What are nasal polyps?

Nasal polyps are soft fleshy swellings that grow inside the nose. They may be yellowish, grey or pink in colour. They are common and are not cancerous (that is, they are 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.

What causes nasal polyps?

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

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

Rhinosinusitis is the name for this inflammation of the nose and sinuses. 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 nose 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 gets nasal polyps?

About 1 in 100 people will develop nasal polyps at some stage in their life. Nasal polyps can affect anyone but most cases occur in people over the age of 40 years. They are four times more common in men than 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.)

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 the 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 sinusitis (infection of the sinuses).
• Large polyps sometimes interfere with breathing at night and cause obstructive sleep apnoea. (See separate leaflet called 'Sleep Apnoea' for more information.)
• 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 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.

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 or 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 malignancy (cancer). 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.

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 (Betnesol® drops or Vistamethasone® drops) or fluticasone (Flixonase Nasule®) are the two steroid nasal 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 the head down for 3-4 minutes after putting in the drops. This will allow the drops to drain fully to the back of the 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. (Do not put in nose drops by tilting your head back. The upper surface inside your nose will not be covered by the liquid.)

Steroid tablets

Sometimes a course of steroid tablets (prednisolone) is prescribed for a week or so to reduce inflammation in the 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 nasal steroid drops or sprays.

Until recently, steroid tablets were mainly used when symptoms were very severe, to provide relief before the action of the drops takes over. However, a short course of steroids may become more commonly used as a routine treatment. This is because a recent research study concluded that a two-week course of steroid tablets followed by steroid nose drops for several weeks gave better cure rates than steroid nose drops alone. A two-week course of steroid tablets is unlikely to cause any serious side-effects. (It is long-term use of steroid tablets that causes most serious side-effects.) Perhaps further research may clarify if this should become the usual treatment rather than steroid nose drops alone.

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 the 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 recurring nasal polyps. Steroid nasal sprays can be used regularly, long-term, to try to prevent further polyps from developing. Steroid nasal sprays include beclometasone (Beconase®), budesonide (Rhinocort Aqua®), flunisolide (Syntaris®), fluticasone (Flixonase® or Nasofan®), mometasone (Nasonex®) and triamcinolone (Nasacort®). 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 recur.

Side-effects of topical steroid medications

These include nasal irritation, sore throat and nose bleeds. 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® spray. 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 glaucoma should be monitored more closely when using steroid nasal sprays or drops. This is because of a small chance of increasing the pressure within the eyes - raised intra-ocular pressure (IOP).

Other treatments

• Nasal decongestants are often bought from pharmacies to clear a blocked nose. They contain ephedrine or xylometazoline. Brands include Otrivine® and Otradrops®. 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 rhinitis (inflammation of the nose), which also causes stuffiness and running of the nose, can be caused by such treatments (rhinitis medicamentosa).
• Saline (salt water) nasal douches are not advised specifically for the treatment of nasal polyps. They can, however, be used to treat chronic (long-term) rhinosinusitis (inflammation of nose and sinuses). It is a cheap and safe treatment.

References

• Guidelines for the management of rhinosinusitis and nasal polyposis, British Society for Allergy and Clinical Immunology (2007)
• Vaidyanathan S, Barnes M, Williamson P, et al; Treatment of chronic rhinosinusitis with nasal polyposis with oral steroids Ann Intern Med. 2011 Mar 1;154(5):293-302. [abstract]
• British National Formulary