Nasal Polyps

Nasal polyps are non-neoplastic, oedematous inflammatory outgrowths of the mucosa of the nasal cavity and paranasal sinuses. They typically present with nasal obstruction, nasal discharge, reduced or absent sense of smell, and postnasal symptoms. Most inflammatory nasal polyps are pale, smooth, soft, and usually do not bleed on gentle touch. The polyp has a loose connective tissue stroma with albumin deposition, pseudocyst formation, and intense inflammatory cell infiltration in the subepithelial and perivascular areas. It is lined by pseudostratified columnar ciliated epithelium.

Nasal polyps are commonly discussed in the context of chronic rhinosinusitis with nasal polyps (CRSwNP). Clinically, they can be broadly considered as localised polyps, such as an antrochoanal polyp (Killian’s polyp), and diffuse bilateral polyposis, typically involving the ethmoid region.

This chapter covers the definition, classification, causes, clinical features, investigations, differential diagnosis, and treatment of nasal polyps, with special emphasis on antrochoanal polyps and diffuse CRSwNP. It also includes MBBS and ENT PG notes, CBME-oriented revision points, NEET PG/INI-CET/FMGE MCQs, clinical cases, and viva questions.

Chronic Rhinosinusitis (CRS)

Chronic rhinosinusitis is inflammation of the nose and paranasal sinuses lasting more than 12 weeks, diagnosed on the basis of characteristic symptoms with objective evidence of sinonasal inflammation on nasal endoscopy or CT.

CRS is broadly divided into:

1. Chronic rhinosinusitis with nasal polyps (CRSwNP)
2. Chronic rhinosinusitis without nasal polyps (CRSsNP)

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)

EPOS 2020 classifies CRS into primary and secondary disease, then into localised and diffuse based on anatomical distribution.

Type	Traditional Clinical Term	EPOS 2020 Classification
Localised	Antrochoanal polyp	Localised CRS
Diffuse	Bilateral ethmoidal polyposis	Diffuse CRS

Important Clinical Distinction: Antrochoanal polyp and diffuse CRSwNP are not the same disease phenotype.

• Antrochoanal polyp is typically a solitary, unilateral inflammatory lesion arising from the maxillary sinus and extending through the nasal cavity to the choana.
• CRSwNP refers to chronic rhinosinusitis with bilateral endoscopically visualised nasal polyps, typically involving the middle meatus. It is usually a diffuse inflammatory disease commonly associated with type 2 inflammation, although endotypes vary.

Antrochoanal polyp (Killian’s polyp)

Site of Origin and Pathogenesis

The antrochoanal polyp originates from the mucosa within the maxillary antrum, near the natural or accessory ostium. It extends into the nasal cavity and grows posteriorly toward the choana.

Proposed mechanisms for posterior growth:

1. Ciliary movement: Cilia in the nasal cavity beat in a posterior direction, guiding the polyp toward the choana.
2. Bernoulli phenomenon: Chronic rhinosinusitis causes oedema and narrowing of the air passage. According to the Bernoulli principle, narrowed pathways increase airflow velocity, causing a pressure drop that draws surrounding structures inward, contributing to polyp protrusion.
3. Anatomy: The nasal cavity has a natural posterior bend that guides the polyp’s growth.

Proposed theories of formation:

1. Bernoulli principle: As described above. Chronic rhinosinusitis can lead to anatomical changes and oedema in the nasal cavity and paranasal sinuses, leading to the narrowing of the air passage in the nasal cavity. Due to the Bernoulli Principle, narrowed pathways increase airflow velocity, resulting in a drop in pressure around the inflamed areas, which draws in the surrounding structures, contributing to polyp formation.
2. Proetz theory: It suggests faulty development of maxillary sinus ostia, wider than normal, allows the mucosa to more easily protrude from the maxillary sinus into the nasal cavity, thus contributing to polyp formation.

