The 45-Year-Old with Unilateral Nasal Obstruction and a 'Polyp'
A 45-year-old man presents with 6 months of progressive right-sided nasal obstruction, blood-stained nasal discharge, and reduced sense of smell. He has no history of allergy or asthma. On examination, a fleshy mass is visible in the right nasal cavity; the left cavity looks normal. He was treated by his GP with a 6-week course of intranasal corticosteroids with no improvement. He is a non-smoker. He asks whether this is 'just a polyp' and whether he can be referred routinely.
1. Why is the 'unilateral polyp' description potentially misleading, and what should you do?
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Unilateral nasal masses must be treated with suspicion. True nasal polyps are usually bilateral and associated with allergy/asthma; a unilateral, fleshy, bleeding mass in an adult is a red flag for a neoplasm (e.g. inverted papilloma, squamous cell carcinoma, adenocarcinoma, olfactory neuroblastoma, or angiofibroma in a younger patient).
Supporting features here:
- Unilateral symptoms.
- Blood-stained discharge.
- Failure to respond to a prolonged course of intranasal steroids (which would usually shrink inflammatory polyps).
- Age 45 (malignancy becomes more likely with age).
Action: This warrants urgent referral (suspected cancer pathway) for specialist assessment with flexible nasendoscopy and imaging (CT/MRI), and biopsy. Do not simply continue medical therapy or reassure.
2. What investigations and initial management would you arrange, and what would you tell the patient about the urgency?
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Investigations:
- Flexible nasendoscopy to characterise the mass and assess the postnasal space.
- CT of the sinuses/face (and MRI if malignancy suspected or to assess extent/intracranial involvement).
- Biopsy under local or general anaesthesia for histology - essential, as imaging alone cannot distinguish benign from malignant.
- Consider staging investigations (e.g. PET-CT, neck imaging) if malignancy confirmed.
Initial management:
- Urgent referral on the suspected head and neck cancer pathway (within the locally agreed timeframe, typically 2 weeks).
- Do not delay with further empirical steroid trials.
- Explain clearly that a one-sided, bleeding nasal mass needs urgent assessment to exclude cancer, while acknowledging that many such masses are benign (e.g. inverted papilloma).
Judgement: The key error to avoid is treating a unilateral bleeding mass as simple rhinosinusitis/polyposis and arranging a routine referral.