Nasal Polyps;

Question 1

What is key about the presentation of nasal polyps and referal? [1]

Answer 1

TOM TIP: If you remember one thing about nasal polyps, remember that unilateral polyps are concerning for malignancy and require a specialist referral for assessment.

Question 2

Nasal polyps are associated with which several conditions? [6]

Answer 2

Chronic rhinitis or sinusitis
Asthma
Samter’s triad (nasal polyps, asthma and aspirin intolerance/allergy)
Cystic fibrosis
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

Question 3

Clinical Manifestations of nasal polyps? [+]

Answer 3

Nasal Obstruction: Often the most prominent symptom, patients frequently report a sensation of a blocked nose, typically bilateral.

Hyposmia or Anosmia: Diminished or absent sense of smell is a hallmark feature, largely due to the obstruction of airflow and impairment of olfactory receptor function.

Rhinorrhoea: Patients frequently complain of a runny nose, either clear or mucoid discharge, sometimes exacerbated by certain triggers such as changes in humidity.

Facial Pain or Pressure: Though less common, some patients experience discomfort or a sense of fullness in the facial sinuses, particularly the maxillary and frontal sinuses.

Snoring: Reduced nasal airflow can lead to mouth breathing and snoring, which may further precipitate or exacerbate sleep apnoea in predisposed individuals.

Epistaxis: While not typical, some patients do report nosebleeds, especially when there is co-existing inflammation or infection.

Postnasal Drip: Accumulation of mucous at the back of the nasal cavity can lead to frequent throat clearing, cough, or a sensation of lump in the throat.

Question 4

Complications of nasal polyps? [3]

Answer 4

Chronic Sinusitis:
- Prolonged inflammation can lead to chronic sinus infections, often requiring more aggressive treatment strategies.

Asthma:
- There is a well-recognised association between asthma and nasal polyps, and management often necessitates a multi-disciplinary approach.

Aspirin Sensitivity:
- Some patients with nasal polyps may also exhibit aspirin sensitivity, manifesting as bronchospasm and skin eruptions upon ingestion.

Question 5

How do you differentiate a nasal polyp and an antrochoanal polyp (ACP)? (what is one) [1]

Answer 5

An antrochoanal polyp (ACP), also known as Killian’s polyp, originates in the maxillary sinus and extends into the nasopharynx.
- Unlike nasal polyps, which are typically bilateral, ACPs are usually unilateral.

Question 6

Nasal polyp vs inverted papilloma? [1]

Answer 6

Inverted papilloma is a benign tumour that arises from the lateral nasal wall and paranasal sinuses. In contrast to the smooth appearance of nasal polyps, inverted papillomas are often irregular and lobulated.

Question 7

Describe the management for nasal polyps [+]

Answer 7

Medical management
* Initial management typically involves topical corticosteroids to reduce inflammation.
* Oral corticosteroids may be considered in severe cases or if topical treatment is ineffective.
* Intranasal saline irrigations can aid in symptomatic relief.

Surgical intervention
* Endoscopic sinus surgery (ESS) is the preferred surgical method for removing nasal polyps.
Surgery should be considered if medical therapy fails or in case of complications such as mucoceles or orbital involvement.

Biological therapies
* Newer biological therapies targeting specific inflammatory pathways (e.g., anti-IL5, anti-IL4Rα) may be considered in refractory cases.

Question 8

Surgical management is used where medical treatment fails. This involves removing the polyps.

What are the two types and when do you do each? [2]

Answer 8

Intranasal polypectomy is used where the polyps are visible close to the nostrils

Endoscopic nasal polypectomy is used where the polyps are further in the nose or the sinuses