Nasal Polyps and Sinus Surgery: What You Need to Know
- 11 hours ago
- 9 min read
Written by Mr Tim Biggs | Consultant ENT Surgeon | Rhinology & Facial Plastics
What Are Nasal Polyps?
Nasal polyps are benign, grape-like growths that arise from the lining of the nose and sinuses. They are not tumours and they are not cancerous, but they can cause considerable problems depending on their size and distribution. Small polyps may be entirely asymptomatic and discovered only incidentally. Larger polyps, or those arising in the sinuses and extending into the nasal airway, can cause significant obstruction, completely abolish the sense of smell, and drive chronic or recurrent sinusitis.
Polyps are the result of persistent mucosal inflammation. In the vast majority of cases, they are associated with a pattern of immune dysregulation driven by type 2 inflammation, a pathway involving mast cells, eosinophils, and cytokines such as IL-4, IL-5 and IL-13. This is the same immune pathway that underlies asthma and eczema, which is why these conditions so commonly coexist with nasal polyp disease. The clinical triad of nasal polyps, asthma, and aspirin sensitivity, known as Samter's triad or aspirin-exacerbated respiratory disease (AERD), represents one of the more challenging phenotypes to manage.
Understanding that polyps are a manifestation of underlying mucosal inflammation, rather than a purely mechanical problem, is fundamental to understanding why treatment is rarely a single event and why the approach needs to be sustained and individualized.
Symptoms: What Nasal Polyps Actually Feel Like
The symptoms of nasal polyp disease vary considerably between individuals, depending on polyp burden, sinus involvement, and whether associated conditions such as asthma are present. The most commonly reported symptoms include:
• Nasal obstruction, ranging from partial to complete bilateral blockage
• Loss or reduction of smell (hyposmia or anosmia), which is often the symptom patients find most distressing
• Postnasal drip and chronic catarrh
• Facial pressure or fullness, particularly around the cheeks and forehead
• Recurrent acute sinusitis, often requiring repeated courses of antibiotics
• Reduced sense of taste, secondary to loss of smell
• Snoring or disturbed sleep due to nasal blockage
Loss of smell deserves particular mention. Olfactory dysfunction in polyp disease is not simply caused by mechanical obstruction of the nasal airway. Inflammatory mediators directly affect the olfactory epithelium, which means smell may not fully recover even when the airway is surgically opened. Early, effective treatment of polyp disease offers the best chance of preserving and recovering olfactory function.
Diagnosing Nasal Polyp Disease
Diagnosis begins with a thorough history and nasal endoscopy. In clinic, I use a nasal endoscope to visualise the nasal cavity and identify polyps directly, assess their extent, and evaluate the middle meatus, where polyps most commonly originate. Endoscopy takes only a few minutes and is well tolerated with no preparation required.
For most patients being considered for surgery, a CT scan of the sinuses is obtained. This provides a detailed roadmap of sinus anatomy, polyp distribution, and any anatomical variants that are relevant to surgical planning. It also allows me to identify complications such as bony erosion or orbital or intracranial extension, which are rare but important to exclude before operating.
Blood tests including a full blood count (to assess eosinophilia) and allergy testing may be requested where relevant. In patients with severe or recurrent disease.
Medical Treatment: The Essential First Step
Surgery is not the first response to nasal polyp disease. Medical treatment forms the cornerstone of management and should be optimised before surgical intervention is considered, and continued rigorously after surgery to reduce the risk of recurrence.
Nasal Steroid Sprays and Drops
High-dose nasal corticosteroid sprays and, for more significant polyp burden, corticosteroid drops (used in the head-down-and-forward position to maximise delivery to the upper nasal cavity) are the mainstay of medical treatment. They reduce mucosal inflammation, can shrink smaller polyps, and are the single most important factor in preventing recurrence after surgery.
Compliance and technique matter enormously. Many patients who report that nasal steroids have not worked have in fact been using them incorrectly, or not consistently enough. I spend time at consultation reviewing technique and addressing barriers to adherence.
Short Courses of Oral Steroids
Oral corticosteroids (typically a short course of prednisolone) can produce a dramatic but temporary reduction in polyp size. They are useful diagnostically, to confirm the steroid-responsive nature of disease, and therapeutically, to open the airway ahead of elective surgery or imaging. They are not appropriate as long-term management due to systemic side effects.
Saline Irrigation
Regular nasal saline douching, using a high-volume rinse, improves mucociliary clearance, helps remove inflammatory debris from the sinuses, and enhances the penetration of topical steroid. It is a simple and underused adjunct that I recommend to all polyp patients.
