Endgames Picture Quiz

A man with a blocked nose

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7567 (Published 16 November 2012) Cite this as: BMJ 2012;345:e7567
  1. O Mulla, specialist registrar, ENT surgery,
  2. N Charaklias, specialist registrar, ENT surgery,
  3. P A Nix, consultant, ENT surgery
  1. 1Ear, Nose, and Throat Department, Leeds General Infirmary, Leeds LS1 3EX, UK
  1. Correspondence to: O Mulla omarmulla22{at}gmail.com

A 40 year old man presented with an 11 year history of nasal blockage and anosmia. He reported that he often had “something” prolapsing from his nose. His medical history included hay fever. He took no regular drugs and had aspirin intolerance. On examination there was a glistening fleshy structure within his left nostril (figure). He had similar masses of the same appearance, consistency, and structure in his right nostril, although they were much smaller.

Questions

  • 1 What is the differential diagnosis of a blocked nose?

  • 2 What does the photograph show?

  • 3 How would you investigate further?

  • 4 What treatment would you recommend?

  • 5 When should patients be referred to specialist care?

Answers

1 What is the differential diagnosis of a blocked nose?

Short answer

A blocked nose can be secondary to the common cold, influenza virus, allergy, rhinosinusitis, nasal polyp, deviated septum, tumour (benign or malignant), septal haematoma, persisting adenoid pad, and rhinitis medicamentosa.

Long answer

Within the medical literature, nasal blockage is used for both nasal obstruction and nasal congestion. In most consultations, patients use it to refer to the process of nasal congestion—when the lining of the nasal passage becomes inflamed. When taking a history, it is important to establish whether this is an acute (less than 12 weeks) or chronic (greater than 12 weeks) problem. It is also important to establish whether symptoms are unilateral or bilateral because this will make the diagnostic process simpler.

The most common acute causes are common cold, influenza virus, intermittent allergic rhinitis, and acute rhinosinusitis.

Chronic allergic rhinitis, chronic rhinosinusitis (with or without nasal polyps), nasal deviation, turbinate hypertrophy, rhinitis medicamentosa, tumours, and adenoid hypertrophy in children are all chronic causes of a blocked nose.

Any allergic reaction can lead to nasal congestion as part of the inflammatory response; however, allergic rhinitis (allergy to dust, pollen, or mites) is commonly associated with nasal congestion. Patients with rhinosinusitis often have nasal blockage because the nasal mucosa becomes increasingly inflamed and oedematous. With increasing oedema of the nasal mucosa, nasal polyps can form, and among other symptoms they too present with nasal obstruction. Allergic rhinitis may also lead to turbinate hypertrophy, which can be seen on inspecting the nasal cavity.

Unilateral nasal obstruction can be caused by a deviated nasal septum. The nasal mucosa is not inflamed or oedematous as in the above conditions, but structural deviation leads to poor or non-existent airflow and nasal blockage. Tumours of the nasal mucosa present with unilateral nasal obstruction secondary to limited airflow beyond the tumour.

Rhinitis medicamentosa is a condition of rebound nasal congestion secondary to extended use of topical decongestants.

Nasopharyngeal space tissue, such as an enlarged adenoid pad (in children) and nasopharyngeal tumours, can also present with bilateral nasal obstruction.

2 What does the photograph show?

Short answer

The photograph shows a gross mass within the left nostril consistent with gross nasal polyps.

Long answer

Nasal polyps consist of oedematous sinonasal mucosa that prolapses into the nasal cavity. They are a common benign inflammation of nasal sinus mucosa. Problematic nasal polyps are seen in about 4% of the adult population; however, cadaveric studies have identified nasal polyps in 40-60% of people.1 2

Although the definitive cause of nasal polyps is unknown, the development of polyps has been linked to chronic inflammation, autonomic nervous system dysfunction, and genetic predisposition.

The symptoms are usually slowly progressive and result from chronic rhinosinusitis, although they may come on rapidly after an acute infection. The main problem is usually nasal obstruction, but patients may also have hyposmia or anosmia, postnasal drip, rhinorrhoea, and rarely a change in facial shape and pain. Simple nasal polyps are usually insensate and mobile, whereas malignant ones tend to be solid and haemorrhagic.

Samter’s triad must be considered in this case because the patient had aspirin intolerance. Samter’s triad consists of aspirin intolerance (aspirin exacerbated respiratory disease), asthma, and nasal polyposis.3 These patients have more aggressive polyps and often have recurrence after medical treatment or surgery.

Unilateral polyps or an isolated nasal polyp should be considered malignant until proved otherwise.4 A unilateral nasal polyp could be an antrochoanal polyp, a benign massive polyp, or any other benign or malignant polyp (such as encephaloceles, haemangioma, papilloma, juvenile nasopharyngeal angiofibroma, rhabdomyosarcoma, lymphoma, or inverting papilloma).