Parts of AC Polyp

The antrochoanal polyp consists of three main sections:

1. Antral Part: A cystic or oedematous component arising from the maxillary sinus, attached by a pedicle/base.
2. Nasal Part: The nasal portion is flattened from side to side and situated in the nasal cavity.
3. Choanal Part: The choanal section is round and globular and is located near the choana.

Age Group and Prevalence

Antrochoanal polyps are most commonly observed in children and young adults. They typically present as single, unilateral growths and are more frequently found in males than in females. It accounts for approximately 4–6% of all nasal polyps. 

Aetiology

The exact aetiology of antrochoanal polyp is uncertain. Chronic sinonasal inflammation, allergy, maxillary sinus ostial obstruction, mucosal oedema, and anatomical factors have been implicated. Chronic rhinosinusitis leads to oedema and prolapse of the maxillary sinus mucosa into the nasal cavity.

Symptoms

1. Unilateral nasal obstruction is the presenting symptom.
2. Obstruction may become bilateral when the polyp grows into the nasopharynx and starts obstructing the opposite choana.
3. Allergic symptoms: watering eyes, sneezing, itching in the nose.
4. Hyponasal speech – voice becomes thick and dull.
5. Unilateral Nasal discharge, mostly mucoid, may be bilateral.
6. Hyposmia/ anosmia
7. Headache
8. Epistaxis is uncommon. Significant bleeding should prompt evaluation for another diagnosis.
9. Hearing loss due to Eustachian tube obstruction
10. Pain over the cheek region

Signs

1. As the polyp grows posteriorly, it may be challenging to detect during anterior rhinoscopy and can only be visualised on endoscopic nasal examination.
2. Large polyps appear as smooth, greyish, glistening masses, often covered with nasal discharge. The polyp is soft and mobile. A large polyp may protrude from the nostril, appearing pink and congested.
3. Posterior rhinoscopy reveals a globular mass filling the choana or nasopharynx. Large polyps may extend behind the soft palate and be visible in the oropharynx.

Investigations

1. Diagnostic nasal endoscopy (DNE): Performed to assess the extent of the polyp and its origin.
2. Nasal endoscopy and CT of the paranasal sinuses (CT PNS): These are the principal investigations. They demonstrate a hypodense, non-enhancing mass filling the maxillary antrum, nasal cavity, and posterior choana. CT helps define the extent of the polyp and identify its attachment within the maxillary sinus, which is important for surgical planning.
3. X-ray of the paranasal sinuses: May show an opaque maxillary antrum. On a lateral view, a globular swelling in the postnasal space with an air column behind the polyp may help differentiate it from an angiofibroma. However, plain X-rays are now considered obsolete, and the “air column” sign cannot reliably exclude juvenile nasopharyngeal angiofibroma (JNA).
4. Culture and sensitivity (C/S) of nasal discharge: May be performed when there is purulent nasal discharge treatment failure. Routine culture is not standard for uncomplicated AC Polyp.
5. Routine investigations: Performed as part of the preoperative work-up.
6. Allergy testing: Not routinely indicated in patients with an antrochoanal (AC) polyp.

 Treatment

Goals of Treatment: The primary goal of treatment is to eliminate any underlying systemic disease, relieve symptoms, restore nasal breathing and sense of smell (olfaction), and prevent recurrence.

1. Endoscopic sinus surgery is the treatment of choice for symptomatic AC polyp. Prior medical management is not required. It aims to improve sinus ventilation, improve drainage, and remove polyps.
2. Caldwell-Luc operation is reserved for rare situations where the antral part cannot be accessed endoscopically via the natural ostium or a middle meatal antrostomy. It is generally avoided in young children because of the risk of injury to developing tooth buds and maxillary growth centres.
   

   Postoperative corticosteroid sprays are not routinely indicated for AC polyp (which is infective/inflammatory, not primarily eosinophilic).

