Bleeding Nasal Polyp

The Critical Message

"Bleeding polyps may indicate malignancy" - Bailey and Love's Short Practice of Surgery, 28th ed.

A nasal polyp that bleeds is not simply a variant of the common inflammatory polyp - it is a red flag that demands investigation. The key clinical principle is: a bleeding, unilateral nasal polyp must be assumed to harbor a sinister pathology until proven otherwise.

Normal Inflammatory Polyp vs. Bleeding Polyp

Typical inflammatory (CRS-associated) nasal polyps have these characteristics:

Bilateral in distribution
Pale, grey, semitransparent in appearance
Mobile and insensitive when probed
Oedematous stroma with eosinophil infiltration
Minimal vascularity - primary surgery polyps are gelatinous with little blood supply (Cummings Otolaryngology)

A polyp that bleeds readily, especially if unilateral, firm, or insensitive to touch, does not fit this picture and raises concern for an underlying lesion.

Differential Diagnosis of a Bleeding Nasal Polyp

1. Inverted (Transitional Cell) Papilloma

Arises from the lateral nasal wall or maxillary sinus (most common benign sinonasal neoplasm after inflammatory polyps)
Presents with unilateral nasal congestion and/or epistaxis
Histologically: hyperplastic epithelium inverts into the underlying stroma
10-15% risk of malignant transformation
CT may show calcification within the tumour and sclerosis at bone margins
Treatment: complete surgical resection with removal of bone at the base; endoscopic approach preferred

2. Sinonasal Malignancy

Squamous cell carcinoma is the most common malignant tumour of the nasal cavity/paranasal sinuses
Also: adenoid cystic carcinoma, adenocarcinoma (linked to hardwood dust exposure)
Presents with: unilateral nasal obstruction, persistent unilateral rhinorrhoea, epistaxis, unilateral bloodstained discharge, facial swelling, proptosis
Warning signs of invasion: diplopia, proptosis, loose teeth, trismus, cranial nerve palsies, regional lymphadenopathy
Almost 50% of sinonasal cancers arise on the lateral nasal wall; 33% in the maxillary antrum

3. Septal Papilloma

Grows on the nasal septum
Exophytic, not associated with malignant degeneration
Can mimic carcinoma - must be excised for histology

4. Angiofibroma (Juvenile Nasopharyngeal Angiofibroma)

Highly vascular, locally destructive tumour - classically in adolescent males
Presents with recurrent profuse epistaxis
CT/MRI essential before biopsy (risk of catastrophic bleeding)

5. Other Vascular Lesions

Hemangioma, arteriovenous malformation
Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) - bilateral telangiectasias of nasal mucosa

6. Antrochoanal Polyp

A large single polyp arising from the maxillary antrum, filling the nose and prolapsing into the nasopharynx
Usually benign but must be distinguished from malignancy

7. In Children

Meningocele or encephalocele must be excluded before any biopsy or removal
High-resolution CT of the anterior cranial fossa is mandatory

Approach to the Patient

History

Duration, laterality, associated symptoms (pain, visual change, loosening teeth)
Occupation (hardwood dust exposure = adenocarcinoma risk)
Age and sex (adolescent male + profuse bleeding = angiofibroma until proven otherwise)
Family history of HHT

Examination

Anterior rhinoscopy + rigid nasal endoscopy
Note: colour (pale grey = inflammatory; red/vascular = sinister), mobility, sensitivity to probe, surface, and whether unilateral or bilateral
Neck for lymphadenopathy

Imaging

CT sinuses (with contrast): assess bony anatomy, extent of disease, calcification (inverted papilloma), bone erosion (malignancy)
MRI with gadolinium: superior soft tissue detail, distinguishes tumour from retained secretions, assesses orbital/skull base invasion
Both CT and MRI are complementary for sinonasal tumours - Sabiston Textbook of Surgery

Biopsy and Histology

All unilateral nasal polyps should be sent for histology after removal
Do not biopsy a suspected angiofibroma in clinic - risk of severe haemorrhage
Surgical excision under endoscopic guidance allows adequate tissue sampling

Management Summary

Pathology	Key Feature	Management
CRSwNP (bilateral)	Pale, bilateral, non-bleeding	Topical/systemic steroids, FESS if refractory
Inverted papilloma	Unilateral, may bleed, calcification on CT	Complete endoscopic resection + bone base removal
SCC / adenocarcinoma	Bleeding, firm, erosion on imaging	MDT: ENT + maxillofacial + oncology
Angiofibroma	Adolescent male, profuse epistaxis	Preoperative embolisation + surgical excision
Antrochoanal polyp	Single large polyp, fills nasopharynx	Endoscopic removal of stalk via antrum

Key Clinical Rules (Summary Box - Bailey and Love's 28th Ed.)

Polyps are insensitive to touch and mobile (inflammatory type)
Inflammatory polyps are usually bilateral
Unilateral nasal polyps should be removed and sent for histology
Bleeding polyps may indicate malignancy
Meningocele and encephalocele must be excluded in children with polyps
Polyps are removed using a powered microdebrider

Sources:

Bailey and Love's Short Practice of Surgery, 28th Edition (Tumours of the nose and sinuses; Chronic rhinosinusitis)
Cummings Otolaryngology Head and Neck Surgery (CRSwNP surgical management)
Sabiston Textbook of Surgery (Sinonasal Benign Neoplasm; Schneiderian papilloma)

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