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.

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