Pediatric nasal polyps are uncommon, but they are an important clinical entity that is often associated with chronic inflammatory conditions such as cystic fibrosis (CF), primary ciliary dyskinesia, and allergic fungal rhinosinusitis (Di Cicco et al., 2021) [1]. Nasal Polyps (NPs) are rare in pediatric age. Compared to adults, in which the prevalence is between 1 and 4% of the general population, in children younger than 10 years old the frequency is estimated at 0.1%. [2] While nasal polyps are common in adults, children with nasal polyps have generally a greater likelihood of having a co-existing systemic disease requiring a full multi-disciplinary workup (Sitzia et al., 2023).[3] The early-development of nasal polyps has the potential to negatively affect a child's quality-of-life, and they can continue to have chronic sinonasal symptoms into adulthood. The knowledge of chronic rhinosinusitis with nasal polyps (CRSwNP) as endotypes continues to grow; endotypes are defined by immunopathologic mechanisms, but not by clinical characteristics (Cho et al., 2020; Dennis et al., 2016) [4,6]. Evidence exists for specific cytokines of type 2 inflammation, including IL-5, IL-13, and IL-25 that cause eosinophilic inflammation. This provided unique opportunities for treatment (Shin et al., 2015; Klimek et al., 2019) [5,8]. Knowledge of Type 2 endotypes led to biologic treatment options for CRSwNP that focus on type 2 inflammation, examples being dupilumab and other monoclonal antibodies, that have been shown to be safe and effective in treating adults with CRSwNP (Bachert et al., 2019) [9]. Nonetheless, we know very little about how common nasal polyps are in children, what the management is and what the outcomes are for children. Because of the unique pathophysiology and tendency to be chronic for children with nasal polyps, this study evaluates the incidence, presentation, and managing outcomes of pediatric nasal polyps in a tertiary care center with new developments in endotypes and treatment (Fokkens et al., 2020) [6].

Study Design and Setting This was a retrospective observational study conducted at a tertiary care hospital, Ahmedabad between January 2020 to December 2022. This study aimed to explore the clinical characteristics, diagnosis, and treatment outcomes of children with nasal polyps. The guidelines were followed in accordance with the Declaration of Helsinki. Patient Selection We included children 3 to 17 years of age who presented to us with symptoms of nasal obstruction, rhinorrhea, mouth breathing, anosmia or facial pain currently diagnosed with nasal polyps. The diagnosis was made based on clinical criteria confirmed utilizing anterior rhinoscopy or nasal endoscopy. This was corroborated with imaging. Patients were excluded if they had isolated adenoid hypertrophy, Antro-choanal polyp, previous sinonasal surgery for non-polypoidal conditions, incomplete medical record, patients with autoimmune disorders and patients with systemic immunodeficiency disorders. Diagnostic Evaluation Each patient underwent a comprehensive clinical assessment that included history taking, emphasizing the duration of symptoms, family history and other co-morbidities such as asthma or allergic rhinitis. Diagnostic nasal endoscopy was used to assess the severity of polyp formation and to stage the disease using the Lund-Kennedy endoscopic scoring system. CT scans of the paranasal sinuses were performed and graded utilizing the Lund-Mackay system for degree of involvement of the sinus disease. In addition to the evaluations for possible underlying systemic disease, other tests were performed, serum IgE levels, Complete Blood Count with eosinophils count, and allergen-specific testing for allergic fungal rhinosinusitis or atopic predisposition. In addition, patients underwent pulmonary function tests for comprehensive evaluation. Treatment Modalities We customized management plans for each patient based on their symptoms, findings during the endoscopic examination, radiological scores, and any co-morbidities. Every patient was started on intranasal corticosteroid sprays and oral antihistamines based on the patient's personal condition as the first-line treatment. We always encouraged saline nasal irrigation as a useful adjunct to the regimen. For the medically managed patients who did not improve with medical treatment, and those who had significant obstruction, repeated sinus infections, or complications, we recommended surgical therapy. Functional endoscopic sinus surgery (FESS) was typically our preferred surgical technique done under general anesthesia. The extent of the surgery depended upon our findings during the surgery and the imaging that occurred prior to surgery. We sent samples obtained during surgery for histopathological examination to exclude neoplastic or fungal disease . Follow-Up and Outcome Assessment Following surgery, we continued to monitor patients at regular intervals: firstly, after two weeks, thereafter at intervals of 1 month for 6 months, and then at intervals of 6 months for the next several transition visits. For each visit, we assessed the patient's clinical symptomatology and underwent nasal endoscopy to identify any sign of recurrence. We defined recurrence as the reappearance of polyps as determined by endoscopy after recovery. We also documented and reported the frequency of patients with good medical adherence, changes in quality of life, and postoperative complications. Patients' treatment results were examined according to actual symptom improvement, endoscopic improvement, recurrence rate, and need for procedures that modify the surgical effect (revision surgeries). We examined whether certain comorbidities, specifically asthma and allergic rhinitis, impacted recurrence and treatment responses.