Biologic Therapy
For patients with severe, refractory type 2 polyp disease, biologic agents targeting the underlying inflammatory pathway are now available. Dupilumab (Dupixent), a monoclonal antibody blocking the IL-4 and IL-13 receptor, has demonstrated substantial efficacy in clinical trials, producing marked reductions in polyp size, significant improvement in smell, and improved quality of life scores. It is licensed for severe chronic rhinosinusitis with nasal polyps (CRSwNP) in adults.
Biologic therapy does not replace surgery in most patients; rather, it sits alongside it. In some patients with very severe disease or significant surgical risk, it may allow deferral of surgery. In others, it is used post-operatively to maintain the gains achieved surgically. Access via NHS requires meeting specific NHSE criteria. I can guide patients through eligibility and, where appropriate, help initiate the pathway.
When Is Surgery Indicated?
Surgery becomes appropriate when nasal polyp disease is causing significant symptoms that have not responded adequately to optimised medical management. The decision is guided by symptom burden, quality of life impact, CT findings, and patient preference. Specific indications include:
• Significant nasal obstruction unresponsive to topical steroids
• Persistent or severe anosmia, particularly where recovery of smell is a priority
• Recurrent acute-on-chronic sinusitis with incomplete resolution between episodes
• Extensive sinus disease on CT with poor access for topical drug delivery
• Suspicion of a complication such as mucocoele, orbital involvement, or intracranial extension
• Patient wish for surgical management after informed discussion of risks and expected outcomes
I do not recommend surgery as a standalone treatment without a commitment to ongoing medical management. Patients who undergo FESS without maintaining nasal steroids and regular douching post-operatively have significantly higher recurrence rates. Surgery and medical treatment are complementary, not alternatives.
Functional Endoscopic Sinus Surgery (FESS): What It Involves
Functional endoscopic sinus surgery, or FESS, is the surgical gold standard for nasal polyp disease requiring operative intervention. It is performed entirely through the nostrils using a fine rigid endoscope, with no external incisions and no visible scarring. General anaesthetic is used.
What I Do During FESS
The goals of FESS in polyp disease are to remove polypoid tissue obstructing the sinuses, open the sinus drainage pathways to restore ventilation and mucociliary clearance, and create a widely patent cavity that allows post-operative topical steroid to reach the diseased mucosa. In more extensive disease, this may involve opening multiple sinuses, including the maxillary, ethmoid, frontal, and sphenoid sinuses.
I use image guidance (navigation) for complex or revision cases, where altered anatomy increases the risk of orbital or intracranial injury. A microdebrider, which simultaneously cuts and suctions tissue, allows precise removal of polypoid mucosa while preserving healthy tissue. I do not use nasal packing post-operatively; patients find recovery considerably more comfortable as a result, and there is no evidence that packing improves outcomes.
Duration and Admission
FESS is performed as a day-case procedure in the vast majority of patients. The duration of surgery depends on the extent of disease but typically ranges from 45 minutes to one and a half hours for bilateral polypectomy with full sinus clearance. Patients go home the same day.
Recovery After FESS
The first week after FESS involves some nasal congestion, blood-stained discharge, and crusting as the sinuses heal. Nasal saline douching begins from the first post-operative day and is important for keeping the cavity clean and promoting mucosal recovery. Most patients are back to normal activity within one to two weeks, though I advise avoiding strenuous exercise and air travel for the first two weeks.
Will My Polyps Come Back?
This is the question I am asked most frequently by patients with polyp disease, and it deserves an honest answer. Nasal polyps recur because the underlying inflammatory condition persists. Surgery removes the polyps and restores sinus ventilation, but it does not alter the immunological substrate that caused them in the first place.
Recurrence rates in the literature vary widely, reflecting differences in disease severity, phenotype, and post-operative management. In general, patients with more severe eosinophilic disease, AERD, or asthma have higher recurrence rates. Those who maintain high-dose nasal steroids, perform regular saline douching, and attend follow-up have lower rates.
Biologic therapy has changed the outlook for patients at high risk of recurrence. For those who meet the criteria, dupilumab in particular has demonstrated the ability to maintain post-surgical gains and, in some cases, prevent re-accumulation of polyps altogether.
My aim is always to give patients the most durable result possible, which means combining meticulous surgery with a clear plan for ongoing medical management tailored to their disease phenotype.
