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Nasal Polyps – Bilateral vs Unilateral:: A PLAB 2 ExamScenario

Updated: Jul 18

🔴 What Are Nasal Polyps?

Nasal polyps are soft, painless, non-cancerous growths that develop on the lining of the nose or sinuses due to chronic inflammation.

They are associated with conditions like:

  • Chronic rhinosinusitis

  • Asthma

  • Aspirin/NSAID sensitivity (Samter's triad)

  • Cystic fibrosis (esp. in younger patients)


🔍 Bilateral vs Unilateral Polyps – Key Differences

Feature

Bilateral Nasal Polyps

Unilateral Nasal Polyp

Commonality

Common

Always suspicious

Likely cause

CRSwNP (chronic rhinosinusitis with nasal polyps)

Inverted papilloma, tumour, fungal infection

Associated with

Asthma, NSAID sensitivity

Malignancy (SCC), inverted papilloma

Referral needed?

Not urgent if no red flags

ENT referral always

GP treatment

Yes – start steroid spray

No treatment – refer first


🔴 Bilateral Nasal Polyps (CRSwNP)


✅ Typical Features

  • Nasal blockage (both sides)

  • Clear or mucoid discharge

  • Loss of smell (anosmia)

  • Often linked with asthma or aspirin sensitivity


💊 Treatment (GP Level)

  • First-line: Intranasal corticosteroids (e.g. mometasone) can be given in primary care.

  • Short course of oral steroids for severe cases

  • ENT referral only if unresponsive to treatment

    • 🔸 When to Refer:

      • If no improvement after 4–8 weeks of regular use

      • If symptoms are severe or worsening

      • If there are red flag symptoms or unilateral findings



🔴 Unilateral Nasal Polyp – Red Flag Consideration

A unilateral polyp in an adult is considered a red flag because of the risk of:

  • Inverted papilloma (HPV-6, HPV-11 related, locally aggressive)

  • Sinonasal tumours (e.g. squamous cell carcinoma, esthesioneuroblastoma)

  • Fungal sinusitis (esp. in immunocompromised)

  • Antrochoanal polyp (benign, especially in children)


❗ Key Red Flag Symptoms to Ask:

  • Epistaxis (nosebleeds) → suggests possible tumour or inverted papilloma

  • Facial pain/swelling → may indicate local invasion

  • Visual changes or proptosis → suggests orbital involvement

  • Cranial nerve involvement (numbness, weakness) → suggests advanced or skull base disease


🚨 When You Are Likely to Find Red Flags:

  • In adults with a unilateral polyp

  • When symptoms are persistent or progressive

  • If there is visible distortion, bleeding, or neurological involvement


🚨 Management:

  • DO NOT treat with steroid spray in primary care

  • Urgent ENT referral for nasoendoscopy ± biopsy


🩺 Investigations


📌 ENT Specialist Investigations:

  • Nasendoscopy (rhinoscopy): Direct visualisation of the polyp

  • CT or MRI scan: To assess extent, bony erosion, or possible tumour invasion

  • Biopsy: If malignancy is suspected


🔍 Differentials to Consider

Condition

Key Clues

CRSwNP

Bilateral, asthma, NSAID-sensitive

Inverted papilloma

Unilateral, adult, HPV-linked, ± bleeding

Sinonasal carcinoma

Pain, bleeding, facial distortion, proptosis

Fungal sinusitis

Unilateral, immunocompromised, foul discharge

Antrochoanal polyp

Benign, unilateral, more common in children


🟡 Safety Netting Advice

"If you notice new symptoms like nosebleeds, facial pain or swelling, vision changes, or numbness, seek urgent medical attention as these may indicate something more serious."


✅ Final Exam Clinchers

  • Bilateral nasal polyps = CRSwNP → GP can treat with nasal steroids

  • Unilateral nasal polyp = RED FLAG → ENT referral ± biopsy

  • Ask for and document epistaxis, facial pain, vision issues

  • Always differentiate benign from sinister causes


📚 References


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