ENT

Nasal Polyps

Nasal polyps are soft oedematous inflammatory growths that usually occur bilaterally and cause nasal obstruction and reduced smell; a unilateral or bloody/atypical mass is a different problem until ENT assessment excludes tumour or another local lesion.

In a nutshell

Nasal polyps are usually bilateral, pale, painless inflammatory growths causing nasal obstruction and reduced smell. First-line treatment is regular intranasal corticosteroid with correct technique and saline irrigation. Unilateral, bloody, painful or visually invasive disease needs ENT assessment to exclude tumour or another lesion. Surgery is for persistent troublesome disease and does not cure the inflammatory tendency; NICE TA1134 now provides a specialist dupilumab pathway for selected adults with severe uncontrolled disease after surgery or systemic steroids.

Classic presentation

An adult with asthma has months of bilateral nasal obstruction and anosmia, with pale smooth polyps visible in both nasal cavities.

Key points

Typical inflammatory polyps are bilateral, pale, soft, mobile and painless.
Nasal obstruction and reduced smell/taste are the cardinal symptoms.
Intranasal corticosteroids and saline irrigation are first-line; correct technique and regular use matter.
A unilateral or bloody/painful mass is a red flag for a localised lesion or malignancy and needs ENT assessment.
Surgery removes obstructing tissue but does not cure the underlying inflammation; topical steroids usually continue afterward.
NICE TA1134 gives specialist dupilumab eligibility criteria for severe uncontrolled chronic rhinosinusitis with nasal polyps in adults.

First-line investigation

Nasal examination to confirm the appearance and establish laterality, with ENT endoscopy and CT when diagnosis is uncertain, disease is unilateral/atypical or surgery is being planned.

Management

Treat typical bilateral inflammatory disease

Use regular intranasal corticosteroid with correct technique and saline irrigation; review adherence, response and adverse effects using BNF/local formulary guidance.^1,4,5

Refer unilateral or complicated masses

Unilateral, bloody, painful, rapidly progressive or orbital/neurologically complicated disease needs urgent ENT assessment and specialist imaging/biopsy planning.^4,3

Use short systemic steroid courses selectively

A short oral corticosteroid course may be considered for severe symptoms under clinician supervision, but repeated courses should prompt ENT review and steroid-risk assessment.^1,5

Offer surgery for persistent troublesome disease

ENT may offer endoscopic sinus surgery/polypectomy after adequate medical treatment; explain that it improves obstruction and topical access but does not cure the inflammatory tendency.^1,3

Consider NICE's specialist biologic pathway

Dupilumab may be used with intranasal corticosteroids for selected adults with severe uncontrolled disease after systemic steroids or surgery, at least one sinus operation, SNOT-22 at least 50 and the relevant commercial arrangement.²

Prevent recurrence and manage comorbidity

Continue specialist-directed intranasal corticosteroid after surgery, optimise associated asthma and review new bleeding, unilateral symptoms, pain, visual change or rapid recurrence.^1,3,4

Exam traps

A unilateral nasal mass is not assumed to be simple polyposis.
Do not biopsy a possible congenital skull-base lesion before specialist imaging.
Oral steroids may shrink severe polyps but repeated systemic courses carry harm and need review.
Polypectomy is not curative; recurrence prevention needs ongoing topical anti-inflammatory treatment.
Dupilumab is a specialist NICE pathway for selected severe disease, not routine first-line treatment.

Illustrations

Middle-meatus nasal polyp on endoscopyAn endoscopic view showing a large pale, glistening nasal polyp arising from the middle meatus and prolapsing into the nasal cavity.Mustafakapadiya, Wikimedia Commons · CC-BY-SA-4.0

Endoscopic view of a nasal polyp filling the nasal cavityA coronal CT of the sinuses showing polypoid mucosal opacification of the nasal cavity and paranasal sinuses.Michael Hawke MD, Wikimedia Commons · CC-BY-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.