Differential Diagnosis of Antrochoanal Polyps

• Mucus blob: A blob of mucus may resemble a nasal polyp but usually disappears after nose blowing or suctioning.
• Concha bullosa: A concha bullosa is a pneumatized middle turbinate containing an air-filled cavity. It is best identified by nasal endoscopy and confirmed on CT when required. Unlike a nasal polyp, it is firm and non-compressible because it contains bone and air. It is usually pink and covered by normal nasal mucosa, whereas nasal polyps are typically pale, smooth, translucent, and edematous. A concha bullosa generally does not bleed on gentle touch.
• Angiofibroma: It typically presents in an adolescent male with recurrent, often profuse epistaxis and progressive unilateral nasal obstruction. On examination, it may appear as a smooth, firm, reddish or pink mass, usually arising in the posterior nasal cavity or nasopharynx, and may bleed easily. Biopsy should be avoided when JNA is suspected until appropriate imaging has assessed the lesion and its vascularity.
• Other neoplasms: Nasal neoplasms may present as irregular, fleshy, friable, or ulcerated masses and may bleed on contact. Their appearance and consistency can vary considerably, so endoscopic examination with appropriate imaging and histopathological evaluation may be required for definitive diagnosis.

Having discussed antrochoanal polyp, we now turn to the diffuse form of CRSwNP, which is bilateral, multiple, and typically seen in adults.

Bilateral ethmoidal polyps (Diffuse CRSwNP)

Site of Origin

Bilateral ethmoidal polyps arise from the lateral wall of the nasal cavity, typically originating in the middle meatus. Common sites include:

• Uncinate Process
• Bulla Ethmoidalis
• Sinus Ostia
• Medial Surface and Edge of the Middle Turbinate

Nasal polyps rarely develop from the nasal septum or the floor of the nasal cavity.

Age Group and Prevalence

Diffuse CRSwNP is most common in adults (peak 30–60 years). It is bilateral and multiple, and more frequent in males than in females.

Aetiology

The aetiology of diffuse CRSwNP is multifactorial. Important associated conditions include:

Associated Diseases with Bilateral Nasal Polyps in Adults

1. AERD (Samter’s Triad): Triad of asthma, aspirin sensitivity, and nasal polyps. AERD occurs in 8–26% of CRSwNP patients. Mechanism: COX-1 inhibition reduces prostaglandin E2 and alters arachidonic acid metabolism, resulting in increased production and release of cysteinyl leukotrienes and downstream type 2 inflammatory responses.
2. Asthma: Asthma is common in patients with CRSwNP and is associated with more severe disease and higher recurrence.
3. Allergic Fungal Sinusitis (AFRS): AFRS is a non-invasive fungal rhinosinusitis characterised by type 2 inflammation and eosinophilic/allergic mucin-containing fungal elements. CT shows heterogeneous hyperattenuating sinus contents, often described as a double-density sign.
4. EGPA (Eosinophilic Granulomatosis with Polyangiitis): A systemic small- and medium-vessel vasculitis associated with asthma and eosinophilia. Symptoms include malaise, fever, weight loss, and polyarthralgia. The historical term Churg-Strauss syndrome is no longer preferred.
5. Young Syndrome:A rare condition characterised by chronic rhinosinusitis, bronchiectasis, and obstructive azoospermia. Unlike primary ciliary dyskinesia, ciliary ultrastructure is typically normal.

Associated Diseases with Bilateral Nasal Polyps in Children

1. Cystic Fibrosis (Mucoviscidosis): An autosomal recessive CFTR disorder causing abnormal chloride and bicarbonate transport, producing dehydrated, viscous airway secretions. This impairs mucociliary clearance, blocks the osteomeatal complex, and results in chronic sinusitis and nasal polyps. The patient may also have repeated lung infections, intestinal obstruction and pancreatitis. Nasal polyps occur in 25–40% of CF patients.

Diagnostic: Sweat chloride test (>60 mmol/L), indicating abnormal chloride levels.

