What is the treatment for a child with nasal polyps?

Treatment of Nasal Polyps in Children

The first-line treatment for children with nasal polyps is intranasal corticosteroids, with oral corticosteroids reserved for severe cases, and surgery considered when medical management fails. 1

Evaluation and Diagnosis

When evaluating a child with nasal polyps, several important considerations should guide your approach:

• Underlying conditions: Nasal polyps in children should prompt evaluation for cystic fibrosis, as they occur in up to 50% of children with this condition 1, 2
• Clinical presentation: Children typically present with nasal obstruction, congestion, and potential loss of smell rather than facial pain or headache 2
• Physical examination: Nasal polyps appear as pale gray, semitranslucent growths in contrast to the surrounding pink nasal mucosa 2

Treatment Algorithm

First-Line Treatment

1. Intranasal corticosteroids
   • Mainstay of treatment for nasal polyps in children 1, 3
   • Significantly reduces polyp size, nasal congestion, and rhinorrhea 2
   • For children 4-11 years: Fluticasone propionate nasal spray 1 spray in each nostril once daily 4
   • Duration: Should use for shortest time necessary to achieve symptom relief; consult doctor if needed beyond 2 months 4

Second-Line Treatment

1. Short course of oral corticosteroids
   • For severe nasal polyposis or when intranasal steroids provide insufficient relief 1, 3
   • Acts as a "medical polypectomy" to rapidly reduce polyp size 3
   • Follow with maintenance therapy using intranasal corticosteroids 2

Adjunctive Treatments

1. Saline nasal irrigation

   • Helps with mechanical clearance of mucus and inflammatory products 5
   • Improves effectiveness of intranasal corticosteroids

2. Antibiotics

   • Reserved for cases with evidence of acute infection 1
   • Not proven effective for long-term management of nasal polyps unless there's a clear infectious component 3

Surgical Management

1. Surgical intervention
   • Indicated when medical management fails to control symptoms 1
   • Consider when polyps cause severe obstruction or recurrent sinusitis 2
   • In children with antral choanal polyps, combined Caldwell-Luc antrostomy and polypectomy may be most successful 6
   • Functional endoscopic sinus surgery (FESS) is the preferred surgical approach for most cases 7

Special Considerations

Cystic Fibrosis

• Children with nasal polyps should be evaluated for cystic fibrosis 2, 6
• In patients with cystic fibrosis, 60% can be adequately managed with intranasal polypectomy alone 6
• The inflammatory profile differs from non-CF polyps, with increased neutrophils rather than eosinophils 1

Allergic Fungal Rhinosinusitis

• Consider this diagnosis in children with nasal polyps and evidence of fungal involvement 1
• May require more aggressive treatment and antifungal consideration

Monitoring and Follow-up

• Monitor growth in children using intranasal corticosteroids, as they may affect growth rate in some children 4
• Regular follow-up is essential to assess treatment response and adjust therapy as needed
• Recurrence is common, requiring ongoing maintenance therapy with intranasal corticosteroids 8, 3

Pitfalls and Caveats

1. Growth concerns: Long-term use of intranasal corticosteroids may affect growth velocity in some children; use for shortest duration necessary 4

2. Misdiagnosis: Unilateral nasal masses in children should be carefully evaluated to rule out other conditions beyond inflammatory polyps 6

3. Incomplete treatment: Focusing only on polyp removal without addressing underlying inflammation leads to high recurrence rates 3

4. Delayed diagnosis of cystic fibrosis: Always consider and test for cystic fibrosis in children with nasal polyps 1, 2

5. Overuse of antibiotics: Antibiotics should only be used when there is clear evidence of infection, not as routine management 3

Remember that nasal polyps in children are unlikely to be completely cured by either medical or surgical therapy alone, but symptoms can generally be controlled with appropriate management 7.