What is the best approach for managing nasal polyps?

Management of Nasal Polyps

Intranasal corticosteroids are the first-line treatment for nasal polyps, with twice-daily dosing being more effective than once-daily administration for reducing polyp size, nasal congestion, and improving sense of smell. 1

Understanding Nasal Polyps

Nasal polyps are inflammatory outgrowths of the paranasal sinus mucosa, typically arising from the middle meatus and ethmoid region. They affect approximately 2-4% of the general population and are characterized by:

• Persistent nasal congestion and obstruction
• Anosmia or hyposmia (reduced sense of smell)
• Rhinorrhea
• Reduced quality of life and sleep disturbances 1, 2

Nasal polyps are often associated with:

• Chronic rhinosinusitis
• Asthma (7-15% of adults with asthma have nasal polyps)
• Aspirin-exacerbated respiratory disease (AERD)
• Cystic fibrosis (especially in children)
• Chronic eosinophilic inflammation 1, 2

Treatment Algorithm

Step 1: Initial Medical Management

• Intranasal corticosteroids (first-line): Twice-daily dosing is more effective than once-daily dosing 1
  • Mometasone furoate, fluticasone propionate, or budesonide
  • Proper administration technique is crucial (see below)
  • Continue long-term to maintain improvement and prevent recurrence

Step 2: For Moderate to Severe Polyps

• Short course of oral corticosteroids (e.g., prednisone) for 1-2 weeks
  • Effectively reduces polyp size, improves nasal flow, and restores sense of smell
  • Follow with maintenance intranasal corticosteroids 1
• Corticosteroid-eluting implants may be considered
  • Bioabsorbable stents releasing mometasone furoate have shown significant reduction in nasal obstruction, polyp grade, and need for surgery 1

Step 3: For Refractory Cases

• Endoscopic sinus surgery when:
  • Medical therapy fails
  • Polyps cause severe obstruction
  • Recurrent sinusitis occurs 2, 3
• Post-surgical management:
  • Continue intranasal corticosteroids to prevent polyp recurrence
  • Studies show significantly reduced polyp recurrence with post-surgical intranasal corticosteroids 1

Special Considerations

• For patients with AERD:
  • Consider aspirin desensitization followed by long-term aspirin therapy
  • May reduce nasal symptoms, frequency of sinus infections, and need for repeated surgeries 1
• Adjunctive therapies:
  • Saline nasal irrigation helps improve symptoms and medication delivery 1
  • Leukotriene modifiers (montelukast, zafirlukast) may provide subjective improvement when added to intranasal corticosteroids 1

Proper Intranasal Corticosteroid Administration

1. Shake the bottle well
2. Look down by bending neck toward the floor
3. Insert nozzle just inside nostril (use right hand for left nostril, left hand for right nostril)
4. Aim toward outer wall and spray as directed; avoid aiming toward nasal septum
5. Change hands and repeat for other side
6. Do not sniff hard 1

Important Clinical Pearls

• Twice-daily dosing of intranasal corticosteroids is more effective than once-daily dosing for nasal polyps 1
• Patients with large polyps (grade 3) may benefit from a short course of oral corticosteroids or surgery before initiating intranasal corticosteroids, as medication delivery is difficult with severe obstruction 4
• Post-surgical patients have significantly greater polyp size reduction with intranasal corticosteroids compared to non-surgical patients 1
• Monitor for adverse effects of intranasal corticosteroids, which are generally mild and include epistaxis, nasal irritation, and dryness 1
• Allergy does not appear to predispose to polyp formation, though 10-15% of patients with allergic rhinitis also have nasal polyps 1

By following this structured approach to nasal polyp management, clinicians can effectively reduce morbidity, improve quality of life, and potentially delay or prevent the need for surgical intervention.