3 How would you investigate further?

Short answer

Often no investigations are performed, but if an allergic component is suspected then allergy tests may be performed. Other specialist tests include measurement of the erythrocyte sedimentation rate, antineutrophil cytoplasmic antibody testing, angiotensin converting enzyme measurement, mucociliary clearance testing, and computed tomography of the paranasal sinuses.

Long answer

Investigations are rarely performed in primary care because of limited access. Therefore a good history and examination are essential, along with focused questions or a questionnaire. Ask about allergy and other common comorbidities, such as aspirin intolerance, and airways diseases, such as bronchiectasis, asthma, and chronic obstructive pulmonary disease.

It is also useful to ask patients to score their rhinosinusitis on a visual analogue scale (VAS; score 0-10). The score can help guide initial treatment and enable evaluation of the response to treatment (box 1).3

Box 1 VAS scores for rhinosinusitis, as categorised by European guidelines3

  • Score 0-3: Mild

  • Score 4-7: Moderate

  • Score 7-10: Severe

Once the patient is referred to specialist care several tests may be carried out1 3 5:

  • Allergy testing (skin prick, paper radioimmunosorbent test (PRIST), and radioallergosorbent test (RAST)) is often performed to exclude an allergic element3

  • Nasal endoscopy, lung function tests, and aspirin provocation tests (to obtain an underlying diagnosis)

  • Erythrocyte sedimentation rate and antineutrophil cytoplasmic antibody values can confirm or exclude granulomatous disease

  • Immunoglobulin values can be helpful6

  • A computed tomogram of the paranasal sinuses will help to determine the extent of disease and is needed for planning any possible surgery.3

If any of these tests are available in primary care it is helpful to complete them before specialist referral because this can save time and ensure that the patient is managed more appropriately and quickly.

4 What treatment would you recommend?

Short answer

Generalised polyps should be treated medically in the first instance. A course of corticosteroids should be given for polyps of this size and nature.

Long answer

Chronic rhinosinusitis with nasal polyposis should be managed medically in the first instance.1 3

Management should be stepwise depending on how blocked the nose is and on the VAS score (box 2):

  • Topical steroid spray

  • If this is not sufficient, add topical steroid drops

  • If the nose is still blocked, add oral steroids

  • If the above approach does not work, surgery will be needed.2

Box 2 Suggested treatment regimen based on the VAS score36789

  • Mild symptoms (score 0-3): Topical steroid nasal spray only and review at three months. If improved, continue spray; if no improvement, refer

  • Moderate symptoms (4-7): Topical steroid nasal drops—for example, betamethasone, two drops right and left twice daily for three months and then review. If there is no improvement then a short course (two to four weeks) of oral steroids can be added. If this is still not helpful then surgery should be considered and intranasal steroids should be restarted two to four weeks after surgery

  • Severe symptoms (7-10): A short course of oral steroids should be trialled and then reviewed at one month. If there is improvement then steroid drops can be given for three months, with a view to steroid spray three months later. However, if no improvement is seen then surgery is recommended

The most recent Cochrane review concluded that a short course (maximum two to four weeks) of oral steroids is beneficial and has no serious side effects. This should reduce polyp size and allow further assessment and application of topical steroids.7

Corticosteroids exert their anti-inflammatory effect by acting on specific receptors present in all human cell types, including polyp tissue. Certain patients, including many who are sensitive or intolerant to aspirin, may develop resistance to steroids.8 9

Antihistamines should also be prescribed if allergy testing is positive or if patients have a strong clinical history of allergy. Surgical polypectomy, with or without functional endoscopic sinus surgery (according to individual surgeon’s preference), is advocated for patients who do not respond to medical management or for those with extremely large polyps. However, patients should be warned of recurrence.2

5 When should patients be referred to specialist care?

Short answer

Specialist care should be considered when medical treatment is unsuccessful or if there is doubt about the cause of the polyps.

Long answer

A routine referral should be made for patients whose nasal polyps do not respond to simple medical treatment and when further investigations, such as nasal endoscopy or allergy tests, are necessary.

Urgent referral is indicated if polyps are unilateral, haemorrhagic, or painful and in the presence of cacosmia (patients imagining a constant foul smell) or orbital signs. Children should also be referred urgently.1 4 7

Patient outcome

The patient was treated with oral and topical steroids according to the suggested pathway above. Because he showed no real improvement, surgery (nasal polypectomy) was performed. He is currently well but thinks that his polyps may be returning. This aggressive recurrence indicates that he has Samter’s triad.

Notes

Cite this as: BMJ 2012;345:e7567

Footnotes

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent obtained.

References