Unilateral Nasal Polyp: Initial Management
A unilateral nasal polyp requires immediate tissue biopsy and CT imaging before any medical treatment, as unilateral presentation is a red flag for inverted papilloma, malignancy, or invasive fungal disease—not routine inflammatory polyps. 1, 2
Critical Diagnostic Principle
Do not treat a unilateral nasal polyp medically without histopathological confirmation. 1 Unlike bilateral nasal polyps (which have <1% misdiagnosis rate and can be managed medically), unilateral polyps carry substantially higher risk of serious pathology:
- Inverted papillomas account for 0.5-4.5% of presumed inflammatory polyps 1
- Malignancies comprise 14% of unilateral nasal masses in surgical series 3
- Diagnostic discrepancy rate is 4.5% in unilateral disease versus 1.1% in bilateral disease 4, 1
Immediate Diagnostic Workup
1. Nasal Endoscopy (Mandatory)
Perform or immediately refer for complete nasal endoscopy to examine the entire nasal cavity and nasopharynx 4, 2. Anterior rhinoscopy alone is insufficient as malignancies may not be visible with limited examination 4, 2.
Look for these red flags during endoscopy: 1, 5
- Firm, lobulated masses with vascular fleshy appearance (inverted papilloma)
- Brick red or black necrotic areas (fungal disease or malignancy)
- Lesions that don't match typical inflammatory polyp characteristics (smooth, glistening, translucent, mobile)
- Unilateral obstruction with bleeding, crusting, or non-healing characteristics 4, 2
2. CT Imaging (Required Before Biopsy)
Obtain CT of paranasal sinuses for all unilateral polyps to evaluate extent of disease, bone destruction, and extrasinus extension 4, 2, 6. CT is superior to plain radiography and provides critical information about:
- Osseous destruction or bone remodeling (suggests malignancy or inverted papilloma) 2
- Extent of involvement throughout nasal cavity and sinuses 4, 6
- Integrity of orbit and cranial vault 4, 6
- Local invasion or extrasinus extension (requires MRI for further characterization) 2
3. Tissue Biopsy (Mandatory)
Obtain histopathological confirmation before initiating any treatment. 1, 2 The American Academy of Otolaryngology mandates tissue biopsy for any unilateral polypoid mass to exclude inverted papilloma and malignancy 1.
Biopsy technique: 1
- Use Fokkens forceps, fenestrated punch forceps, or scissors
- Do not crush tissue during collection
- Send for routine histology, fungal staining, and culture if invasive fungal disease suspected
High-Risk Populations Requiring Urgent Biopsy
Immunocompromised patients (diabetes, hematologic malignancies, immunosuppression) with unilateral disease require immediate biopsy due to 50-80% mortality from invasive fungal disease without urgent intervention 1.
Children or adolescents with nasal polyps warrant heightened suspicion and biopsy due to increased risk of juvenile angiofibroma and other pathologies 1.
Common Pitfalls to Avoid
Never assume unilateral disease is inflammatory even if it appears similar to typical polyps—inverted papillomas present as unilateral masses in >95% of cases and have malignant potential 1, 5.
Do not rely on vasoconstrictor response to distinguish inflammatory polyps from other lesions, as inverted papillomas also fail to shrink after topical vasoconstrictors 1.
Do not initiate corticosteroid therapy (topical or systemic) before obtaining tissue diagnosis, as this may delay diagnosis of malignancy or inverted papilloma that requires surgical excision 1.
Referral Pathway
Refer immediately to otolaryngology if you cannot perform nasal endoscopy yourself, for complete endoscopic examination, tissue biopsy, CT interpretation, and surgical planning 2. Unilateral disease requires specialist evaluation even if initial appearance seems benign 4, 2.