Nasal Polyps

What Are Nasal Polyps? Anatomy and Basic Definition

A nasal polyp is a benign, pendulous and translucent–gelatinous tissue growth that develops on the mucosal lining of the nose and sinuses against a background of long-standing inflammation. It typically looks like a grape or a peeled grape; it may occur singly or in clusters.

Polyps are usually bilateral and most often originate from the middle meatus, the region where the sinus openings drain. Unilateral polyps, on the other hand, always require special attention, because they may be confused with different diagnoses such as inverted papilloma and invariably require histopathological examination.

Structurally, a polyp consists of oedematous stroma, numerous eosinophils and loose connective tissue. In other words, it is not a “tumour” but a persistent form of swelling that chronic inflammation creates in the mucosa. For this reason, removing the polyp alone is often not enough — the underlying inflammatory process must also be managed.

When Are Polyps Suspected?

An ENT specialist will include nasal polyps in the differential diagnosis in the following situations:

• Bilateral nasal obstruction lasting for months
• Marked and progressive loss of smell (hyposmia/anosmia)
• A reduced sense of taste
• Frequently recurring or treatment-resistant chronic sinusitis
• Asthma — particularly adult-onset asthma
• Aspirin / NSAID (painkiller) sensitivity (Samter’s triad: asthma + polyps + aspirin intolerance)
• Children diagnosed with cystic fibrosis
• Recurrent obstruction after previous sinus surgery

The presence of polyps is generally classified as a subgroup of chronic rhinosinusitis (CRSwNP – chronic rhinosinusitis with nasal polyps). Evaluation is therefore directed not only at the polyp but at the entire upper airway ecosystem.

Symptoms and Causes

Typical symptoms

Because polyps grow slowly, patients often cannot clearly remember when their complaints began. The most common include:

• Persistent nasal obstruction (bilateral) that does not resolve with sprays
• Inability to smell or perceiving odours very faintly
• Finding that food tastes less flavourful
• Postnasal drip, constant throat clearing
• Fullness in the face and forehead, headache
• Sleeping with the mouth open at night, snoring
• Nasal-sounding speech (rhinolalia)
• Sometimes a sensation of a mass / hanging tissue in the nose

Underlying causes

Nasal polyps do not have a single cause; chronic mucosal inflammation is the common denominator. The main triggers are:

• An underlying chronic rhinosinusitis
• Asthma and eosinophilic airway diseases
• Allergic fungal sinusitis
• Aspirin/NSAID intolerance (Samter’s triad)
• Cystic fibrosis (this should always be screened for if bilateral polyps are seen, particularly in the paediatric age group)
• Immune system disorders
• Environmental irritants: tobacco smoke, occupational chemicals, chronic air pollution
• Genetic predisposition

An important note: allergy is not as dominant a cause of polyp formation as is often assumed. Many patients with polyps have a negative allergy test. The process is more an eosinophilic–inflammatory one.

The Diagnostic Process

Diagnosing nasal polyps is a stepwise process ranging from a simple examination to advanced imaging.

1. History. The duration of obstruction, loss of smell, asthma, aspirin reactions, previous sinus operations, smoking history and family history are questioned in detail.
2. Anterior rhinoscopy. The initial examination performed with a speculum; large polyps may be visible even at this stage.
3. Nasal endoscopy. This is the most valuable tool for making a definitive diagnosis. A thin endoscope provides a clear view of the middle meatus, sinus openings and nasopharynx; the location and size of the polyp, and whether it is unilateral or bilateral, are determined.
4. Paranasal sinus CT scan. This shows how much of the sinuses is filled, the bony anatomy and anatomical variations, and provides the map needed for surgical planning. A surgical decision is not made without a CT scan.
5. Smell test. Applied if an objective assessment of hyposmia/anosmia is needed.
6. Allergy testing, eosinophil count, IgE level. To identify systemic triggers.
7. Histopathology. Tissue removed during surgery is always sent for pathology; ruling out malignant / atypical pathology is essential, especially in unilateral or bleeding polyps.

Treatment Approaches

Treating nasal polyps is not a process that ends in a single step but one that requires long-term management. The aim is to shrink the polyps, control symptoms and delay recurrence.

1. Medical (conservative) treatment

Intranasal corticosteroid sprays (mometasone, fluticasone, budesonide, etc.) are the mainstay of treatment. Regular, daily and long-term use is essential; if stopped after a week or two, the effect disappears. Correct spray technique (tilting the head slightly forward, aiming towards the opposite side) significantly increases effectiveness.

Systemic corticosteroid (oral) courses are used short-term for large polyps, in situations where loss of smell needs to be corrected quickly, or in preparation before surgery. Chronic use is not recommended because of its side effects.

Saline rinses (hypertonic or isotonic) increase mucus clearance, reduce crusting and enhance the effect of the spray.

Antihistamines are added only if there is an accompanying allergic component.

Antibiotics have no place in routine polyp treatment; they are used short-term only during acute bacterial sinusitis flare-ups. In some resistant cases, low-dose long-term macrolide treatment may be tried in selected patients.

Biologic therapies (anti-IL-4, anti-IL-5, anti-IgE). These are targeted antibody treatments that have come into use in recent years for recurrent, resistant polyp cases. In cases with accompanying asthma that recur despite surgery, they are planned through joint assessment by respiratory medicine and ENT.

2. Surgical treatment: FESS (Functional Endoscopic Sinus Surgery)

For polyp clusters that do not respond adequately to medication and that seriously affect vision or breathing, the gold standard is FESS. Under endoscopic guidance, without any external incision, the polyps and blocked sinus openings are cleared through the nostrils.

