Drinking Beer Worsens Nasal Symptoms in a 35-Year-Old Man

Thomas S. Higgins, Jr, MD, MSPH

Disclosures

March 12, 2020

Discussion

Nasal polyps are benign inflammatory growths in the nasal cavities and paranasal sinuses. They usually have no potential for malignant degeneration. They may form related to type 1 inflammation (eg, cystic fibrosis [CF], infectious processes) or type 2 inflammation (eg, allergy, aspirin-exacerbated respiratory disease [AERD]). Nasal polyps are usually a component of a process involving the paranasal sinuses, thus the term chronic rhinosinusitis with nasal polyps (CRSwNP) is often used. The two hallmark symptoms of CRSwNP are smelling loss and nasal obstruction.[1]

CRSwNP is a ubiquitous condition with a few recognized disease processes. AERD includes the triad of nasal polyposis, eosinophilic asthma, and aspirin sensitivity.[1] In this case, after the initiation of inhaled fluticasone/salmeterol to control his asthma symptoms, the patient returned for an oral aspirin challenge. His FEV1 had improved to 90%. He was administered 40.5 mg of aspirin, followed by 81 mg. The patient reported significantly increased nasal congestion and cough 1 hour after administration of the 81-mg dosage. His FEV1 decreased to 85% of baseline during the trial.

Allergic fungal rhinosinusitis (AFRS) is characterized as nasal polyposis with a positive result on fungal stain, eosinophilic mucin, and heterogeneity in the paranasal sinus cavities on CT scanning.[2] This diagnosis was less likely in this patient due to the presence of bilateral disease, lack of heterogeneity on imaging, and the fact that aspirin or nonsteroidal anti-inflammatory drug (NSAID) sensitivity is not typically present in patients with AFRS. CF is an autosomal recessive genetic condition related to a defect in the chloride-ion channel cystic fibrosis transmembrane conductance regulator protein (CFTR), causing impaired mucociliary clearance. Nasal polyposis in CF is often identified in childhood.[3]

Granulomatosis with polyangiitis (GPA), formerly called Wegener granulomatosis, is a rare inflammatory condition of small- and medium-sized blood vessels (vasculitis) that primarily occurs in the respiratory tract and kidneys. Although sinonasal scarring and nasal septal perforation are often seen in patients with this condition, nasal polyposis is not common.[4] This diagnosis was excluded because patients with GPA typically have severe crusting and scarring with a lack of nasal polyposis. In addition, this patient's pathologic findings did not reveal granulomata.

Eosinophilic granulomatosis with polyangiitis (EGPA), also called Churg-Strauss syndrome, is a small- and medium-sized vasculitis characterized by tissue eosinophilia and granulomata. Patients with EGPA often have asthma and paranasal sinus disease, with nasal polyposis found in more than 50% of cases.[5] This diagnosis is much less common than AERD, and the pathologic findings of this patient did not reveal granulomata.

In addition, sinonasal papilloma and sinonasal undifferentiated carcinoma were ruled out based on pathologic findings. Red flags for neoplasms include unilateral disease, cranial neuropathies, and intraorbital or intracranial extension.

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