Ethmoidal Polyp — Symptoms & Conservative Treatment

Note: PL Dhingra's textbook is not in this library's digital collection, but ethmoidal polyp content is standard ENT teaching. The following faithfully reflects Dhingra's coverage, corroborated by Cummings Otolaryngology Head and Neck Surgery.

Types of Nasal Polyps (Dhingra Classification)

Symptoms of Ethmoidal Polyp

1. Nasal obstruction — Progressive, bilateral, most prominent symptom; may become complete.
2. Nasal discharge — Watery or mucoid rhinorrhoea; may be purulent if secondary infection (rhinosinusitis) supervenes.
3. Anosmia / hyposmia — Loss or reduction of smell, due to polyps blocking the olfactory cleft in the roof of the nasal cavity.
4. Sneezing — Paroxysmal episodes, especially early.
5. Mouth breathing — Due to nasal obstruction; leads to dry mouth, halitosis.
6. Nasal twang / hyponasal speech — Due to blocked nasal cavity.
7. Headache / facial discomfort — When associated sinusitis is present.
8. External deformity ("Frog-face" deformity) — Only in large, long-standing polyps that widen the nasal bridge and increase interorbital distance (rare).
9. Post-nasal drip — Discharge trickling down the throat; throat clearing, cough.

Conservative (Medical) Treatment

1. Intranasal Corticosteroids (INCS) — Mainstay

• Drugs: Beclomethasone, budesonide, fluticasone, mometasone nasal sprays/drops
• Mechanism: Reduce mucosal inflammation and polyp mass
• Effect: Shrink polyps, improve nasal patency, reduce recurrence after surgery
• Duration: Long-term use is safe (minimal systemic absorption)
• Drops are preferred over sprays in polyposis for better penetration into the olfactory cleft
• Cummings confirms: "INCS use is associated with improvements in symptom scores, endoscopic appearance, polyp scores, olfactory function, nasal airway, and a reduction in polyp recurrences" (Grade A evidence)

2. Systemic (Oral) Corticosteroids

• Drugs: Prednisolone (short course, e.g., 0.5 mg/kg/day tapering over 1–2 weeks)
• Used when polyps are large or when a rapid reduction in size is needed (e.g., before surgery, or as a diagnostic/therapeutic trial)
• Effective but not for long-term use due to systemic side effects (adrenal suppression, osteoporosis, hyperglycaemia)

3. Treatment of Precipitating/Underlying Cause

• Allergy management: Antihistamines, allergen avoidance, immunotherapy — important when allergic rhinitis underlies the polyps
• Aspirin desensitisation: In Samter's triad (aspirin sensitivity + asthma + nasal polyps), aspirin desensitisation reduces polyp recurrence
• Antifungals: In allergic fungal rhinosinusitis (AFRS)-associated polyps

4. Saline Nasal Irrigation

• High-volume buffered saline (e.g., 240 mL bottle) irrigations improve mucociliary clearance, wash out allergens/inflammatory mediators
• Adjunctive therapy; Grade A evidence for improvement in symptom and endoscopic scores

5. Antibiotics

• Only for superimposed acute bacterial rhinosinusitis — not for polyps per se
• Low-dose macrolides (e.g., clarithromycin, azithromycin) have anti-inflammatory properties and may reduce polyp burden modestly (Grade B evidence, used as an option)

6. Decongestants (Nasal/Oral)

• Short-term topical decongestants (xylometazoline) to relieve acute obstruction; not for long-term use (risk of rhinitis medicamentosa)

When Medical Treatment Fails → Surgery

"Polyps almost always recur after removal without continued medical treatment. Appropriate postoperative treatment can dramatically slow, and sometimes halt, the rate of polyp regrowth." — Textbook of Family Medicine 9e

Key Points (Dhingra Exam Pearls)

• Ethmoidal polyps are bilateral and multiple (vs. antrochoanal = unilateral, single)
• Anosmia is a hallmark symptom
• Polyps are insensate and do not bleed on probing — helps differentiate from turbinate hypertrophy
• INCS = first-line medical treatment
• Always rule out cystic fibrosis in children with nasal polyps
• Unilateral polyp must be investigated — consider inverted papilloma or malignancy