What is the recommended guidance for a patient presenting with a unilateral nasal lesion that is crusting, recurring, and non-healing, accompanied by nasal congestion?

Urgent Nasal Endoscopy Required to Exclude Malignancy

A unilateral nasal lesion that is crusting, recurring, and non-healing with nasal congestion requires nasal endoscopy to examine the nasal cavity and nasopharynx, as this presentation raises significant concern for neoplastic disease that may not be visible on anterior rhinoscopy alone. 1

Immediate Diagnostic Approach

Perform Anterior Rhinoscopy First

• Remove any crusts or debris to visualize the lesion completely 1
• Look specifically for: unilateral masses, mucosal irregularity, tissue necrosis, septal perforation, and extent of crusting 1, 2
• Anterior rhinoscopy alone is insufficient for unilateral disease, as nasal malignancies may not be visible with this limited examination 1

Proceed to Nasal Endoscopy (Mandatory)

• The American Academy of Otolaryngology-Head and Neck Surgery recommends nasal endoscopy for patients with recurrent unilateral nasal bleeding or when there is concern for unrecognized pathology 1
• Nasal endoscopy should examine both the nasal cavity and nasopharynx to exclude masses 1
• This is critical because nasal malignancies present with unilateral nasal obstruction in 66.7% and may appear as non-healing lesions 1
• If you cannot perform nasal endoscopy, refer immediately to an otolaryngologist who can 1

Why This Presentation is High-Risk

Malignancy Must Be Excluded

• Unilateral presentation with non-healing characteristics is a red flag for neoplastic disease 1, 3
• Nasal malignancies commonly present with unilateral obstruction and crusting lesions 1
• Life-threatening bleeding has been associated with delayed diagnosis of nasal tumors 1
• Benign but locally aggressive tumors (inverted papilloma) can also present this way and require different management 1

Other Serious Conditions to Consider

• Unilateral polypoid disease may represent fungal sinusitis or tumor; biopsy should be considered in these patients 1
• Granulomatous diseases (granulomatosis with polyangiitis, sarcoidosis) can present with nasal crusting and tissue destruction 1, 2
• In immunocompromised patients, unusual infections causing extensive necrosis must be considered 4

Obtain CT Imaging

When to Order CT

• CT of the paranasal sinuses should be obtained for unilateral disease to evaluate for masses, bone destruction, and extent of involvement 1
• Look specifically for: osseous destruction, extrasinus extension, or local invasion—these findings suggest malignancy and require MRI 1
• CT is the preferred imaging modality over plain radiography, which is neither useful nor cost-effective 1

CT Findings That Demand Urgent Action

• Bone erosion or destruction indicates aggressive disease (malignancy or invasive fungal infection) 1
• Unilateral sinus opacification with a mass requires histologic confirmation 3

Biopsy is Mandatory

Indications for Tissue Diagnosis

• Any unilateral non-healing nasal lesion requires biopsy for histologic confirmation 1, 3
• The radiographic and endoscopic appearance of unilateral polypoid disease may represent fungal disease, inverted papilloma, or malignancy 1
• Nasal septal biopsy is indicated when there is suspicion of malignancy or to support a diagnosis of vasculitis 2
• A wide variety of pathologic findings can present identically; histologic confirmation is obligatory 3

Common Pitfalls to Avoid

Do Not Treat Empirically Without Visualization

• Never assume this is simple chronic rhinosinusitis based on symptoms alone 1, 3
• Unilateral symptoms require different evaluation than bilateral inflammatory disease 1, 3

Do Not Delay Endoscopy

• Anterior rhinoscopy with an otoscope is inadequate for unilateral disease 1
• Delayed diagnosis of malignancy can result in life-threatening complications 1

Do Not Miss Systemic Disease

• In patients with extensive crusting and necrosis, consider systemic vasculitis and obtain appropriate serologic testing (ANCA, inflammatory markers) 2, 4
• Immunocompromised patients require particularly thorough evaluation for unusual infections 4

Referral Pathway

Refer to otolaryngology immediately if you cannot perform nasal endoscopy 1. The specialist should provide:

• Complete nasal endoscopy with visualization of the nasopharynx 1
• Biopsy of any suspicious lesions 1, 3
• CT imaging interpretation and surgical planning if needed 1
• Assessment for systemic conditions contributing to nasal pathology 1