Nasal polyp and its homoeopathic management

Dr. Ashok Yadav¹, Dr. Kanika Agarwal², Dr. Yogita Kumari²

¹ Professor & Head of Department, Department of Practice of Medicine, Dr. MPK Homoeopathic Medical College, Hospital & Research Centre (under Homoeopathy University), Jaipur, Rajasthan, India

² PG Scholar (Part-I), Dr. MPK Homoeopathic Medical College, Hospital & Research Centre (under Homoeopathy University), Jaipur, Rajasthan, India

ABSTRACT
Nasal polyps are hypertrophied oedematous mucosa and sub mucosa of nose and paranasal sinuses appearing as smooth, round, semi-translucent pale masses. Their aetiology remains unclear, but they are known to have association with allergy, asthma, infection, cystic fibrosis, and aspirin sensitivity. Patients with nasal polyposis may present clinically with complaints of nasal obstruction, congestion, hyposmia , rhinorrhea, postnasal drip, headaches, and snoring. Nasal polyps can be managed and treated with homoeopathic medicines which are selected on the basis of symptom similarity.

KEYWORDS- nasal polyp, homoeopathy

INTRODUCTION
Nasal Polypi are non-neoplastic masses of oedematous nasal or sinus mucosa. Depending on the site of origin they are divided into two main varieties: Bilateral ethmoidal polyp  and Antrochoanal polyp. Ethmoidal polyp  are more common ,generally multiple, nearly always bilateral ,appear as grape like masses and are usually visible on anterior rhinoscopy or may even appear at the nostril .  Antrochoanal polyp arise from mucosa of maxillary antrum and its assessoy ostium,  comes out of it and grows in choana and nasal cavity. It is usually unilateral and diagnosed by posterior rhinoscopy.^[1]

ETIOLOGY
The exact etiology of nasal polypi isnot well understood but it may arise in inflammatory conditions of  nasal mucosa( rhinosinusitis), disorders of ciliary motility or abnormal composition of nasal mucus. Various diseases associated with it are  chronic rhinosinusitis, asthma, aspirin intolerance,  cystic fibrosis, nasal mastocytosis, young syndrome and kartagener’s  syndrome.^[2]

PATHOPHYSIOLOGY
Polypi are the end product of prolonged edema in the mucosa of nose and sinuses. The submucosa around  the middle meatus is especially lax and easily waterlogged, causing swelling of the tissues. Although polyps can grow from any part of the nose or sinus but they commonly originate in region of middle turbinate and ethmoids. Similarly in the small cells of ethmoidal labyrinth the   mucosa membranes swells to occupy  all the lumen, and then projects through the ostia  into the nose. Then it becomes constructed at ostia thus forming the polyp.^[3] 

CLINICAL FEATURES
Symptom:
Nasal stuffiness due to nasal obstruction, partial or total loss of smell, headache due to associated sinusitis, sneezing and watery discharge of nose due to associated allergy and mass protruding out of nostril are  the presenting symptoms in nasal polyp.Voice may become dull due to hypo nasality^[1]

Signs:
Bilateral ethmoidal polyp are seen on anterior rhinoscopy as smooth and  glistening, grape like masses often pale in colour, which may be sessile or pedunculated.  Antro chondral polyp are seen on posterior rhinoscopy as globular, smooth grayish mass covered with nasal discharge. A large polyp may protrude from nostril and show pink congested look on its exposed partor hang down behind the soft palate and present in oropharynx.

They are insensitive to probing and do not bleed on touch^[1]

DIFFERENTIAL DIAGNOSES^.

• Blob of mucus: It may look like a polyp but disappears on blowing the nose.^[2]
• Hypertrophied middle turbinate: It is pink in color and hard like bone and can be easily differentiated from polyp with probe testing.^[2]
• Angiofibroma: It usually occurs in adolescent males and present with profuse recurrent episodes of epistaxis. If suspected, it should not be probed because that can cause brisk bleeding. X-ray lateral view soft tissue nasopharynx shows presence of a column of air behind the polyp. ^[2]
• Malignancy: They are fleshy pink in appearance, friable in nature and have tendency to bleed on touch. Some time a polyp may masquerade a malignancy, so all polyps are subjected to histology. ^[2]
• Pediatric masses: Mucoviscidosis, gliomas and encephalocele. Encephalocele, which should be aspirated (CSF), as they presents like a polyp. ^[2]

INVESTIGATIONS
Nasal polyps can be easily clinically diagnosed by anterior and posterior rhinoscopy. 

Investigations like PNS-X ray, X-ray lateral view-soft tissue nasopharynx, CT scan and histopathological examination can be done to rule out other pathology.

