Nasal Polyps

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credits: Sourced from the website Patient UK, authored by Dr Louise Newson, reviewed by Dr Helen Huins (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

Overview

Nasal polyps are fleshy, non-cancerous (benign) swellings that grow inside the nose or sinuses. The most common symptoms they cause are a stuffy, runny nose. Steroid nasal drops are commonly used to shrink the polyps. Surgical removal of polyps is sometimes needed. Nasal polyps often return after treatment, so steroid nasal sprays can be used daily to prevent recurrence.

What are nasal polyps?

Nasal polyps are soft fleshy swellings that grow inside your nose. They may be yellowish, grey or pink in colour. They are common and non-cancerous (benign). Nasal polyps can vary greatly in size. There may be only one but sometimes several grow like a small bunch of grapes on a stem.

Causes

What causes nasal polyps?

In most cases the cause is not known. It is thought that ongoing (chronic) inflammation in your nose causes swelling (oedema) of the lining of your nostril. Due to gravity, this swelling hangs down (dependent oedema), forming the polyp. Polyps usually affect both nostrils and can gradually enlarge, blocking your nose.

Polyps can also grow in your sinuses. Your sinuses are air-filled spaces in your skull which drain into your nose. The biggest sinuses are called the maxillary sinuses. They are found under your eyes, behind your cheeks. The lining of your sinuses is the same as the lining of your nose, so this is why polyps can also form in your sinuses.

The medical name for the inflammation of your nose and sinuses is rhinosinusitis. Often the cause is unknown but it can be due, in part, to infection. Nasal polyps can be a part of this condition.

Certain conditions make nasal inflammation and polyps more likely. These include asthma, an allergy to aspirin, cystic fibrosis and some rare conditions of the nose (such as allergic fungal sinusitis and Churg-Strauss syndrome).

Who develops nasal polyps?

Around 4 in 100 people will develop nasal polyps at some stage in their lives. Nasal polyps can affect anyone but most cases occur in people over the age of 40 years. They are twice as common in men as in women. Nasal polyps are uncommon in children. A child with nasal polyps should also be checked for cystic fibrosis, as cystic fibrosis is a risk factor for developing nasal polyps. (About 1 in 2 people with cystic fibrosis have nasal polyps).

Symptoms

What are the symptoms of nasal polyps?

Initially you might think you have a cold. This is because a blocked or runny nose is a common symptom in viral infections like colds. Colds usually only last 2-14 days and the symptoms improve on their own. If you have nasal polyps, the symptoms will not get better without treatment.

• The main symptom is a blocked feeling in your nose. You may find it difficult to breathe through your nose. You may then have to breathe through your mouth for much of the time. This is especially troublesome at night and your sleep may be affected.
• Watering from the nose (rhinorrhoea) is common.
• A postnasal drip may occur. This is the sensation of something continually running down the back of your throat. It is due to mucus coming from the back of the nose because of large polyps.
• Your sense of smell and taste may be dulled or lost.
• A blocked nose may make your voice sound different.
• Larger polyps may cause headaches and snoring.
• Sometimes polyps block the drainage channel of the sinuses into the nose. This can make you more prone to infection of the sinuses (sinusitis).
• Large polyps sometimes interfere with breathing at night and cause obstructive sleep apnoea. 
• Very large untreated polyps can make your nose and front of your face enlarge. This is rare. In extremely rare cases, double vision can occur. This is due to huge polyps changing the structure of the face and pressing on the nerves that send vision signals from the eyes to the brain. 

Diagnosis

Do I need any tests?

Your GP might suspect that you have nasal polyps from your symptoms. A GP can examine the lower part of the nostrils, so might be able to see a large polyp. It is usual for you to be referred to an ear nose and throat (ENT) surgeon the first time you have symptoms of nasal polyps.

An ENT surgeon can usually diagnose nasal polyps based on your symptoms and on examination of your nose (and perhaps your sinuses).

Large polyps may be easily visible through your nostrils. Smaller polyps and polyps in the sinuses are not visible via the nostrils. In such cases, the ENT specialist will pass a small flexible telescope with a camera on it (an endoscope) into your nose. This procedure is called nasendoscopy. It allows the extent and location of the polyps to be assessed.

Occasionally a CT scan or an MRI scan may be needed. These scans may show more detail about where the polyps are and what effects they might have had on other parts of the face, sinuses and skull.

Note: nasal polyps in one nostril only (unilateral) are unusual. In some cases they might be a sign of cancer (malignancy). They should be examined by an ENT surgeon to rule this out. Bloody discharge from one nostril is also a potentially worrying symptom. It can happen due to infection, nose picking or incorrect use of nasal sprays, all of which are generally harmless. However, if you have a bloody discharge from one side of the nose, you should see your GP, as in rare cases it can be another sign of tumour.

Treatment

What are the treatments for nasal polyps?