Arrange a Consultation
If you have been struggling with nasal polyps, blocked sinuses, or loss of smell and feel that your current treatment is not working, I would be glad to assess you. A full rhinological assessment, including nasal endoscopy, will clarify the extent of your disease and allow us to agree on the most appropriate management plan, whether that is optimisation of medical treatment, surgery, or a combination of both.
I see patients privately at Medicana Hospital in Winchester. I perform a high volume of FESS procedures and manage complex and revision polyp disease regularly, drawing on both my specialist rhinology training and my NHS caseload to offer the full breadth of modern sinus surgery techniques.
To arrange a consultation, please contact my secretary Michele Hewlett. Current fees are available on the Hampshire ENT Clinics website at www.hampshireentclinics.co.uk.
Michele Hewlett, Secretary to Mr Tim Biggs
Frequently Asked Questions
What causes nasal polyps?
Nasal polyps develop as a result of chronic mucosal inflammation driven by a type 2 immune response involving eosinophils and cytokines such as IL-4, IL-5 and IL-13. They are strongly associated with asthma, aspirin sensitivity, and allergic conditions. They are not caused by infection and are not malignant.
Can nasal polyps be treated without surgery?
Yes, in many cases. High-dose nasal corticosteroid sprays or drops are the mainstay of medical treatment and can shrink smaller polyps and control symptoms effectively. Short courses of oral steroids may be used for larger polyp burden. For severe, refractory disease, biologic therapy such as dupilumab is now available. Surgery becomes necessary when medical treatment fails to provide adequate symptom control.
What is FESS and how is it performed?
FESS stands for functional endoscopic sinus surgery. It is performed entirely through the nostrils using a fine rigid endoscope under general anaesthetic, with no external cuts or scarring. The procedure removes polypoid tissue, opens the sinus drainage pathways, and creates a widely patent cavity for post-operative topical steroid penetration. It is a day-case operation.
Will I lose my sense of smell after sinus surgery?
Surgery for nasal polyps is more likely to improve or preserve smell than to worsen it. Loss of smell in polyp disease is caused partly by mechanical obstruction and partly by inflammatory damage to the olfactory epithelium. Removing polyps and improving sinus ventilation gives the olfactory mucosa the best chance of recovery. However, if there has been long-standing inflammatory damage, some degree of anosmia may be permanent.
How long does recovery take after FESS?
Most patients are back to normal daily activities within one to two weeks. The first week involves nasal congestion, some blood-stained discharge, and crusting. Nasal saline douching from day one helps the sinuses heal. Strenuous exercise and air travel are avoided for two weeks. A post-operative endoscopic review in clinic is usually arranged at two to four weeks.
Is nasal packing used after sinus surgery?
Yes, small disolvable packing is used after FESS. They wash out within the first 3 days. You will be able to breathe straight away after surgery
What is dupilumab and is it available for nasal polyps?
Dupilumab (Dupixent) is a biologic monoclonal antibody that blocks the IL-4 and IL-13 signalling pathway, reducing the type 2 inflammatory response that drives polyp formation. It is licensed for severe chronic rhinosinusitis with nasal polyps and has demonstrated impressive efficacy in clinical trials. NHS access requires meeting specific NHSE criteria. I can advise on eligibility and help navigate the referral pathway where appropriate.
Can nasal polyps become cancerous?
Nasal polyps are benign inflammatory growths and do not become cancerous. However, on rare occasions, what appears to be a polyp on clinical examination may turn out to be a different type of lesion, including a sinonasal tumour. This is one reason why all apparent polyps should be assessed by an experienced rhinologist with nasal endoscopy, and why any atypical features on imaging or examination should be investigated further.
How likely are nasal polyps to recur after surgery?
Recurrence depends on disease severity, phenotype, and the quality of post-operative medical management. Patients with eosinophilic disease, AERD, or asthma have higher recurrence rates. Regular nasal steroids, saline douching, and follow-up significantly reduce the risk. Biologic therapy such as dupilumab has shown the ability to maintain surgical gains and reduce recurrence in high-risk patients.
Where does Mr Tim Biggs perform sinus surgery?
Mr Biggs performs FESS and nasal polyp surgery privately at the Medicana Hospital in Winchester, Hampshire. He undertakes a high volume of sinus procedures and manages complex and revision cases regularly.
How do I find out the cost of sinus surgery?
Consultation and surgical fees are listed on the Hampshire ENT Clinics website at www.hampshireentclinics.co.uk. To book a consultation, please contact Michele Hewlett, Mr Biggs's secretary.