2. Primary ciliary dyskinesia (PCD): An inherited disorder characterised by abnormal ciliary structure and/or function, leading to impaired mucociliary clearance. Kartagener syndrome is the classic PCD phenotype with bronchiectasis, chronic sinusitis (with nasal polyps), and situs inversus (dextrocardia).

Diagnostic tests:

1. Nasal nitric oxide (nNO) — low supports PCD; high-speed video microscopy (HSVM) — assesses ciliary beat pattern/frequency.
2. Immunofluorescence (IF) and transmission electron microscopy (TEM) — identify ciliary protein/ultrastructural defects.
3. Genetic testing — confirms pathogenic variants; saccharin test is not recommended.

Symptoms

• Bilateral nasal obstruction (progressive)
• Anosmia/hyposmia (often the most bothersome symptom)
• Nasal discharge (anterior and/or posterior)
• Facial pain or pressure
• Headache
• Snoring and obstructive sleep apnoea symptoms
• Mouth breathing
• Reduced quality of life

Signs

• Ethmoidal polyps present as smooth, multiple, grape-like masses that are usually pale in colour. They may be either sessile (without a stalk) or pedunculated (with a stalk).
• Chronic cases may lead to a broadening of the nose and increased intercanthal distance (sometimes referred to as a “frog face” appearance).
• In advanced cases, a polyp may protrude from the nostril, appearing pink and congested, which can mimic a neoplasm.
• The nasal cavity may display purulent discharge due to concurrent sinusitis.

Pathology

Nasal polyps are composed of loose connective tissue with inflammatory cells, covered by pseudostratified ciliated epithelium. The submucosa has large intercellular spaces filled with serous fluid, with infiltration of eosinophils and other inflammatory cells. Eosinophilic CRS (eCRS): Defined as ≥10 eosinophils/HPF on histopathology (EPOS 2020). eCRS is associated with higher asthma prevalence and higher polyp recurrence rates.

Investigations

1. DNE – to see the extent of polyp
2. C/S of discharge.
3. Imaging –CT PNS defines disease extent and assists surgical planning. Bony erosion, expansion, or atypical features should raise suspicion for neoplasia, AFRS, or other diagnoses. The Lund-Mackay score can be used to quantify CT disease burden.
4. Routine Investigations – For workup of surgery.
5. Allergic testing – Skin prick test, RAST to identify the allergen. IgE and absolute eosinophil count may be elevated.
6. SNOT-22 — quality of life assessment.

Treatment

Goals of Treatment: The primary goal of treatment is to eliminate any underlying systemic disease, relieve symptoms, restore nasal breathing and sense of smell (olfaction), and prevent recurrence. 

Medical Management

1. Corticosteroids:

• Topical: Intranasal corticosteroid spray reduces early polypoidal changes and recurrence. Common side effects include local irritation and rare systemic effects. Saline nasal spray can also be given to improve mucociliary function.
• Systemic: Mainly used for larger polyps or severe cases. For larger polyps, short courses of systemic corticosteroids like prednisolone (0.5 mg/kg each morning for 5–10 days) may be used, followed by maintenance therapy with topical sprays to sustain improvement.

Before prescribing systemic corticosteroids, assess individual risks (diabetes, hypertension, peptic ulcer, osteoporosis, active infection, pregnancy). These are not absolute contraindications to a short course.

2. Antihistamines: Beneficial only if an allergy is present.

3. Leukotriene Inhibitors: Helpful for patients with asthma or aspirin sensitivity.

4. Nasal Douching:  Large-volume saline irrigation helps clear mucus and inflammatory material.

Surgical Management

1. Functional Endoscopic Sinus Surgery (FESS) is the most common procedure, aiming to improve sinus ventilation, improve drainage, and remove polyps. FESS offers a precise view of the surgical area, allowing for effective clearance of inflammatory tissue. The extent of surgery depends on the severity of the disease, the surgeon’s expertise, and available technology. In cases of allergic fungal sinusitis and antrochoanal polyps, endoscopic removal with complete clearance of the maxillary attachment is the treatment of choice.