Everyone with nasal polyps should try treatment with medicines, before considering surgery (unless there is any doubt about whether there is a more serious problem, such as tumour).

Medicines for nasal polyps might be topical (for example, drops and sprays), or tablets.

Steroid nose drops

Steroid nose drops are the usual first-line treatment for nasal polyps.

Nose drops that contain steroid medicines reduce inflammation in the nose. Gradually, nasal stuffiness reduces and the polyps shrink. Drops may take a week or two to make any obvious difference to your symptoms. You will probably be advised to use them for at least 4-6 weeks.

It is important to use the drops exactly as prescribed every day for the best chance of success.

Betamethasone or fluticasone are the two steroid nose drops available on prescription only.

To insert the drops you should kneel, or stand and bend fully down and forwards (as if you were about to stand on your head). Stay with your head down for 3-4 minutes after putting in the drops. This will allow the drops to drain fully to the back of your nostrils. If this is difficult, you can put in the drops by lying on a bed with your head falling back off the edge of the bed.

Steroid tablets

Sometimes a course of steroid tablets (prednisolone) is prescribed for a week or so to reduce inflammation in your nose. This often works very well to shrink the polyps. A course of steroid tablets is a short-term solution, as taking steroid tablets long-term can have important side-effects. It should be used in combination with topical nose steroid drops or sprays.

Surgery

An operation may be advised if polyps are large, or if steroid nose drops or tablets have not worked.

• Polypectomy involves removing the polyps with a surgical instrument. It can be done through your nostrils, either with local anaesthetic (awake), or under general anaesthetic. The type of anaesthetic might depend on the number and size of the polyps, where they are and how fit you are for an operation.
• Endoscopic sinus surgery is done with a general anaesthetic. It might be done where the polyps are very large and numerous, or where they are seriously blocking your sinuses. The endoscope allows the surgeon to see into the sinuses with a camera and to do the operation in a place that is difficult to reach with normal surgical instruments.

Keeping polyps away with steroid nose sprays

Some people are prone to repeated nasal polyps. Steroid nasal sprays can be used regularly, long-term, to try to prevent further polyps from developing. Steroid nasal sprays include beclometasone, budesonide, fluticasone, mometasone and triamcinolone. You can buy some of these sprays over the counter (OTC) from pharmacies, without a prescription.

It is best to see a doctor first, to have the correct diagnosis of nasal polyps, before buying medicines and treating yourself.

Regular use of a steroid nasal spray is safe. The amount of steroid in a spray is less than in the drops. Drops are better at clearing polyps if they do come back.

Side-effects of topical steroid medications

These include nasal irritation, sore throat and nosebleeds. About 1 in 10 people using these medications will experience one of these symptoms. Some people are sensitive to a preservative called benzalkonium chloride, found in all all nasal steroid treatments (drops and sprays), except for Flixonase Nasule® and Rhinocort Aqua®. This preservative can cause irritation of the lining of the nose.

Some side-effects are caused by not using the treatments correctly. It is important to follow the instructions carefully.

Patients who have raised pressure in the eye (glaucoma) should be monitored more closely when using steroid nose sprays or drops. This is because of a small chance of increasing the pressure within the eyes - raised intraocular pressure (IOP).

Other treatments

• Nasal decongestants are often bought from pharmacies to clear a blocked nose. They contain ephedrine or xylometazoline. They are not advised for the treatment of nasal polyps. If they are used for nasal blockage due to other causes (a cold or sinusitis, for instance), they should be stopped within 10 days. Prolonged use of these medicines can actually worsen your symptoms on stopping (so-called rebound). In some cases, inflammation of the nose (rhinitis), which also causes stuffiness and running of the nose, can be caused by such treatments (rhinitis medicamentosa). 
• Salt water (saline) nasal douches are a cheap and safe treatment which are sometimes used in combination with other treatments.

About the Author

Dr Louise Newson

BSc (Hons) (Pathology), MB ChB (Hons), MRCP, MRCGP DFFP, FRCGP

Louise qualified from Manchester University in 1994 and is a GP and menopause expert in Solihull, West Midlands. She is an editor for the British Journal of Family Medicine (BJFM). She is an Editor and Reviewer for various e-learning courses and educational modules for the RCGP.  Louise has a keen interest on the menopause and HRT and is one of the directors for the Primary Care Women’s Health Forum.  She runs a menopause clinic in Solihull and is a member of the International Menopause Society and the British Menopause Society. 

Dr Helen Huins

MB BS Lond, DCH, DRCOG, MRCGP, JCPTGP, DFFP

Helen qualified at Guy’s Hospital in 1989 and left London in 1990 to settle in the countryside. She works as a GP partner in a rural dispensing practice and is passionate about family medicine and continuity of care with interests in sport and nutrition. Helen has been a member of the EMIS authoring team since 1995.

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