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A. Nasal Polyps

Nasal polyps are pale, edematous, mucosally covered masses commonly seen in patients with allergic rhinitis, but compelling evidence argues against a purely allergic pathogenesis. They may result in chronic nasal obstruction and a diminished sense of smell. In patients with nasal polyps and a history of asthma, aspirin should be avoided as it may precipitate a severe episode of bronchospasm, known as triad asthma (Samter triad). Such patients may have an immunologic salicylate sensitivity. The presence of polyps in children should suggest the possibility of cystic fibrosis.

Use of topical intranasal corticosteroids improves the quality of life in patients with nasal polyposis and chronic rhinosinusitis. Initial treatment with topical nasal corticosteroids (see Allergic Rhinitis section for specific drugs) for 1–3 months is usually successful for small polyps and may reduce the need for operation. A short course of oral corticosteroids (eg, prednisone, 6-day course using 21 [5-mg] tablets: 6 tablets [30 mg] on day 1 and tapering by 1 tablet [5 mg] each day) may also be of benefit. When polyps are massive or medical management is unsuccessful, polyps may be removed surgically. In healthy persons, this is a minor outpatient procedure. In recurrent cases or when surgery itself is associated with increased risk (such as in patients with asthma), a more complete procedure, such as ethmoidectomy, may be advisable. In recurrent polyposis, it may be necessary to remove polyps from the ethmoid, sphenoid, and maxillary sinuses to provide longer-lasting relief. Intranasal corticosteroids should be continued following polyp removal to prevent recurrence, and the clinician should consider allergen testing to determine the offending allergen and avoidance measures. Biologic therapies with interleukin-specific blocking antibodies are currently in preclinical and clinical trials and may be a valuable means of controlling nasal mucosal polyps in the future.

Brescia  G  et al. Nasal polyposis pathophysiology: endotype and phenotype open issues. Am J Otolaryngol. 2018 Jul–Aug;39(4):441–4.
[PubMed: 29550078]
Rivero  A  et al. Anti-IgE and anti-IL5 biologic therapy in the treatment of nasal polyposis: a systematic review and meta-analysis. Ann Otol Rhinol Laryngol. 2017 Nov;126(11):739–47.
[PubMed: 28918644]

B. Inverted Papillomas

Inverted papillomas are benign tumors caused by human papillomavirus (HPV) that usually arise on the lateral nasal wall. They present with unilateral nasal obstruction and occasionally hemorrhage. They are often easily seen on anterior rhinoscopy as cauliflower-like growths in or around the middle meatus. Because squamous cell carcinoma is seen in about 10% of inverted or schneiderian papillomas, complete excision is strongly recommended. This usually requires a medial maxillectomy, but in selected cases an endoscopic approach may be possible. Because recurrence rates for inverted papillomas are reported to be as high as 20%, subsequent clinical and radiologic follow-up is imperative. All excised tissue (not just a portion) should be carefully reviewed by the pathologist to ...

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