When should patients with nasal polyps be referred to a specialist, such as an otolaryngologist (ear, nose, and throat specialist)?

When to Refer Patients with Nasal Polyps to a Specialist

Patients with nasal polyps should be referred to an otolaryngologist when they fail to respond adequately to medical therapy with intranasal corticosteroids (with or without oral steroids), have severe obstructive symptoms, experience recurrent infections despite treatment, or require confirmation of the diagnosis when polyps cannot be adequately visualized in primary care. 1

Primary Indications for Specialist Referral

Failure of Medical Management

• Refer patients who do not respond satisfactorily to appropriate medical treatment, which should include topical intranasal corticosteroids for at least 1-3 months. 1, 2
• Patients requiring repeated courses of oral corticosteroids (more than 2-3 courses per year) should be referred, as the risks of repeated systemic steroid use surpass the risks of endoscopic sinus surgery. 2
• Surgery should be reserved specifically for patients who fail medical therapy, as appropriate medical treatment is as effective as surgical treatment in the majority of chronic rhinosinusitis patients. 1

Severe or Complicated Disease

• Patients with extensive polyposis causing severe nasal obstruction warrant expedited referral to avoid unnecessary delays in care and disease progression. 2
• Refer patients with obstructing nasal polyps after an appropriate trial of medical treatment including oral corticosteroids. 1
• Patients with recurrent or chronic symptoms and radiographic evidence of ostiomeatal obstruction despite aggressive medical management benefit from surgical intervention. 1

Diagnostic Confirmation Required

• Refer when you cannot adequately visualize the nasal cavity to confirm or exclude polyps with certainty. 1
• Small polyps in the middle meatus or posterior nasal cavity may only be detected by nasal endoscopy, requiring specialist evaluation. 1
• Unilateral polyps require referral for thorough evaluation, as they may represent neoplasia or other atypical presentations requiring CT imaging and possible biopsy. 1

Specific Clinical Scenarios Requiring Referral

Associated Comorbidities

• Refer patients with nasal polyps and concurrent asthma, particularly those with aspirin-exacerbated respiratory disease (AERD), as they may benefit from aspirin desensitization and specialized management. 1, 3
• Children with nasal polyps should be referred immediately for evaluation of cystic fibrosis. 3
• Patients with recurrent or chronic infectious rhinosinusitis may have humoral immunodeficiency, fungal sinusitis, or granulomatous diseases requiring allergist-immunologist evaluation. 1

Recurrent Disease

• Patients with recurrent acute rhinosinusitis (3 or more episodes per year with clearing between episodes) should be referred for specialist consultation. 1
• Refer patients who continue to deteriorate clinically despite extended courses of antimicrobial therapy. 1

High-Risk Populations

• Seriously ill or immunocompromised patients with presumed rhinosinusitis require specialist referral. 1
• Patients with suspected suppurative complications (orbital or intracranial extension) require immediate otolaryngology consultation. 1

Role of Different Specialists

Otolaryngologist Referral

• Primary specialist for surgical evaluation and management of nasal polyps. 1
• Performs nasal endoscopy for definitive diagnosis and functional endoscopic sinus surgery when indicated. 1
• Functional endoscopic surgery is superior to minimal conventional procedures including simple polypectomy. 1, 2

Allergist-Immunologist Referral

• Refer to allergist-immunologist for evaluation and management of underlying allergic factors, aspirin sensitivity, and immunodeficiency states. 1
• Allergist-immunologists are specifically trained in medical management of nasal polyps, including intranasal steroids, oral steroids, and treatment of complicating sinusitis. 1
• Consider referral for patients with chronic eosinophilic rhinosinusitis, which often coexists with aspirin sensitivity, asthma, and sinus-nasal polyposis. 1

Common Pitfalls to Avoid

• Do not delay referral in patients with severe polyposis by rigidly adhering to prolonged medical trials, as this can be harmful and allow disease progression. 2
• Do not assume all nasal masses are benign inflammatory polyps—unilateral polyps, atypical appearance, or bleeding lesions require urgent specialist evaluation to rule out malignancy. 1
• Do not refer for surgery without first attempting appropriate medical therapy with intranasal corticosteroids, as this is the treatment of choice and many patients respond adequately. 3, 4
• Recognize that nasal polyps typically do not cause headache or facial pain—if these are prominent symptoms, consider alternative diagnoses. 3