A 38-year-old man from Delhi presents with a 3-year history of progressive nasal obstruction, rhinorrhoea, and post-nasal drip. He reports recurrent episodes of acute rhinosinusitis treated with antibiotics. On nasal endoscopy, bilateral smooth, pale, gelatinous masses are seen arising from the lateral nasal wall near the ostiomeatal complex. CT paranasal sinuses shows multiple polyps with widening of the maxillary and ethmoid sinuses. He denies asthma, aspirin sensitivity, or chronic diarrhoea. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Chronic Rhinosinusitis with Nasal Polyposis ### Key Features in This Case **Key Point:** Bilateral nasal polyps in a middle-aged patient with chronic rhinosinusitis symptoms and no systemic features is the classic presentation of chronic rhinosinusitis with nasal polyposis (CRSwNP). ### Pathophysiology Chronic rhinosinusitis with nasal polyposis results from: 1. Chronic mucosal inflammation of the paranasal sinuses 2. Edema and polypoidal degeneration of the mucosa 3. Impaired mucociliary clearance and ostial obstruction 4. Secondary bacterial colonization and recurrent infections [cite:Bhattacharyya 2009 Otolaryngology] ### Diagnostic Criteria | Feature | CRSwNP | AERD | CF | AFS | |---------|--------|------|----|---------| | **Polyps** | Bilateral, pale | Bilateral | Bilateral | Unilateral/asymmetric | | **Asthma** | 20–40% | 100% | Variable | Rare | | **Aspirin sensitivity** | Absent | Present | Absent | Absent | | **Age of onset** | 30–50 years | 30–50 years | Childhood | 20–50 years | | **Imaging** | Opacified sinuses | Opacified sinuses | Opacified sinuses | Hyperdense material | | **Systemic features** | None | Asthma, rhinitis | Diarrhea, malabsorption | Fungal allergy | ### Why This Patient Has CRSwNP **High-Yield:** The absence of asthma, aspirin sensitivity, chronic diarrhea, and the bilateral presentation with typical ostiomeatal complex involvement all point to idiopathic CRSwNP. This is the most common form of nasal polyposis in non-atopic, non-allergic populations. ### Management Approach ```mermaid flowchart TD A[Nasal Polyps diagnosed]:::outcome --> B[Assess severity & symptoms]:::decision B -->|Mild| C[Intranasal corticosteroids]:::action B -->|Moderate-Severe| D[Functional Endoscopic Sinus Surgery]:::action D --> E[Post-op intranasal steroids]:::action E --> F[Long-term surveillance]:::outcome B -->|Refractory| G[Biologics: Dupilumab/Omalizumab]:::action ``` **Clinical Pearl:** Intranasal corticosteroids are first-line therapy for all CRSwNP. Functional endoscopic sinus surgery (FESS) is indicated for polyps causing significant obstruction or recurrent sinusitis despite medical management. ### Differential Exclusion **Key Point:** The absence of asthma and aspirin sensitivity rules out AERD (Aspirin-Exacerbated Respiratory Disease), which presents as a triad of asthma, chronic rhinosinusitis with polyps, and reactions to NSAIDs. [cite:Settipane & Stevenson 1999 Otolaryngology]