A 38-year-old man from Delhi presents with a 2-year history of progressive nasal obstruction and recurrent rhinosinusitis. On nasal endoscopy, multiple pale, smooth, glistening polyps are seen bilaterally in the nasal cavity and extending into the maxillary sinuses. He has no history of asthma or aspirin sensitivity. CT PNS shows opacification of bilateral maxillary and ethmoid sinuses with polypoidal masses. Which of the following is the most likely diagnosis?

Explanation

## Diagnosis: Chronic Rhinosinusitis with Nasal Polyposis ### Clinical Presentation The patient presents with: - Bilateral, pale, smooth, glistening polyps (classic appearance) - Progressive nasal obstruction over 2 years - Recurrent rhinosinusitis - Bilateral sinus involvement on imaging - Absence of asthma or aspirin sensitivity (atypical for allergic polyps, but not exclusionary) ### Key Diagnostic Features **Key Point:** Chronic rhinosinusitis with nasal polyposis (CRSwNP) is characterized by bilateral polypoidal masses arising from the ethmoid sinuses, with pale, smooth, translucent appearance on endoscopy. **High-Yield:** The hallmark is **bilateral involvement** — this distinguishes CRSwNP from unilateral lesions like antrochoanal polyp or inverted papilloma. ### Pathophysiology CRSwNP results from chronic inflammation with: - Eosinophilic infiltration (Type 2 inflammation) - Increased mucin production - Tissue edema and remodeling - Polyp formation from ethmoid mucosa ### Differential Considerations | Feature | CRSwNP | Antrochoanal Polyp | Allergic Fungal Sinusitis | Inverted Papilloma | |---------|--------|-------------------|---------------------------|--------------------| | **Laterality** | Bilateral | Unilateral | Usually unilateral | Unilateral | | **Origin** | Ethmoid sinus | Maxillary sinus | Paranasal sinuses | Lateral nasal wall | | **Appearance** | Pale, smooth, glistening | Single stalk, smooth | Opacified sinuses, allergic mucin | Granular, cerebriform | | **Age** | Middle-aged adults | Children/young adults | Atopic individuals | Older adults | | **Malignant potential** | No | No | No | Yes (10–15%) | **Clinical Pearl:** CRSwNP is associated with Type 2 inflammation (elevated eosinophils, IL-5, IL-13) and may coexist with asthma and NSAID sensitivity (Samter's triad), though absence of these does not exclude the diagnosis. ### Management Approach 1. **Medical:** Intranasal corticosteroids (first-line) 2. **Surgical:** Functional endoscopic sinus surgery (FESS) for symptomatic polyps unresponsive to medical therapy 3. **Biologic therapy:** Dupilumab (anti-IL-4Rα) for severe, recurrent CRSwNP **Tip:** Always assess for associated asthma and atopy; CRSwNP is a marker of Type 2 inflammation.