What is the appropriate management for an adult patient with a nasal fungating mass, potentially with a history of nasal symptoms or previous diagnoses of nasal polyps?

Management of Nasal Fungating Mass

Any adult presenting with a nasal fungating mass requires immediate tissue biopsy to exclude malignancy, inverted papilloma, or invasive fungal disease before initiating any medical therapy. 1

Immediate Diagnostic Approach

Red Flag Assessment

The term "fungating" indicates an atypical, concerning lesion that mandates urgent evaluation. You must immediately assess for:

• Unilateral versus bilateral presentation - Unilateral polypoid masses raise immediate suspicion for inverted papilloma (>95% unilateral) or malignancy and mandate tissue biopsy 1
• Endoscopic appearance suggesting neoplasia - Brick red or black necrotic areas, firm lobulated masses with vascular fleshy appearance, or any lesion that doesn't match typical inflammatory polyp characteristics warrants biopsy 1
• Immunocompromised status - Patients with diabetes, hematologic malignancies, or immunosuppression require immediate biopsy with fungal staining and culture due to 50-80% mortality rates from invasive fungal disease without urgent intervention 1

Required Workup Before Any Treatment

Complete nasal endoscopy must be performed to examine the entire nasal cavity and nasopharynx, looking for bleeding, crusting, or non-healing characteristics 1

CT imaging of paranasal sinuses is required before biopsy to evaluate extent of disease, bone destruction, and extrasinus extension 1

Tissue biopsy is mandatory for any fungating or unilateral polypoid lesion, as the diagnostic discrepancy rate is 4.5% in unilateral disease versus 1.1% in bilateral disease 1

Biopsy Technique

When performing biopsy:

• Tissue must not be crushed during collection - Use Fokkens forceps, fenestrated punch forceps, or scissors in the operating theater 1
• Send specimens for routine histology, fungal staining, and culture when invasive fungal disease is suspected 1
• Microdebrider tissue is adequate for histological analysis 1

Critical Differential Diagnoses to Exclude

Inverted Papilloma

• Accounts for 0.5-4.5% of presumed inflammatory nasal polyps 1
• Appears as firm, lobulated masses with vascular, fleshy appearance 1
• Requires surgical excision, not medical management 1

Malignancy

• Sinonasal tumors and nasopharyngeal tumors must be excluded 2
• Any unilateral mass with bone destruction on CT requires oncologic evaluation 1

Invasive Fungal Disease

• Presents with black necrotic areas in immunocompromised patients 1
• Requires immediate surgical debridement and antifungal therapy 1

Granulomatous Disease

• Wegener granulomatosis, sarcoidosis, or tuberculosis require biopsy when diagnosis is unclear 1

Referral Algorithm

Immediate otolaryngology referral is required for complete endoscopic examination, tissue biopsy, CT interpretation, and surgical planning 1

Do not attempt medical management with corticosteroids before obtaining tissue diagnosis, as this may delay diagnosis of malignancy or invasive fungal disease and worsen outcomes.

Common Pitfalls to Avoid

• Never assume a fungating mass is a benign inflammatory polyp - The misdiagnosis rate is significantly higher with atypical presentations 1
• Never start oral or topical corticosteroids before tissue diagnosis - This delays appropriate treatment for malignancy or invasive fungal disease
• Never rely on clinical appearance alone - Inverted papillomas and early malignancies can mimic inflammatory polyps 1

Only After Benign Inflammatory Polyps Are Confirmed

If histology confirms bilateral inflammatory nasal polyps without concerning features, then medical management with intranasal corticosteroids becomes first-line therapy 3, with oral corticosteroids reserved for severe cases 3. However, this determination can only be made after tissue diagnosis excludes the serious conditions outlined above.