We performed a three-year research investigation on 42 pediatric patients with nasal polyps. The mean age when initial symptoms started was 11.2 years of age, with a male to female ratio of 59.5%. Most of the patients (61.9%) came in with nasal obstruction, followed by symptoms like rhinorrhea (59.5%) and mouth breathing (40.4%). We also noticed that many of them had other comorbidities, with asthma affecting (30.9%) and allergic rhinitis (26.19%). Clinical Presentation and Comorbidities The distribution of symptoms and related comorbidities is neatly outlined in Table 1. We found that bilateral polyposis occurred in 61.9% of the cases, while unilateral involvement was noted at 38.1% On average, the Lund-Kennedy endoscopic score at the time of presentation was 5.6 ± 1.2, and the mean Lund-Mackay CT score came in at 12.4 ± 3.1. Table 1. Demographic Information for Patients Characteristics Number (N=42) Percentage (%) Age (Years) 3-7 years 8 19.1% 8-12 years 14 33.3% 13-17 years 20 47.6% Sex Boys 25 59.5% Girls 17 40.5% Table 2. Clinical Features and Comorbidities of Pediatric Patients with Nasal Polyps Feature Frequency (n=42) Percentage (%) Bilateral nasal obstruction 26 61.9% Rhinorrhea 25 59.5% Mouth breathing 17 40.4% Anosmia 15 35.7% Facial pressure/pain 12 28.5% Asthma 13 30.9% Allergic rhinitis 11 26.19% Family history of nasal polyps 6 14.2% Treatment Modalities and Outcomes In the total group of patients, all patients initially treated with medical therapy from which around 13 (30.9%) patients had symptomatic relief. These patients have been included in the medical group. In contrast, 29 (69.1%) patients required surgery due to persistent symptoms or their imaging showed extensive disease. These patients are included in the surgical intervention plus medical group. All patients who underwent surgery had functional endoscopic sinus surgery, and thankfully, there were no major complications. A histopathological examination confirmed that all cases involved inflammatory nasal polyps, with 5 of those showing a predominance of eosinophils and 2 linked to fungal elements. After the surgery, most patients reported significant relief from their symptoms. However, 8 patients (19%) experienced a recurrence during the follow-up period, with those having asthma and allergic rhinitis showing higher recurrence rates. Table 3. Treatment Outcomes and Recurrence Variable Medical Group (n=13) Surgical +Medical Group (n=29) Total (n=42) Complete symptom resolution 11 (84.6%) 24 (82.7%) 35 (83.3%) Partial improvement 2 (15.4%) 4 (13.7%) 6 (14.2%) Recurrence 0% 8 (27.5%) 8 (19%) Revision surgery required – 7 (24.13%) 7 (16.6%) Recurrence by Comorbidity Figure 1 presents a bar graph depicting recurrence rates associated with different comorbid conditions. Patients diagnosed with asthma exhibited the highest recurrence rate at 30.7%, followed by those with allergic rhinitis at 27.2%. On the other hand, children who didn’t have any systemic diseases experienced a much lower recurrence rate of just 6%.

