Pictorial case study - Nasal polyps

Dr Jean Watkins discusses the presentation and treatment of this common condition.

Presentation

For some time, this 60-year-old man had been aware of bilateral nasal obstruction and a watery nasal discharge. He had attended the surgery when the blockage seemed worse, the discharge changed to green and he felt unwell, with a fever, headache and facial pain and tenderness. The GP prescribed a broad-spectrum antibiotic to treat the sinusitis.

The patient was asked to return for examination once the infection had cleared, and bilateral yellowish-grey, grape-like nasal polyps were visible with the help of a nasal speculum. He was referred to ENT.

Management

Nasal polyps arise in the mucosa in the nasal cavity or paranasal sinuses. The cause is unknown, but their development seems to be associated with chronic rhinosinusitis and antigens produced by Staphylococcus aureus.

Nasal polyps are usually bilateral, but unilateral symptoms of blockage, discharge or bleeding should raise suspicions of a foreign body in the nose (more likely in children), or a malignancy.

All patients presenting with nasal polyps should be referred to an ENT surgeon.

Medical management involves the short-term use of nasal corticosteroid drops to help to shrink the polyp, but to be effective, these must be administered in the 'head down' position; drops are preferable to sprays.

If mometasone or budesonide nasal drops are used, systemic absorption is minimal and growth in children is not affected. In the case of large polyps, a short course of systemic corticosteroid for five to 10 days may be required. Sometimes, surgical removal may be necessary, but recurrence is common. Other approaches include a saline douche, or if an allergy is involved, an antihistamine. An antibiotic is necessary if an acute bacterial sinusitis develops.

Differential diagnoses

  • Sinusitis - without polyps
  • Foreign body - in children with unilateral bloodstained discharge
  • Cystic fibrosis - should be excluded in children with nasal polyps
  • Malignant tumours - should be suspected with unilateral symptoms

Dr Watkins is a retired GP in Hampshire.

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