Advantages:

• No externally visible incision
• Healthy sinus mucosa is preserved (only diseased tissue is removed)
• The sinus drainage pathways are opened
• Pain is minimal and recovery is rapid
• Afterwards, spray treatments reach the sinuses much more effectively

When required, septoplasty, turbinate reduction and ethmoidectomy are performed together in the same session.

3. Post-surgical maintenance treatment

The most critical issue with polyps is preventing recurrence. Steroid spray and saline rinse treatment is started from the first day after surgery and continued for months to years. Any accompanying asthma, allergy or aspirin intolerance is treated in parallel. Otherwise, recurrence of the polyps within 2–5 years is a common occurrence.

The Process and Recovery (After Surgery)

Recovery after FESS is considerably more comfortable than after classic open nasal surgery. The typical course:

• First 24 hours: Discharge the same day or after one night’s stay. If packing is used, dissolvable types are preferred.
• Days 1–7: Light bloody discharge, postnasal drip and crusting are normal. Saline rinses are started early.
• Week 2: Endoscopic check-up; accumulated crusts are gently cleared. This check is the most critical step for a good outcome.
• Weeks 3–6: The mucosa heals and the sense of smell gradually returns. Obstruction usually eases during this period.

Practical rules for the patient:

• The nose is kept clean without blowing or sniffing inwards.
• Strenuous exercise, working while bent over, long flights and saunas are restricted for the first 2 weeks.
• Tobacco smoke must be strictly avoided.
• Steroid spray and saline rinses are continued without interruption, as advised by the physician.
• Endoscopic check-ups (weeks 1, 4 and 12) must not be skipped.

Quality of Life and Long-Term Follow-Up

The change most commonly reported by patients whose polyps are managed is the return of the sense of smell. This directly affects quality of life, from being able to taste food again to noticing hazards such as gas or chemical odours. Other gains include:

• A free nose and uninterrupted sleep
• Fewer headaches and less facial fullness
• A reduction in sinusitis attacks
• Better concentration and daytime energy

It is important to be realistic about long-term follow-up: chronic rhinosinusitis with polyps is a chronic disease. Surgery or medication does not eliminate it completely, but keeps it under control. For this reason:

• Annual (or at the interval recommended by the physician) endoscopic check-ups are planned.
• If there is asthma, allergy or aspirin intolerance, joint follow-up is carried out with the relevant specialties.
• Spray treatment should become a daily habit, like routine tooth brushing.

Nasal Polyps in Children: An Important Warning

In the paediatric age group, bilateral nasal polyps are rare and are a finding that must always be taken seriously. The most important differential diagnosis is cystic fibrosis (CF); for this reason, when a polyp is detected in a child, screening for CF should be carried out with a sweat test or the necessary genetic investigation.

A unilateral nasal mass in children, on the other hand, is often not a polyp: endoscopic examination and imaging are needed to distinguish different pathologies such as an antenatal lesion or nasoangiofibroma. For this reason, the term “polyp-like swelling” in paediatric patients always warrants further investigation; the routine adult approach is not applied directly to children.

Common Misconceptions in Polyp Treatment

Some beliefs frequently heard in the clinic that need to be corrected:

• “Polyps are cancer.” Nasal polyps are benign, not cancer. However, unilateral, bleeding or rapidly growing lesions raise the possibility of different diagnoses, and pathological examination is essential.
• “I used the spray for 2 weeks and it had no effect.” Steroid sprays show their effect with regular use over weeks; a few days’ trial will not produce a result.
• “If I have surgery the polyps will never come back.” Chronic rhinosinusitis with polyps is a chronic disease; surgery alone is not a permanent solution. Maintenance spray + rinses must be continued without interruption.
• “If I take antibiotics the polyps will go away.” Antibiotics do not shrink polyps; they are used only in acute bacterial flare-ups for specific indications.
• “Polyps are always caused by allergy.” Allergy may play a role but is not the only cause; eosinophilic inflammation, asthma and aspirin intolerance are dominant in most cases.
• “I will never get my sense of smell back.” With the right treatment process, the sense of smell gradually improves in most patients; however, in those who have been obstructed for a very long time the gain may be more limited.

Frequently Confused Conditions

• Turbinate hypertrophy: An enlarged inferior turbinate may resemble a polyp on anterior rhinoscopy. Endoscopic examination clarifies the distinction; a decongestant test also helps (the turbinate shrinks, the polyp does not).
• Inverted papilloma: Often unilateral and similar in appearance to a polyp, but it is a different tumour requiring more aggressive monitoring. A unilateral polyp-like appearance is always handled with care, and histopathology is essential.
• Antrochoanal polyp: A special type of unilateral polyp that originates from the maxillary sinus and extends towards the nasopharynx. Its treatment is endoscopic surgery.
• Tumoral masses: If there is accompanying unilateral bloody discharge, progressive unilateral obstruction or facial swelling, different diagnoses should be considered and evaluation should be carried out promptly.

When Should You See an ENT Specialist?

If any of the following situations is present, you should consult an ENT specialist for a polyp assessment:

• Nasal obstruction lasting longer than 12 weeks
• Progressive, unexplained loss of smell
• Frequently recurring sinusitis attacks that do not respond to antibiotics
• Nasal obstruction together with a history of asthma or an aspirin reaction
• The return of complaints after previous sinus surgery
• A sensation of a mass in the nose, unilateral obstruction or bloody discharge (prompt evaluation)
• Bilateral nasal polyps in a child (important for cystic fibrosis screening)

When recognised at the right time, nasal polyps are a condition that can be kept under long-term control with medication and relieved with endoscopic surgery when necessary. The important thing is to accept that it is a chronic disease and to remain committed to regular follow-up and maintenance treatment.