Postoperative care:

• For AFRS: INCS sprays are recommended to reduce inflammation and prevent recurrence
• For AC polyp: postoperative corticosteroid sprays are not routinely indicated
• For other CRSwNP: nasal douching and corticosteroid therapy to minimise recurrence

Biologics (for refractory CRSwNP): Four biologics are FDA-approved for CRSwNP:

• Dupilumab (anti-IL-4Rα) – 300 mg initially, then 300 mg every 2 weeks
• Omalizumab (anti-IgE) – 75–600 mg subcutaneously every 2 or 4 weeks based on body weight and serum IgE
• Mepolizumab (anti-IL-5) – 100 mg subcutaneously every 4 weeks
• Tezepelumab (anti-TSLP) – 210 mg subcutaneously every 4 weeks

EPOS 2020 indications for biologics (in surgically treated patients, meet 3 of 5; in non-surgical patients, meet 4 of 5):

1. Evidence of Type 2 inflammation: tissue eosinophils ≥10/HPF, or blood eosinophils ≥250, or total IgE ≥100
2. Need for systemic corticosteroids or contraindication to systemic steroids (≥2 courses/year, or long-term low-dose steroids)
3. Significantly affected QoL (SNOT-22 ≥40)
4. Significant loss of smell
5. Comorbid asthma needing regular inhaled corticosteroids 

Important Considerations in Nasal Polyps

1. Polyps in Infants. Nasal polyps are uncommon in infants. When present, they may indicate conditions such as glioma, encephalocele, or meningoencephalocele. Do not biopsy or aspirate a suspected encephalocele before imaging. Improper removal or aspiration can lead to CSF rhinorrhoea or meningitis. The correct approach is imaging first (MRI preferred), then surgical planning with neurosurgery.

• Furstenberg Test: For encephaloceles, this test can help with diagnosis; the mass increases in size when intracranial pressure rises (e.g., during crying or jugular vein compression). A positive Furstenberg sign supports the possibility of an encephalocele but is not diagnostic. Imaging is essential.

2. Multiple Polyps in Children. The presence of multiple nasal polyps in children may be associated with mucoviscidosis (cystic fibrosis), a condition requiring further evaluation and management.

3. Polyps in the Elderly. In elderly patients, nasal polyps that appear red, fleshy, or granular may indicate potential malignancy. Careful examination and additional testing are recommended to exclude cancer.