The study findings demonstrate the complex nature and diversity of outcomes related to pediatric nasal polyps, reflecting our increasing understanding of the underlying mechanisms and treatment. The data showed that the presence of bilateral polyps was observed in our group and that certain percentage of patients had an associated condition such as asthma and allergic rhinitis which aligns with previous studies which have suggested that pediatric nasal polyposis can be associated with an underlying systemic or inflammatory disorder. These findings complement Hoggard et al. (2018) [12] who advocated that inflammatory endotypes (Th2-skewed inflammatory responses) appear to be particularly important factors for the persistence and recurrence of nasal polyps in their cohort. We noted that the recurrence rate was particularly high in our patients with asthma and allergic rhinitis, which highlighted how systemic inflammation can complicate treatment and impact the long-term efficacy of surgical treatment as noted by Kanemitsu et al. (2020) [14] who described an ongoing status of inflammation and elevated levels of periostin in polyp patients who had asthma. Some patients showed improvement with corticosteroid therapy, a significant proportion still required surgery, particularly those who had advanced endoscopic and radiologic findings. This does align with the general consensus on stepwise management strategies per the clinical guidelines set forth by Rosenfeld et al. (2015) [11] that recommend surgical intervention when conservative approaches fail. Patients were pleased to ultimately receive a surgical intervention that serves to relieve their symptoms, although recurrence remains a challenge for some patients, especially those patients with ongoing eosinophilic or fungal issues. This is consistent with Kucuksezer et al.'s (2018) [10] acknowledgement that ongoing eosinophilic inflammation is the main reason for high recurrence rates, even after surgical intervention is performed optimally. The introduction of targeted biologic therapies, most notably dupilumab, which blocks the IL-4 and IL-13 pathway, has limited treatment of CRSwNP in adults. While our study focused solely on conventional therapies, there is a growing body of literature in support of biologic therapies in severe and/or recurrent patients, including children. Kim and Naclerio (2020) [13] provided good insight into dupilumab's efficacy in adults and referenced its use in difficult pediatric cases, but there likely still is not enough built up in that regard. Likewise, Lombardi et al. (2024) [16] suggested anti-IL-5 agents can be effective across all ages and emphasized the need to target eosinophils in difficult expansive disease. In addition, our results corroborate the emerging notion of precision medicine in chronic rhinosinusitis as mentioned by Xu et al. (2021) [15], we should encourage the treatment of disease based on endotypes to optimize long-term management of chronic rhinosinusitis. It is possible that, by integrating endotypic classification into the pediatric setting, we may obtain better treatment outcomes and experience fewer relapse rates. As our understanding of chronic rhinosinusitis continues to grow, we seek to describe our guiding principles for the future of immunologic profiling. Specifically, we will be pursuing early identification via diagnosis and treatment development based on endotypes to lessen the toll on children.

In summary, pediatric nasal polyps are an uncommon but distinct clinical issue sometimes associated with other systemic or inflammatory diseases such as allergic rhinitis and asthma. The study demonstrates that while most children are managed well with pharmacologic therapies, there are still children with more severe disease or comorbidity who require surgical intervention, and if the patient has eosinophilic inflammation or systemic impact, they are at risk of recurrence. This makes individualized treatment plans important in managing children with pediatric nasal polyps and associated chronic rhinosinusitis, based on the endotype of the disease. As we advance our understanding of the immunopathogenesis of chronic rhinosinusitis with nasal polyps and we see the introduction of targeted biologics, we have exciting opportunities to improve long-term outcomes in children with nasal polyps through targeted and sustained treatment strategies.

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