PRACTITIONER ’ S CORNER Recalcitrant Nasal Polyposis : Achievement of Total Remission Following Treatment With Omalizumab

The incidence of rhinosinusitis and nasal polyposis is higher among asthmatic patients, probably because the pathogenesis of both conditions is characterized by eosinophilic infl ammation. Surgical treatment for polyps may be necessary when medical treatment is not effective, although relapses can occur even after surgery [1]. Omalizumab is a chimeric monoclonal anti-immunoglobulin E (anti-IgE) antibody, indicated for the treatment of diffi cult-to-control allergic asthma. It has also proven effective in patients with seasonal and perennial allergic rhinitis [2]. Anti-IgE may be effective in the treatment of refractory chronic rhinosinusitis [3], and a pilot study has shown that it may reduce the severity of the recurrence of nasal polyps [4]. We present the case of a 54-year-old man who was an exsmoker (<10 pack-years) and had been affected by allergic asthma (sensitized to house dust mites and pollens) and chronic rhinosinusitis with nasal polyposis since the age of 42. Polyps were diagnosed in 1999, when he underwent bilateral microscopic radical sinus surgery because of the severity of his condition. In June 2006, the patient had a relapse of nasal polyposis and underwent functional endoscopic sinus surgery, with histological evidence of noneosinophilic nasal polyposis. At the follow-up visits, the ENT specialist prescribed repeated cycles of topical and systemic corticosteroids for the recurrence of nasal obstruction, hyposmia, and headache. This patient also experienced asthma exacerbations almost once per month; consequently, his pulmonologist prescribed cycles of antibiotics and systemic corticosteroids. The patient had to stop practicing sports. He experienced nighttime awakenings and daytime symptoms, despite continuous high-dose therapy with inhaled corticosteroids and longacting ß 2 agonists (fl uticasone 1000 μg/salmeterol 100 μg) and montelukast. Spirometry revealed moderate obstruction (forced expiratory volume in 1 second [FEV 1 ], 65%). In April 2006, because of the persistence of the asthma symptoms, the pulmonologist prescribed omalizumab. The patient received 225 mg every 2 weeks (total IgE 294 IU/L, body weight 74 kg). The patient’s health gradually began to improve: he no longer experienced limitations on his daily activities or night awakenings, and he was able to reduce his need for a rescue bronchodilator. After 2 months, even forced sports activity was well tolerated, with no exertional dyspnea due to bronchospasm. The patient did not need any further periodical cycles of systemic corticosteroids, and his spirometry values showed a nonsignifi cant improvement (FEV 1 , 69%). An unexpected dramatic improvement in nasal symptoms (including hyposmia) was also observed. After the fi rst dose of omalizumab, there was no further need for systemic or topical corticosteroids to control nasal symptoms. Congestion due to continuous recurrence of nasal polyps was successfully controlled. This striking efficacy was also confirmed by endoscopy fi ndings, which revealed, for the fi rst time in some years, normal mucosa with complete remission of the polyps and completely unobstructed nasal compartments (previous endoscopic examinations had revealed that the sinusal mucosa was hyperplastic, with polypoid formations causing obstruction of the ostium-meatus complex). The effi cacy of this agent against nasal obstruction leads to a considerable improvement in quality of life for this type of patient, as nasal polyps are responsible for symptoms of nasal obstruction, excessive nasal secretions or mucopurulent postnasal drip, hyposmia, and anosmia with concomitant alterations in taste, sleep disturbances, headache, and facial pain. Furthermore, better control of rhinitis may facilitate control of asthma symptoms [5]. In conclusion, our observations and the evidence in the literature [3,4] lead us to suggest that, when nasal polyposis and allergic asthma co-occur, anti-IgE therapy could prove effective. Further studies should be performed to better evaluate the effi cacy of this treatment in similar clinical conditions.