What is the initial treatment for nasal polyps?

Initial Treatment for Nasal Polyps

Intranasal corticosteroids are the cornerstone of initial treatment for nasal polyps, significantly reducing inflammation, polyp size, and improving symptoms including nasal congestion and sense of smell. 1

First-Line Treatment Approach

• Intranasal corticosteroids should be administered twice daily for optimal effectiveness in controlling nasal polyp symptoms 1, 2
• Fluticasone propionate and other nasal corticosteroids have demonstrated efficacy in reducing polyp size and improving nasal airflow 3
• Nasal saline irrigation is recommended as an adjunctive therapy to help clear mucus and improve medication delivery 1
• Relief may begin on the first day of using intranasal corticosteroids, but several days of consistent use are required for full effectiveness 4

For Moderate to Severe Nasal Polyps

• When polyps are large (grade 3) or symptoms are severe, a short course of oral corticosteroids (7-21 days) is recommended 1, 5
• Typical regimens include oral prednisolone 25-60 mg daily for 1-2 weeks 1, 2
• After the short course of systemic corticosteroids, maintenance with intranasal corticosteroids is essential to sustain the beneficial effects 1, 2
• Short courses of oral corticosteroids significantly reduce total symptom scores and nasal polyp size within 2-4 weeks of treatment initiation 2

Treatment Algorithm

1. Initial therapy: Intranasal corticosteroids twice daily + saline irrigation 1
2. If inadequate response after 1-2 weeks: Short course of systemic corticosteroids (7-21 days) followed by maintenance intranasal corticosteroids 1, 2
3. For maintenance: Continue intranasal corticosteroids for long-term control 5

Advanced Treatment Options

• For patients with inadequate response to standard therapy, corticosteroid-eluting sinus implants placed in the ethmoid sinus can significantly reduce nasal obstruction and polyp grade 1
• Leukotriene modifiers (montelukast, zafirlukast, zileuton) may provide subjective improvement when used as add-on therapy to intranasal corticosteroids 1, 2
• The combination of oxymetazoline plus intranasal corticosteroids may be more effective than intranasal corticosteroids alone for short-term (4-6 weeks) treatment without causing rebound congestion 2

Surgical Management

• Functional endoscopic sinus surgery (FESS) is recommended when medical treatment fails to adequately control symptoms 1, 6
• Surgery aims to restore the physiological properties of the nose by removing polyps and allowing drainage of infected sinuses 6
• Complementary medical treatment with intranasal corticosteroids should be continued postoperatively to prevent recurrence 5, 7

Special Considerations

• For patients with aspirin-exacerbated respiratory disease (AERD) and nasal polyps, aspirin desensitization followed by long-term daily aspirin therapy may reduce nasal symptoms and frequency of sinus infections 1, 2
• Children with nasal polyps should be evaluated for cystic fibrosis 8
• Patients with AERD and nasal polyps typically have worse outcomes with FESS compared to aspirin-tolerant patients 1

Common Pitfalls and Caveats

• Relying solely on short courses of systemic corticosteroids without maintenance therapy leads to symptom recurrence 1, 5
• Using nasal decongestants alone without intranasal corticosteroids can lead to rebound congestion 2
• Failing to identify and address comorbid conditions such as asthma, AERD, or allergic fungal rhinosinusitis can lead to suboptimal treatment outcomes 1
• Intranasal corticosteroids do not cause rebound effects like decongestant sprays and can be used for extended periods (up to 6 months in patients age 12 or older) 4