Abstract
Unilateral nasal obstruction with intermittent epistaxis is a common presentation in ENT practice, yet it may represent a spectrum ranging from benign inflammatory disease to neoplastic pathology. This case describes an adult patient presenting with progressive unilateral nasal blockage and recurrent epistaxis initially treated as chronic rhinosinusitis. Further evaluation revealed an inverted papilloma with secondary sinus obstruction. The case highlights the importance of red-flag symptom recognition, appropriate imaging, and timely surgical referral to prevent delayed diagnosis and complications.
Introduction
Chronic nasal obstruction is frequently attributed to inflammatory conditions such as allergic rhinitis or chronic rhinosinusitis. However, unilateral symptoms, particularly when associated with epistaxis, facial pressure, or anosmia, should prompt clinicians to consider structural or neoplastic causes. Early recognition and investigation are essential to avoid delayed diagnosis, especially in lesions with malignant potential. This case illustrates the clinical reasoning required when evaluating persistent unilateral nasal symptoms.
Case Presentation
Clinical History
A middle-aged patient presented with a 9-month history of progressive right-sided nasal obstruction accompanied by intermittent epistaxis and reduced sense of smell. The patient had previously been treated in primary care with intranasal steroids and antihistamines for presumed chronic rhinosinusitis with minimal improvement. Over time, the patient developed facial pressure and reported occasional blood-stained nasal discharge, prompting referral to ENT services.
Examination
Anterior rhinoscopy demonstrated congestion and a polypoid mass within the right nasal cavity. Flexible nasendoscopy revealed a unilateral polypoid lesion arising from the lateral nasal wall with contact bleeding on examination. No cervical lymphadenopathy was present. These findings raised concern for a unilateral sinonasal mass rather than simple inflammatory polyposis.
Investigation Findings
CT imaging of the paranasal sinuses demonstrated a unilateral soft tissue lesion occupying the right nasal cavity and maxillary sinus with focal hyperostosis along the lateral
nasal wall. [Figure 1]
MRI confirmed a cerebriform pattern suggestive of inverted papilloma without intracranial or orbital extension. Endoscopic biopsy supported the diagnosis of inverted papilloma.
Figure 1
Discussion
This case highlights the importance of distinguishing unilateral sinonasal disease from bilateral inflammatory rhinosinusitis. While nasal polyps are common, unilateral lesions require thorough evaluation due to the risk of neoplasia. Inverted papilloma is a benign but locally aggressive tumour with a recognised risk of recurrence and malignant transformation. Typical features include unilateral obstruction, epistaxis, and a polypoid mass with focal hyperostosis on CT.
Delayed diagnosis may occur when symptoms are initially attributed to inflammatory disease. Endoscopic examination and imaging are therefore essential when symptoms persist despite appropriate medical therapy. Definitive management involves complete endoscopic surgical excision with long-term surveillance due to recurrence risk.
Conclusion
This case emphasises that unilateral nasal obstruction with epistaxis should always be considered a red-flag presentation requiring prompt ENT assessment. Early endoscopic examination and appropriate imaging are critical to avoid delayed diagnosis of neoplastic pathology.
For clinicians in primary care and ENT training, the case reinforces the need to escalate investigation when symptoms persist despite standard medical therapy. Multidisciplinary collaboration and structured postoperative surveillance remain essential to ensure optimal outcomes and early detection of recurrence.