4. Histological Examination: All removed polyps should be examined histologically to rule out malignancy.

5. Epistaxis and Orbital Symptoms: These symptoms in a patient with nasal polyps may suggest malignancy.

Table showing differences between Antrochoanal polyps and Ethmoidal polyps 

Feature	Antrochoanal Polyp	Ethmoidal Polyps
Age	Common in children and young adults	Common in adults
Aetiology	Usually associated with chronic inflammation or rhinosinusitis	Multifactorial; commonly associated with chronic rhinosinusitis and type 2 inflammation
Number	Usually solitary	Usually multiple
Laterality	Usually unilateral	Usually bilateral
Origin	Arises from the mucosa of the maxillary sinus, usually near the sinus ostium	Usually arises from the ethmoid region and middle meatus, often involving the ethmoid sinuses and adjacent sinonasal mucosa
Growth	Extends from the maxillary sinus into the nasal cavity and posteriorly toward the choana; a large polyp may extend into the nasopharynx	Typically involves the middle meatus and multiple sinonasal regions; polyps may extend anteriorly and may protrude through the nares when large
Size and Shape	Has antral, nasal, and choanal components. The choanal part is usually rounded and may fill the choana or extend into the nasopharynx.	Usually appears as multiple, smooth, pale, grape-like masses.
Symptoms	Usually presents with unilateral nasal obstruction. Obstruction may become bilateral when the polyp extends into the nasopharynx. Mucoid nasal discharge may occur on one or both sides. Hyponasal speech may occur with a large lesion. Reduced sense of smell may occur.	Usually presents with bilateral nasal obstruction. Reduced or absent sense of smell is common. Nasal discharge and postnasal drip may occur. Facial pressure or headache may occur with associated chronic rhinosinusitis. Sneezing and watery rhinorrhoea may occur when allergic rhinitis coexists.
Signs	May be difficult to detect on anterior rhinoscopy because it grows posteriorly. Appears as a smooth, greyish or pale, glistening mass, often covered with nasal discharge. Usually soft and mobile. A large polyp may protrude through the nostril or extend behind the soft palate into the oropharynx.	Appears as smooth, pale, translucent, grape-like masses. Usually multiple and bilateral. May be sessile or pedunculated. Usually does not bleed on gentle touch. Long-standing extensive disease may cause broadening of the nose and increased intercanthal distance.
Recurrence	Recurrence is more likely if the maxillary attachment is not completely removed.	Recurrence is common because of the underlying chronic inflammatory disease.
Treatment	Endoscopic sinus surgery is the treatment of choice for symptomatic antrochoanal polyps. Complete clearance of the maxillary sinus attachment is important to reduce recurrence. Caldwell-Luc operation is reserved for selected cases when the maxillary attachment cannot be adequately accessed endoscopically.	Intranasal corticosteroids and saline irrigation are the mainstays of medical treatment. Short courses of systemic corticosteroids may be used in selected patients with severe disease or marked polyposis. Endoscopic sinus surgery is considered for persistent or uncontrolled disease despite appropriate medical treatment and for selected patients with extensive disease. Postoperative saline irrigation and intranasal corticosteroids help control inflammation and reduce recurrence. Biologic therapy may be considered in appropriately selected patients with severe uncontrolled CRSwNP.

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High-Yield Points for Exams

1. AC polyp = Killian’s polyp = unilateral, solitary, children/young adults, maxillary antrum origin, grows posteriorly.
2. Diffuse CRSwNP = bilateral, multiple polyps, usually in adults, commonly involving the middle meatus.
3. ACP is a localised inflammatory lesion; diffuse CRSwNP is heterogeneous, with type 2 inflammation common but not universal.
4. Proetz theory: wide maxillary ostium → mucosal prolapse. Bernoulli: negative pressure → suction effect.
5. AERD (formerly Samter’s triad) = asthma + aspirin sensitivity + nasal polyps. AERD occurs in 8–26% of CRSwNP.
6. AFRS: type 2 inflammation, eosinophilic mucin-containing fungal elements, CT double-density sign.
7. Kartagener syndrome: bronchiectasis + chronic sinusitis + situs inversus (autosomal recessive).
8. Cystic fibrosis: sweat chloride ≥60 mmol/L is consistent with CF.
9. Biologics for CRSwNP: dupilumab, omalizumab, mepolizumab, tezepelumab.
10. Nasal polyps in infants: suspect encephalocele/glioma. Do NOT biopsy or aspirate. Furstenberg sign may support encephalocele, but imaging is essential.

