A 45-year-old man presents to the clinic with a 4-month history of persistent nasal congestion, facial pressure that worsens when bending forward, and a decreased sense of smell. He notes a constant thick, yellow discharge in the back of his throat. He has completed two courses of oral amoxicillin-clavulanate over the past few months with only temporary improvement. He has a history of seasonal allergies and asthma. Vital signs are within normal limits. On physical examination, there is tenderness over the maxillary sinuses and erythematous, edematous nasal mucosa. Anterior rhinoscopy reveals several pale, translucent, grape-like masses obstructing the middle meatus.
Which of the following is the most likely diagnosis?
The correct answer is:
C) Chronic rhinosinusitis with nasal polyposis
Chronic rhinosinusitis (CRS) is defined as inflammation of the paranasal sinuses lasting ≥ 12 weeks. It requires at least two of the following symptoms: nasal obstruction, nasal discharge (anterior or posterior), facial pain/pressure, or decreased sense of smell. This patient meets all criteria. The physical exam finding of grape-like masses in the middle meatus is pathognomonic for nasal polyps, which are non-cancerous outgrowths of inflamed sinonasal mucosa. The presence of asthma and allergies increases the risk for this specific phenotype of CRS.
Answer choice A: Acute rhinosinusitis, is incorrect. By definition, acute rhinosinusitis lasts less than 4 weeks. While the symptoms are similar, the 4-month duration and the presence of nasal polyps point definitively to a chronic process.
Answer choice B: Allergic rhinitis, is incorrect. While allergic rhinitis presents with congestion and rhinorrhea, it typically features clear, watery discharge and sneezing rather than thick, purulent discharge and facial pressure. While nasal polyps can occur in patients with allergies, CRS involves more extensive sinus inflammation than rhinitis alone.
Answer choice D: Granulomatosis with polyangiitis (GPA), is incorrect. GPA can present with chronic sinusitis symptoms, but it is typically associated with bloody nasal crusting, septal perforation (saddle nose deformity), and systemic symptoms like kidney involvement (hematuria) or pulmonary nodules.
Answer choice E: Inverted papilloma, is incorrect. This is a benign but locally aggressive tumor that typically presents as a unilateral nasal mass. Nasal polyps in CRS are usually bilateral and symmetric. Inverted papillomas also carry a risk of malignant transformation into squamous cell carcinoma and require surgical excision.
Key Learning Point
Chronic rhinosinusitis is diagnosed by symptoms lasting >12 weeks plus evidence of inflammation such as polyps on exam or opacification on CT. Management includes saline irrigation, intranasal corticosteroids, and, in cases with polyps, occasionally oral steroids. Patients with the triad of asthma, Aspirin sensitivity, and nasal polyps have Samter’s triad (aspirin-exacerbated respiratory disease).