MANAGEMENT AND TREATMENT
Small polypi occasionally undergo spontaneous regression if the cause is removed with the help of antihistaminics and steroids. However in majority of instances polypi must be removed surgically.

Homoeopathic management
Homeopathy is a system based on “Law of Similars” which means it treat the disease with medicine producing similar symptoms when given in healthy individuals. Therefore medicines are selected on the basis of Totality of Symptoms.

It is evident from past researches that homoeopathy is effective in management of nasal polyps. A prospective, open, non-randomized, single arm, observational trial of pre-post comparison design was conducted on 44 patients suffering from symptomatic nasal polyps. Sino-nasal outcome test (SNOT-20) and European Quality of Life (EQ-5D-5L) questionnaires were taken as the primary and secondary outcome measures respectively; assessed at baseline and after 3 months. Individualized homoeopathic medicines were prescribed on ‘totality of symptoms’. has  revealed complete regressions of polyps in 23 (58%) cases. Statistically significant improvements were observed in both the subjective patient-rated outcomes – mean reduction of SNOT-20 scores.^[4]

Representation of nasal polyp related rubrics in Repertories-

REPERTORY	CHAPTER AND/OR RUBRIC	SUB-RUBRIC	INDICATED MEDICINES
Kent	NOSE – polypus (34 medicine are given)	Right	Kali-n.
		Left	Alumn,Apis, Calc,Merc – i -r
		Bleeds easily	Calc, calc-p , Phos, Thuj.
		Posterior nares	Teucr.[5]
BBCR	NOSE- Polypi, hypretrophies(21 medicine are given)		Aur, aur-mur, bell, Calc-c, cad-s, con,grap. ,Kali-bi, kali-n, mar. ,merc., merc-aur.,nit-ac., pho., pul.,sang., sep.,sil.,stap.,sul.,thu.[6]
Boericke’s Repertory	NOSE-ERUPTIONS,growths	Polypi	Cadm. s., Calc. c., Calc. iod., Calc. p., Caust., Cepa, Con., Formica, Kali bich., Kali n., Lemna m., Merc. i. r., Nit. ac., Phos., Psor., Sang., Sang. n., Staph., Teucr., Thuya, Wyeth.[7]
Clarke in ‘The Prescriber’	Polypus	Of NOSE	Thuj.,Formica.,Calc c., Kali nit., Kali bichr., Nit ac., Teucr.[8]
Nash in “Leaders In Homoeopathic Therapeutics”	Polypus		Calc., Thuj., Mar-v. [9]
Knerr Repertory of Hering Guiding Symptoms	NOSE- Polypus	Antrum Highmorii, 1st in, deforming face, forcing eyeball upward, everting lid, obstructing nostrils into mouth, so that breathing and mastication were impeded	Hecla.
		Bleeding easily	Phos.
		Bone, extended to ethmoid, into choanæ and into antrum of Highmore	Teucr.
		Fossæ, in	Sang.
		Large, after a severe, badly-treated cold	Teucr.
		Left side, in	Alumn.
		Mucous, of pale red color, on left side, and of large size, mostly in anterior nares, and in plain sight	Teucr.
		Mucous, greenish white, attached to upper turbinated bone, and completely filling nasal cavity and causing occlusion, after repeated attacks of coryza	Teucr.
		Mucous, large, of right side, distending nose	Kali-n.
		Nose, with stoppage of, on side he lies	Teucr.
		Pedunculated, large	CALC-P.
		Recent, or of long standing	Kali-bi.
		Removed every 2 or 3 years by operative means, for 30 years	Teucr.
		Right nostril, in, growing more rapidly after each attack of headache, which was better by camphor	Kali-n.
		Right nostril, occupying entire, projecting slightly	Teucr.
		Smell, with loss of	CALC.
		Water, much discharge of mucus and	Teucr.
		Weather, enlarges in wet	Teucr.
		Women, especially among old and middle-aged	Teucr.
		Year’s, of 1, duration	Teucr. [10]

Symptomatic indications of some homoeopathic medicines-  

• AGRAPHIS NUTANS

Nasal polyps obstruct the nostrils; enlarged and inflamed tonsils; throat deafness.Tendency to catch cold and free discharge from mucus membrane on every exposure to cold wind. ^[7]

• ALLIUM CEPA

Sneezing, especially when entering a warm room. Copious, watery and extremely acrid discharge. Feeling of a lump at root of nose. Hay-fever. Fluent coryza with headache, cough, and hoarseness Polypus.^[7]