NEET PG-Style MCQs

1. The most common site of origin of an antrochoanal polyp is: A) Ethmoid air cells B) Maxillary sinus mucosa C) Frontal sinus D) Sphenoid sinus
2. Killian’s polyp is another name for: A) Ethmoidal polyp B) Antrochoanal polyp C) Fungal polyp D) Inverted papilloma
3. The “double density sign” on CT is characteristic of: A) Antrochoanal polyp B) Allergic fungal rhinosinusitis C) Inverted papilloma D) Angiofibroma
4. Samter’s triad includes all EXCEPT: A) Asthma B) Nasal polyps C) Aspirin sensitivity D) Bronchiectasis
5. Which of the following tests is NOT recommended for diagnosis of primary ciliary dyskinesia? A) Nasal nitric oxide B) High-speed video microscopy C) Saccharin test D) Transmission electron microscopy
6. Which biologic is FDA-approved for CRSwNP? A) Adalimumab B) Dupilumab C) Infliximab D) Rituximab
7. eCRS is defined as eosinophils per high power field: A) ≥5 B) ≥10 C) ≥15 D) ≥20
8. Furstenberg test is positive in: A) Antrochoanal polyp B) Encephalocele C) Angiofibroma D) Inverted papilloma
9. Caldwell-Luc operation is avoided in young children primarily because of the risk of: A) Facial nerve injury B) Injury to developing tooth buds and maxillary growth centres C) Optic nerve injury D) Intracranial haemorrhage
10. Which syndrome includes bronchiectasis, chronic sinusitis, and situs inversus? A) Young syndrome B) Kartagener syndrome C) EGPA D) Samter’s triad

Answers: 1-B, 2-B, 3-B, 4-D, 5-C, 6-B, 7-B, 8-B, 9-B, 10-B

Case-Based Scenario Questions

• Case 1: A 12-year-old boy presents with unilateral nasal obstruction and thick nasal discharge for 6 months. Anterior rhinoscopy shows a pale, glistening mass in the right nasal cavity. Posterior rhinoscopy reveals a globular mass in the choana. CT shows a hypodense mass filling the right maxillary antrum and extending into the nasopharynx. Diagnosis: Antrochoanal polyp. Management: Endoscopic sinus surgery with complete clearance of the maxillary attachment.
• Case 2: A 45-year-old man with asthma and known aspirin sensitivity presents with bilateral nasal obstruction, anosmia, and recurrent polyps after two previous surgeries. CT shows pansinusitis with bilateral ethmoidal opacification. Blood eosinophil count is elevated. Diagnosis: AERD (Samter’s triad) with recurrent CRSwNP. Management: Medical therapy (INCS, short oral steroids, leukotriene inhibitor). Consider biologic (dupilumab/omalizumab) if refractory.
• Case 3: A 30-year-old man presents with bilateral nasal polyps, chronic productive cough, and infertility. Chest X-ray shows bronchiectasis. Semen analysis shows azoospermia. Diagnosis: Young syndrome (sinusitis-infertility syndrome). Management: Endoscopic sinus surgery for polyps, bronchiectasis management, fertility counselling.

Frequently Asked Questions in Viva

• Q1: What is Killian’s polyp? A: Another name for antrochoanal polyp.
• Q2: Why does AC polyp grow posteriorly? A: Due to ciliary beat direction (posterior) and negative pressure during inspiration (Bernoulli phenomenon).
• Q3: What is the Proetz theory? A: Faulty development of the maxillary sinus ostium (wider than normal) allows mucosa to prolapse into the nasal cavity.
• Q4: What is Samter’s triad? A: Asthma + aspirin sensitivity + nasal polyps (now termed AERD).
• Q5: What is the double density sign? A: CT finding in AFRS showing hyperattenuating fungal mucin surrounded by hypodense mucosa.
• Q6: What is the Furstenberg test? A: Compression of the jugular vein causes enlargement of the encephalocele due to increased intracranial pressure. It supports the diagnosis but is not diagnostic; imaging is essential.
• Q7: Why should you not biopsy a nasal mass in an infant? A: It may be an encephalocele; biopsy or aspiration can cause CSF leak and meningitis.
• Q8: What is eCRS? A: Eosinophilic chronic rhinosinusitis, defined as ≥10 eosinophils/HPF on histopathology (EPOS 2020).
• Q9: Name the biologics for CRSwNP. A: Dupilumab, omalizumab, mepolizumab, tezepelumab.
• Q10: When is Caldwell-Luc avoided in children? A: It is generally avoided in young children because of the risk of injury to developing tooth buds and maxillary growth centres.

——– End ——–

Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.

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