Step 1 of 14
Presentation & the Unilateral Red Flag
Unilateral obstruction/epistaxis · the bilateral-polyp vs unilateral-tumour rule · orbital/neuro features
A nasal mass presents with nasal obstruction, epistaxis or blood-stained discharge, hyposmia, facial pain or swelling, and a visible or palpable mass, and — when advanced — with epiphora (nasolacrimal obstruction), proptosis, diplopia or visual change, cheek or palatal swelling, facial numbness, and cranial neuropathy. The single most important observation is laterality and character: a unilateral nasal mass, unilateral obstruction, or recurrent unilateral epistaxis in an adult is a neoplasm until proven otherwise, whereas bilateral, pale, insensate masses are usually inflammatory polyps.
The presentation also flags the likely category. A child with a midline nasal mass raises a congenital lesion (dermoid, glioma, encephalocele); an adolescent boy with recurrent epistaxis and a nasopharyngeal mass raises juvenile nasopharyngeal angiofibroma; an adult with a fleshy unilateral mass raises an inverted papilloma or carcinoma; and a bony-hard mass raises an osteoma. Defining laterality, character, age, and any orbital or neurological feature at the outset sets the whole differential and the urgency.
- Symptoms — unilateral obstruction, epistaxis/blood-stained discharge, hyposmia, facial pain/swelling, visible mass
- Advanced — epiphora, proptosis, diplopia/visual change, cheek/palatal swelling, facial numbness, cranial neuropathy
- Cardinal rule — unilateral in an adult is a neoplasm until proven otherwise; bilateral pale masses are usually polyps
- Pattern by age — child/midline (congenital); adolescent boy/epistaxis (angiofibroma); adult fleshy (papilloma/carcinoma); bony-hard (osteoma)
★ High-yield pearls (chapter-wide)
- A unilateral nasal mass, unilateral obstruction, or recurrent unilateral epistaxis in an adult is a neoplasm until proven otherwise — never settle for 'polyp' on one side.
- Image before you biopsy — a vascular tumour (juvenile nasopharyngeal angiofibroma, haemangioma) or a meningoencephalocele biopsied in clinic can bleed catastrophically or open the subarachnoid space.
- Bilateral, pale, insensate masses in an adult are usually inflammatory polyps; a fleshy, vascular, or bony-hard unilateral mass is a tumour — laterality is the first discriminator.
- CT reads bone (erosion, remodelling, hyperostosis, calcification — and the focal hyperostosis that marks an inverted papilloma's attachment); MRI separates tumour from trapped secretions and defines orbital, dural, brain, and perineural spread — you need both.
- An adolescent boy with recurrent epistaxis and a nasopharyngeal mass has a juvenile nasopharyngeal angiofibroma until proven otherwise — diagnose it on contrast imaging, never by clinic biopsy, and embolise before resection.
- Inverted papilloma carries a ~5–10% risk of harbouring or developing squamous carcinoma, recurs if its attachment is left behind, and is cured by attachment-oriented resection with drilling of the underlying bone.
- Histology dictates strategy — sinonasal undifferentiated carcinoma and olfactory neuroblastoma favour multimodality or induction-first therapy, mucosal melanoma is surgery-led, and sinonasal lymphoma is not a surgical disease at all.
- Send fresh tissue and request flow cytometry whenever lymphoma is on the differential — formalin alone can lose the diagnosis.
- A persistent unilateral middle-ear effusion in an adult, or a midline nasal mass in a child, is a tumour or a congenital lesion until imaging and endoscopy say otherwise.
- Every malignant or skull-base case goes through a multidisciplinary tumour board before treatment, and the vascularised nasoseptal flap should be planned before resection because tumour or prior surgery may have destroyed its pedicle.
Evidence base
3 sources- MOD
Kuan EC et al. · Int Forum Allergy Rhinol · 2024Narrative reviewPMID 37658764
ICAR multidisciplinary consensus on sinonasal tumours — the contemporary reference standard for evaluation and staging.
- MOD
Llorente JL et al. · Nat Rev Clin Oncol · 2014Narrative reviewPMID 24935016
Comprehensive review anchoring epidemiology, risk factors, histologic/molecular classification, and treatment of sinonasal carcinoma.
- LOW
Turner JH & Reh DD · Head Neck · 2012Narrative reviewPMID 22127982
SEER analysis anchoring the rarity and the modest survival trends of sinonasal malignancy.
Decision tree
The triage screen is the first gate. Classification routes the stable patient to one of the aetiology-keyed pathways below. Cross-cut cards capture the chapter's must-not-miss rules.