• AMMONIUM MURITICUM

Free acrid, hot watery discharge corroding the lip.Sneezing.Nose sore to touch; ulcerative pain in nostrils. Loss of smell. Obstructed, stuffy feeling; constant and unavailing efforts to blow it out.Itching.^[7]

• AMMONIUM CARBONICUM

Discharge of sharp, burning water.Stoppage at night, with long-continued coryza. Cannot breathe through nose. Snuffles of children. Epistaxis after washing and after eating. Ozaena, blows bloody mucus from nose . Tip of nose congested. ^[7]

• CADMIUM SULPH

Ozaena. Tightness at root. Nose obstructed; polypus.Caries of nasal bones. Boils on nose. Nostrils ulcerated.^[7]

• HEPAR SULPH – 

Sore, ulcerated. Soreness of nostrils, with catarrhal troubles. Sneezes every time he goes into a cold, dry wind, with running from nose, later, thick, offensive discharge. Stopped up every time he goes out into cold air. ^[7]

• KALI NITRICUM

Sneezing.Swollen feeling; worse, right nostril.Point red and itching. Polypus. ^[7]

• LEMNA MINOR

Putrid smell; loss of smell. Crusts and muco-purulent discharge very abundant.  Post-nasal dropping.Pain like a string from nostrils to ear. Reduces nasal obstruction when it is an oedematous condition.Dryness of naso-pharynx.^[7]

• SANGUINARIA

Ozaena, with profuse, offensive yellowish discharges. Nasal polypi. Coryza, followed by diarrhoea.Chronic rhinitis; membrane dry and congested Ears.^[7]

• SANGUINARIA NITRICUM

Feels obstructed. Profuse, watery mucus, with burning pain. Enlarged turbinates  at   beginning of hypertrophic process. Secretion scanty, tendency to dryness. Small crusts which bleed when removed. Post-nasal secretions adherent to nasopharynx , dislodged with difficulty.  Dry and burning nostrils; watery mucus, with pressure over root of nose.Nostrils plugged with thick, yellow, bloody mucus.Sneezing.Rawness and soreness in posterior nare.^[7]

• STICTA PULMONARIA

Feeling of fullness at the root of the nose. Atrophic rhinitis. Dryness of nasal membrane. Constant need to blow the nose, but no discharge. Dry scabs, especially in evening and night. Hay-fever; incessant sneezing.^[7] 

• TEUCRIUM MARUM VERUM

Catarrhal condition of both anterior and posterior nostrils. Mucous polypus. Chronic catarrh ; discharge of large, irregular clinkers. Foul breath. Crawling in nostrils, with lachrymation and sneezing. Coryza, with stoppage of nostrils. ^[7]

• GERANIUM MACULATUM – 

The tincture should be applied over the Nasal Polyps once a day ,the tumour will shrink speedily.^[7]

REFERENCE

1. Dhingra PL, Dhingra S. Diseases of ear, nose & throat. 5th ed. Gurgaon: Elsevier Publishers (P) Ltd; 2012.
2. Bansal M. Disease of ear nose & throat . New Delhi :1^st ed. Jaypee Brothers Medical Publishers.(P)Ltd;2013
3. Hall I. Simson, ColmanH. Bernard. Disease of the nose, throat and ear a handbook for students and practioners. 12^th ed. Churchill Livingstone
4. Banerjee A, Srivastava BP, Koley M, Saha S. An Open-Label Observational Trial to Evaluate the Possible Effects of Individualized Homoeopathic Medicines in Symptomatic Nasal Polyp.Bengal Journal of Otolaryngology and Head Neck Surgery [INTERNET]2019 April ;27 (1) Available from:  file:///C:/Users/abc/Downloads/570-2142-1-PB%20(1).pdf
5. Kent JT. Repertory of Homeopathic Materia Medica. Reprint Edition. New Delhi: B. Jain Publishers (P) Ltd.; 2007.
6. Boger CM. Boenninghausen’s Characteristics Materia Medica and Repertory. New Delhi, B. Jain Publishers, 2004.

7. Boericke W. New Manual of Homoeopathic Materia Medica and Repertory. Reprint Edition  New Delhi: B. Jain Publishers(P)Ltd. 2011.

8. Clarke JH. The Prescriber. Available from: http://www.homeoint. org/books1/clarkeprescriber/n.htm

9. NashE.B. Leaders in Homoeopathic Therapeutics. Therapeutic index. Available from: http://www.homeoint.org/books2/nashtherap/theraindex.htm

10. Knerr CB. Repertory of Hering’s Guiding Symptoms of our Materia Medica. Available from: http://www.homeoint.org/hering/nose-lr.htm