Pictorial case study

Contributed by Dr Jean Watkins, a sessional GP in Hampshire

The case
Mrs B was 79. She attended in a panic one afternoon, after a bout of sneezing, with a large mass protruding from her left nostril. She had previously attended with complaints of nasal obstruction, loss of smell and persistent, clear nasal discharge.

A couple of times the discharge had thickened, become purulent and was accompanied by sinus pain. What is the diagnosis, management and differential diagnosis?

Nasal polyps

Diagnosis and management
The diagnosis was nasal polyps. Polyps are uncommon in children and are more likely to develop after middle age. They are more common in those with cystic fibrosis or aspirin hypersensitivity. Fleshy, grey, translucent masses develop in the nasal cavity and obstruct the airway, causing excess rhinorrhoea, snoring and often leading to secondary infection. They do not normally bleed.

Polyps may not be immediately obvious, unless large. Small ones may be missed on anterior rhinoscopy with an otoscope.

If the polyps are small, intranasal corticosteroid sprays may help about half of patients by shrinking and reducing growth. Antihistamines may be beneficial if allergy is a problem, although there is no evidence that this will improve the polyps. The most effective treatment is oral corticosteroids, which help to shrink the polyps, but they are recommended only for short-term use. Antibiotics may be necessary if an infective sinusitis develops.

In more severe or persistent cases, surgery with polypecotomy and/or ethmoidectomy may be recommended.

Possible different diagnoses

  • Allergic rhinitis.
  • Deviated nasal septum.
  • Malignant tumours of the nasal cavity.

Differential diagnosis
Malignant tumours of the nasal cavity:

  • Possibilities include squamous cell carcinoma, adenocarcinoma, sarcoma, lymphoma or metastatic carcinoma.
  • Represent only 3 per cent of head and neck tumours.
  • Present with unilateral nasal obstruction, nasal discharge, epistaxis, facial swelling, pain and headache.
  • Ethmoidal tumours may present with orbital signs such as diploplia or blurred vision.
  • Palpable enlarged lymph glands in the neck usually present later.
  • Beware the patient with unilateral nasal symptoms and epistaxis, and problems that continue despite prolonged treatment.

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

Woman holding face in pain

Should GPs treat patients presenting with dental problems?

The MDU's Dr Kathryn Leask considers what GPs should do if a patient presents with...

Conservative Party leadership candidate and foreign secretary Liz Truss

Liz Truss vows to resolve GP pension tax crisis if she becomes prime minister

Liz Truss has affirmed her commitment to resolving the GP pensions crisis but has...

Baby receiving a vaccine in their thigh

JCVI advises changes to routine childhood and HPV immunisation schedules

The Joint Committee on Vaccination and Immunisation (JCVI) has recommended a change...

GP consultation

General practice delivering 'up to double the appointments it is paid for'

General practice in England may be delivering as many as double the number of appointments...

Sign outside BMA House

GP suicide sparks calls for measures to protect doctors from spiralling workloads

The government and policymakers must do more to safeguard doctors and NHS staff from...

Talking General Practice logo

Podcast: Living with long COVID

In August we’re bringing you some of the best interviews from series one of the podcast....