide. Steroids should be given under antibiotic cover. Surgical debridement, removal and disruption of the Biofilm may require surgery.
4. Instead of Itraconazole, I recommend that he takes an even broader spectrum anti-fungal such as Posaconazole (or Voriconazole).
5. Probably the bony defects allow the allergy to spill out of the nasal passages into the orbit. You may delay the repair and reconstruction till you have ruled out CSF leaks and lacrimal problems.
6. There is no harm in vaccinating him with Gardasil. There is always a small risk with all vaccines. You should attempt aspirin desensitization again.
7. You should also try rupatidine and levocetrizine instead of fexofenadine. Patients who feel worse after steam inhalation are those who have significant nasal obstruction. Do you have access to rhinomanometry and nasal nitic oxide measurement?
8. Prof. Dr. H. Stammberger at the Medical University of Graz is one of the world's foremost specialists in sinus surgery and nasal polyposis. Graz, Austria is about 300 miles east of Konstanz. You should consult him (if you have not already done so). Do you have details of all the eight surgeries?
Hope I have answered your questions. If I have missed out on any or if you have any follow up queries I will be available to answer them.
Regards.
Note: For further information on diet changes to reduce allergy symptoms or to boost your immunity, Ask here.
Above answer was peer-reviewed by :
Dr. Raju A.T
Answered by
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