HNY Policy and Pathway Repository - York

Benign growth of yellowish, grey, pedunculated tissue in the Polyp nose, mostly from the ethmoid sinuses. The aetiology is not entirely clear, but there is a significantly higher prevalence in asthmatics.

• Unilateral growth
• Unclear aetiology and doubts regarding benign quality
• Associated facial swelling
• Bloody discharge
• Nasal polyps in children (think cystic fibrosis)

General Points

• Nasal polyps can be difficult to manage long-term, because they tend to recur
• Beware of any unusual features (e.g. unilateral growth), which may need a review to exclude possible malignancy
   

Management

• Enquire about allergies (specifically aspirin sensitivity), history of lung disease, asthma, chronic cough or sneezing, smoking, trauma to nose, snoring, sense of smell, post-nasal drip or discharge.
• Establish actions taken by patient so far.
• Examination of external nose (any bulging, asymmetry, skin changes) and internal nose (signs for inflammation, infection, foreign body, perforation) and test both nostrils for degree of obstruction. Polyps typically have a grey, smooth, slightly shiny appearance, are mobile and not tender to touch. Don't confuse septal haematomas after head / nose injury with possible polyps!
• Consider a check for any cervical or facial lymphadenopathy or abnormal findings in the oral cavity.
• Advise patient that a cure may be difficult or impossible, but control can be achieved.
• Topical nasal steroids are and remain the mainstay of treatment. Drop formulations, e.g. betamethasone 0.1% nasal drops, are more concentrated than sprays and therefore not recommended for long-term maintenance, but for e.g. 6 week cycles, followed by topical spray. The intranasal corticosteroids that are available in the UK are equally effective and therefore choice should be based on cost-effectiveness (first line: beclometasone 50mcg spray, second line: budesonide 64mcg spray, third line: fluticasone furoate 27.5mcg spray). Ensure correct application (ask a pharmacist; get a leaflet)
• Advise patients who are paying for prescriptions that several steroid nasal sprays are available over the counter e.g. beclometasone as Beconase® and fluticasone as Flixonase®
• A course of oral prednisolone (20-30mg once daily for up to two weeks) may control severe symptomatic polyposis quickly – but probably only temporarily
• Use of a regular oral (or topical) antihistamine may reduce a possible allergic element – see medal ranking for antihistamines for preferred choices
• Non-medical option to relieve symptoms of post-nasal drip: regular nasal saline douches over the counter. The solution can be easily and cheaply made up by patients by mixing some sodium bicarbonate and a pinch of salt into moderately warm water (more specific measurements can be found online). Ready-made sachets are available but expensive.
• Surgical treatments are possible but potentially risky and not at all guaranteed to be curative

Indications for referral

• Deforming or functionally disabling nasal polyps with no apparent realistic scope of response to topical treatment in primary care.
• Failed topical treatment with betamethasone 0.1% drops for six weeks, followed by nasal spray for another four weeks + additional advice and interventions outlined above.
• Concerns about benign quality of polyps or nasal polyps in children.
• Persistent blood stained nasal discharge.
• Please allow sufficient time for topical treatments to take effect
   

Information to include in referral letter

• Time line, possible triggers and impact on daily function.
• Exclusion of suspicious features.
• Allergy and smoking history; Aspirin sensitivity; PMH asthma.
• Medical and non-medical treatments attempted so far.
• Patient’s understanding and expectation of possible options available to the specialist.
   

Investigations prior to referral

• usually none needed

Patient information leaflets/ PDAs

http://www.nhs.uk/conditions/polyps-nose/Pages/Introduction.aspx

http://www.patient.info/health/nasal-polyps-leaflet
 

References

• Kalish L, Snidvongs K, Sivasubramaniam R, Cope D, Harvey RJ. Topical steroids for nasal polyps. Cochrane Database Syst Rev. 2012 Dec 12;12:CD006549.
• NICE CKS Corticosteroids – topical (skin), nose and eyes