Management of Incidental Mild Polypoidal Mucosal Thickening in the Left Maxillary Sinus
In an otherwise healthy adult with incidental mild polypoidal mucosal thickening of the left maxillary sinus and no sinus symptoms, no treatment or ENT referral is required—observation alone is appropriate. 1
Clinical Significance of Asymptomatic Mucosal Thickening
The finding of mild mucosal thickening in an asymptomatic patient is a common incidental radiologic finding that does not correlate with disease requiring intervention:
Mucosal thickening ≥2 mm is present in 17.7% of completely asymptomatic individuals without any sinonasal symptoms or chronic rhinosinusitis (CRS). 2
The degree of mucosal thickening does not correlate with symptom severity or quality of life in patients. 2 Sinus-specific opacification may not be correlated with CRS symptomatology at all. 2
Even minimal activities like nose blowing can cause up to 0.5 mm of mucosal thickening in the maxillary sinuses. 2 Additionally, radiologic evidence of sinonasal inflammation may persist after resolution of an upper respiratory tract infection. 2
Asymptomatic individuals may have mean Lund-Mackay scores between 1.8 and 2.24, indicating that some degree of radiologic abnormality is normal. 2
Key Management Principle: Symptoms Drive Treatment
The presence or absence of clinical symptoms—not imaging findings—should determine management:
If the patient has no symptoms (no facial pain/pressure, nasal congestion, purulent discharge, or decreased sense of smell lasting >4 weeks), no specific treatment is needed. 1
The patency of the ostiomeatal complex (OMC) is more clinically important than the degree of mucosal thickening. 1 Minimal thickening with a patent OMC generally does not require ENT referral or treatment. 1
Only 29% of asymptomatic control patients have ≥2 mm of maxillary sinus mucosal thickening, compared to 94% of patients meeting symptom criteria for CRS. 2 This demonstrates that imaging findings must be interpreted in the clinical context.
When to Reconsider or Escalate Care
While observation is appropriate for this asymptomatic patient, certain findings would warrant further evaluation:
Air-fluid levels within the sinuses, bone erosion or destruction, and complete opacification are concerning findings that may indicate active disease requiring evaluation. 1
Development of symptoms lasting more than 4 weeks (facial pain/pressure, nasal congestion, purulent discharge, or decreased sense of smell) would indicate potential sinusitis requiring treatment. 1
If symptoms develop, saline nasal irrigation and intranasal corticosteroids may be considered for mild symptoms. 1
Antibiotics should be prescribed based on clinical symptoms rather than imaging findings alone. 1
Common Pitfall to Avoid
Do not initiate treatment or refer to ENT based solely on radiologic findings in an asymptomatic patient. 2, 1 The 2025 American Academy of Otolaryngology-Head and Neck Surgery guidelines explicitly state that surgical planning should avoid nonvalidated radiological criteria and arbitrary thresholds for mucosal thickening. 2 The degree of thickening should be interpreted for clinical relevance based on the patient as a whole, not isolated imaging findings. 2