Nasal Polyps: Clinical Features, Diagnosis and Management
Nasal polyps are benign, soft, oedematous protrusions of inflamed sinonasal mucosa. They are commonly bilateral and associated with chronic rhinosinusitis, asthma and sensitivity to aspirin or other NSAIDs.
A unilateral, irregular, painful or bleeding nasal mass is not assumed to be a simple inflammatory polyp; it requires specialist assessment and often imaging or biopsy.
Learning objectives
- Describe the appearance and associations of nasal polyps.
- Differentiate polyps from turbinates and neoplasms.
- Outline examination, imaging, medical therapy and surgery.
Pathology and associations
Persistent mucosal inflammation causes oedema and polyp formation, often around the middle meatus and ethmoid sinuses. Common associations include chronic rhinosinusitis, asthma, allergic disease and NSAID-exacerbated respiratory disease. In children, consider cystic fibrosis or another systemic disorder where appropriate.
Review nasal anatomy and sinusitis.
Clinical features
- Progressive bilateral nasal obstruction and mouth breathing.
- Reduced or absent smell with impaired flavour.
- Watery or mucopurulent rhinorrhoea and post-nasal drip.
- Facial pressure, snoring, sleep disturbance or recurrent sinus symptoms.
Examination appearance
| Feature | Inflammatory polyp | Inferior turbinate |
|---|---|---|
| Colour | Pale grey or translucent | Pink or red mucosa |
| Sensation | Insensitive to gentle touch | Sensitive |
| Consistency | Soft, mobile, gelatinous | Firm, fixed to lateral wall |
| Bleeding | Usually does not bleed easily | May bleed with trauma |
Anterior rhinoscopy may reveal large polyps, but nasal endoscopy gives a better assessment of origin and extent.
Diagnosis and investigations
- Ask about duration, laterality, smell loss, asthma, NSAID reactions, previous surgery and treatment response.
- Perform complete ENT and respiratory examination.
- Nasal endoscopy confirms polyps and checks for purulence or atypical lesions.
- CT of the paranasal sinuses defines disease extent when treatment fails or surgery is planned.
- Allergy assessment may be useful when symptoms suggest allergy.
- Biopsy is considered for unilateral, atypical, ulcerated, firm or bleeding tissue.
See ENT investigations.
Differential diagnosis and red flags
| Alternative | Clues |
|---|---|
| Hypertrophied turbinate | Sensitive, vascular and continuous with the lateral wall. |
| Antrochoanal polyp | Usually unilateral, from maxillary sinus and extends posteriorly. |
| Inverted papilloma | Unilateral lobulated mass, possible bleeding and recurrence. |
| Malignancy | Pain, epistaxis, facial swelling, numbness, eye or cranial signs. |
| Encephalocele | Superior mass, possible CSF leak; biopsy is dangerous. |
Unilateral bloody discharge, recurrent epistaxis, facial deformity, severe pain, orbital symptoms, neurological signs or a rapidly growing mass requires urgent ENT assessment.
Management
Medical treatment
- Regular intranasal corticosteroid spray or drops is first-line therapy.
- Saline irrigation improves secretion clearance and delivery of topical medicine.
- Manage associated asthma and allergic rhinitis.
- A short course of systemic corticosteroid may be used by an appropriate clinician for severe disease after risks are assessed.
- Antibiotics are reserved for suspected bacterial exacerbation, guided by current protocols.
Teach spray technique and adherence. Direct the nozzle away from the septum and use treatment consistently; improvement may take several weeks.
Surgery
Functional endoscopic sinus surgery is considered when adequate medical therapy fails, obstruction is severe, complications occur or tissue diagnosis is required. Surgery restores ventilation and access for topical therapy but does not cure the inflammatory tendency, so recurrence can occur.
Advanced therapy
Specialists may consider biologic medicines for selected severe chronic rhinosinusitis with polyps when standard therapy and surgery are inadequate or unsuitable.
Complications and follow-up
- Chronic loss of smell and reduced quality of life.
- Recurrent infection and sleep disturbance.
- Orbital or intracranial complications from associated sinusitis are uncommon but serious.
- Postoperative recurrence, bleeding, adhesions or infection.
Key examination points
- Simple inflammatory polyps are pale, smooth, soft and usually bilateral.
- They commonly accompany chronic rhinosinusitis and asthma.
- Intranasal corticosteroids and saline are first-line therapy.
- CT is useful for resistant disease and surgical planning.
- Unilateral or bleeding masses must be investigated for alternative pathology.
References and further reading
- MSD Manual Professional: Nasal Polyps.
- MSD Manual Professional: Evaluation of nasal and pharyngeal symptoms.
For education only. Apply current Uganda Clinical Guidelines, local protocols and specialist advice.
