Nasal polyps

A nasal polyp is not a tumour and not a lump that sprang up out of nowhere. It is a piece of lining that has been inflamed for years, filled with fluid and finally drooped into the nasal passage as a soft, pale drop, rather like a seedless grape. Polyps do not hurt and do not bleed, which is why hardly anyone spots them early: you get used to breathing through your mouth, stop noticing smells and put it down to the weather, to hay fever or to getting older. They do not shrink away on their own, and they do not turn into cancer. The question is usually not whether they are dangerous, but how many more years you are willing to spend with a blocked nose and no sense of smell.

What it feels like

The blockage that polyps cause is steady and even. It does not so much get worse at night as simply never let go, on both sides, and decongestant sprays barely touch it. Your nose clears neither after a hot shower nor in fresh air.

The second thing almost everyone notices is smell. The delicate ones go first: coffee has no aroma, perfume only registers with the bottle held under your nose. Then the rest fade, and food loses its character along with them and tastes flat, even though the tongue is working perfectly well. Plenty of people come to the doctor because of this rather than because of the nose itself.

• mucus trickles down the back of the throat, so you have to clear it in the morning;
• the voice turns nasal, as though you were speaking with your nose pinched;
• snoring starts, sleep breaks up and you wake unrested;
• the forehead and cheekbones feel heavy and pressed, especially when you bend forward;
• lips dry out and crack from constant mouth breathing.

Polyps do not cause sharp pain. If the face genuinely starts to ache, the temperature rises and thick discharge appears, an infection of the sinuses has joined in, and that is a different matter.

Why this is not a cold or hay fever

A cold fits into a week: first it runs, then it thickens, then it lets go. Smell disappears with it too, but comes back as soon as the nose opens up. Polyps behave nothing like that — they last for months and, untreated, only grow.

Allergic rhinitis is the more common mix-up. Allergy has its own signature: itching in the nose and eyes, volleys of sneezing, clear watery discharge, a link with the season, with the cat or with cleaning day. With polyps there is almost no itch and no sneezing, but there is a dull, complete blockage and a loss of smell that is the same in January as in June. The two are not mutually exclusive: allergy often sits in the background and feeds the inflammation, but it would be a mistake to explain everything by it.

The third trap is a deviated septum: it makes breathing harder, but it does not take away your sense of smell. If the septum has been straightened and the smells have not returned, it is worth looking for polyps.

Where they come from

Polyps are not a disease in their own right but the visible part of long-standing inflammation in the lining of the nose and sinuses. Why that inflammation takes this particular course in some people and not in others is not fully understood, but the group it happens to is fairly well defined.

• Asthma. About half of people with polyps have it, and the reverse is also true: in severe asthma, polyps are a frequent finding. It is the same inflammation on two different floors of the airway.
• Intolerance of anti-inflammatory painkillers, the NSAID group. This is a distinct form of the illness: polyps, asthma and an attack of wheezing, streaming nose or facial swelling after taking aspirin, ibuprofen or their relatives. The combination is recognisable and worth knowing about, because the person who has it needs to agree with a doctor what to use for pain — an ordinary painkiller can tip them into a severe attack.
• Long-running rhinosinusitis: inflammation of the sinuses that drags on for months, with thick mucus and a swollen lining.
• Allergic fungal sinusitis in strongly allergic people: dense, sticky contents, plentiful polyps and a tendency to return after surgery.
• Inherited conditions in children. Polyps in a child are rare and never appear for no reason: cystic fibrosis or a congenital fault in the tiny hairs that clear the lining usually lies behind them.

Smoking and dry, dusty air do not create polyps, but they keep the inflammation alive and get in the way of treatment.

When it may not be a polyp at all

Ordinary polyps almost always grow on both sides and look alike. A growth in one nostril only is a different story and deserves different handling: benign tumours such as inverted papilloma hide behind that appearance, and occasionally malignant ones do too. A one-sided lesion is therefore not treated with drops to see what happens; it is shown to an ear, nose and throat specialist and, if needed, a small piece of tissue is taken for examination.

See a doctor promptly if any of the following applies:

• only one side of the nose is blocked and feels stuffed;
• there is repeated bleeding or blood-stained discharge;
• the cheek, cheekbone or upper teeth ache or go numb;
• the face changes: an eye bulges, vision doubles, one eye waters constantly;
• the growth has appeared in a child, and above all in a baby.

A word about babies: what looks like a polyp in a tiny child's nose is sometimes tissue connected to the inside of the skull, and it must never be poked at blindly. Such findings are always imaged before anything is done to them.

Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single number is 112) if, alongside a blocked nose, an eye or eyelid becomes red and swollen, the eye is hard to move, vision drops, or a severe headache appears with a high temperature, vomiting or confusion. These are the complications of sinusitis, and they are counted in hours.

