A 38-year-old man from Delhi presents with a 2-year history of progressive nasal obstruction, rhinorrhoea, and post-nasal drip. He reports recurrent sinusitis requiring multiple courses of antibiotics. On nasal endoscopy, bilateral smooth, pale, glistening masses are seen arising from the lateral nasal wall near the ostiomeatal complex. CT paranasal sinuses shows opacification of the maxillary and ethmoid sinuses with polypoid masses. He denies asthma, but spirometry reveals mild airflow obstruction. What is the most likely diagnosis?

Explanation

## Diagnosis: Chronic Rhinosinusitis with Nasal Polyposis ### Clinical Presentation **Key Point:** Bilateral nasal polyps with chronic rhinosinusitis symptoms (obstruction, rhinorrhoea, post-nasal drip) and recurrent sinusitis is the classic presentation of chronic rhinosinusitis with nasal polyposis (CRSwNP). ### Pathophysiological Features - Arises from lateral nasal wall and ostiomeatal complex (site of sinus drainage) - Bilateral involvement is typical - Associated with chronic inflammation and impaired mucociliary clearance - Polyps are smooth, pale, and glistening (oedematous mucosa) ### Associated Conditions **High-Yield:** The triad of nasal polyposis + asthma + aspirin sensitivity = Samter's triad (aspirin-exacerbated respiratory disease, AERD). This patient has mild airflow obstruction on spirometry, suggesting possible asthma association. ### Imaging Findings - CT shows opacification of maxillary and ethmoid sinuses - Polypoid masses visible on endoscopy - Ostiomeatal complex obstruction ### Pathological Features **Clinical Pearl:** Histopathology shows eosinophil-rich infiltration, basement membrane thickening, and stromal oedema. Type 2 helper T-cell (Th2) inflammation predominates. ### Management Approach 1. Nasal corticosteroid sprays (first-line) 2. Functional endoscopic sinus surgery (FESS) if medical management fails 3. Investigate for underlying asthma and AERD 4. Long-term follow-up due to recurrence risk (20–30%) [cite:Booth 27e Ch 402]