AKT · ENT/Nose & sinuses

Nasal polyps

Chronic inflammatory oedematous outgrowths of nasal/sinus mucosa

Overview

Benign, oedematous, pale outgrowths of inflamed nasal/sinus mucosa, part of chronic rhinosinusitis. Bilateral nasal obstruction, reduced smell and rhinorrhoea in adults. UNILATERAL polyps are a red flag; polyps IN A CHILD warrant a cystic fibrosis check.

Recognise

Bilateral nasal obstruction, reduced/absent sense of smell (hyposmia/anosmia), rhinorrhoea, postnasal drip
Pale/grey, insensate, mobile, glistening masses in the nasal cavity (an insensate polyp does not hurt when touched)
Associations: asthma, aspirin sensitivity (Samter triad = asthma + aspirin sensitivity + nasal polyps), chronic rhinosinusitis

Red flags

UNILATERAL polyp, bleeding, or atypical appearance → exclude malignancy/inverted papilloma (ENT, biopsy/imaging); polyps in a CHILD → test for cystic fibrosis

Differentials & how to tell them apart

Inverted papilloma / sinonasal malignancyUNILATERAL, may bleed, atypical — biopsy

Hypertrophied turbinatepink, sensate, does not have the pale mobile polyp appearance

Cystic fibrosis (in a child)polyps in childhood are abnormal — screen for CF

Allergic rhinitismucosal swelling without discrete polyps

Nasal polyp — pale, in the nasal cavity
MathieuMD / CC BY-SA 3.0 — Wikimedia Commons

Investigations

Anterior rhinoscopy/nasal endoscopy. Unilateral/atypical → ENT + imaging (CT) ± biopsy. Child with polyps → sweat test/CF screen.

Management

Intranasal corticosteroid (± a short oral steroid course); ENT/FESS if refractory

1Intranasal corticosteroids first-line; a short course of oral corticosteroid can rapidly shrink large polyps.Gate: UNILATERAL nasal polyps are a red flag for malignancy/inverted papilloma → refer to ENT for endoscopy ± biopsy rather than just treating; and nasal polyps in a CHILD warrant a cystic-fibrosis test
2Refractory or large polyps → functional endoscopic sinus surgery; ongoing topical steroids to prevent recurrence; manage associated asthma/aspirin sensitivity.

Intranasal corticosteroid — first-line — shrinks polyps and improves symptoms

Short course of oral corticosteroid — for large polyps to gain rapid control

Functional endoscopic sinus surgery (FESS) — for refractory/large polyps

Key points

Bilateral, pale, insensate = benign polyps → topical steroid. Unilateral = think tumour. Child = think CF. Aspirin-sensitive asthmatics get them (Samter triad).

Monitor & prognosis

Symptom/smell response; recurrence after surgery.

Respond to steroids but commonly recur.

Source: NICE CKS; ENT UK