How the diagnosis is confirmed

Looking into the nose with a torch and a speculum reaches only the entrance. Large polyps do show up that way, but they usually grow further back, beyond what that view covers, so "your nose looks clear" after a quick glance rules nothing out.

• Nasal endoscopy — a slim tube with a camera passed along the floor of the nose under local anaesthetic. It is the main way to see the polyps and to judge how many there are and where they arise. It takes a few minutes and is done in the clinic.
• CT of the sinuses is needed when surgery is on the table or when the picture is unusual: it shows which sinuses are filled, whether bone has been eroded and whether there is a growth on one side only.
• Smell testing with a set of standard odours, used to measure how much has been lost and whether it returns with treatment.
• Allergy testing and a look at the lungs. Skin prick tests or blood tests for specific antibodies map the background, and spirometry is needed if there is cough, wheeze or breathlessness: undiagnosed asthma keeps company with polyps surprisingly often.
• A sweat test in a child. Polyps in childhood are a direct reason to test for cystic fibrosis, even when nothing else about the child's health raises questions.

A plain sinus X-ray adds almost nothing here: it cannot separate a polyp from a thickened, swollen lining, and it should not be the last word.

How they are treated

The aim of treatment is not to remove polyps for good but to give you back nasal breathing and smell and to keep the inflammation in check. The tendency to form polyps cannot be cured at present, yet it is entirely possible to go for years without thinking about them.

The foundation is a steroid nasal spray or drops. They work where they land, barely reach the bloodstream and, used properly, are safe over long periods. They do not act at once: the first shift comes after a few weeks and the full effect later, so giving up after seven days "because it isn't working" is the commonest mistake of all. With bulky polyps a doctor may prescribe the drop form together with a particular head position, so that the medicine reaches higher, to the root of the polyp.

Steroid tablets are used as a short course when the nose is completely closed and things need moving quickly, including before an operation. They bring marked relief but do not last, and they cannot be repeated often because of their side effects, so they are not a way of treating the condition day to day.

When surgery is needed

Surgery is offered when medicines have failed over several months or when polyps fill almost the whole nose. It is done from inside, through the nostrils, guided by an endoscope and with no cuts on the face; the drainage openings of the sinuses are widened at the same time so that they ventilate better. Breathing improves almost immediately; smell returns more slowly and not for everyone. The essential point is this: an operation removes what has already grown, but it does not cancel the inflammation. Without a steroid spray afterwards the polyps grow back, usually within a few years and sooner in severe forms.

In stubborn disease, where polyps return after repeated operations, monoclonal antibody treatments are added: they damp down that same allergic inflammation in a targeted way and help the accompanying asthma as well. A specialist prescribes them and they are given over long periods. For some people with NSAID intolerance, a supervised programme to build tolerance to aspirin is possible; it is never something to attempt alone.

What you can do yourself

Rinsing the nose with salt water is not a folk remedy but part of the treatment: it washes away thick mucus and crusts, settles the swelling and lets the spray reach the lining instead of landing on mucus. Do it before the medicine, not after. A ready-made sachet from the pharmacy is the simplest option; if you mix your own, use cooled boiled or distilled water, never straight from the tap, even where tap water is safe to drink. Lean over the sink, rinse one side then the other, breathe through your mouth and do not swallow.

Use the spray correctly: aim the nozzle at the outer wall, towards the outer corner of the eye on the same side, never at the septum, and do not sniff hard. Spraying into the septum is what produces the bloody crusts that make people abandon treatment.

Decongestant sprays make life easier for a few days, but with continued use they stop working and turn the blockage into a permanent one. Do not carry on with them beyond a few days in a row.

The rest is plain and unglamorous: stop smoking and stay out of smoke, treat the asthma and the allergy rather than the nose alone, humidify the air in the heating season, and do not put off an appointment if smells fade again after a good spell. An early relapse is far easier to settle with medication than an established one.

Online consultation

A remote appointment is useful where information has to be sorted out and decisions made, not where someone needs to look inside your nose. The doctor will work out whether your blockage looks more like allergy, prolonged sinusitis or polyps, will ask about smell, snoring and reactions to painkillers, will go through any scans and reports you already have, and will say whether endoscopy is needed and who to see.

Once the diagnosis is known, day-to-day questions are answered well online: why the spray has not worked yet, what to do after surgery so that the polyps take longer to come back, what to use for pain if NSAIDs are not an option for you, whether biological treatment is worth raising when relapses keep coming. Have your medicines list, your reports and any scans to hand.

The limits are obvious: seeing a polyp and telling it apart from a one-sided growth takes an endoscope, and a swollen eye, double vision or a severe headache with fever calls for urgent care in person rather than a conversation on a screen.

This material is for information only and does not replace medical advice.