What is the medical management for nasal polyps?

Medical Management of Nasal Polyps

Intranasal corticosteroids are the first-line treatment for nasal polyps, with oral corticosteroids reserved for severe cases, and leukotriene modifiers as potential adjunctive therapy. 1

First-Line Treatment: Intranasal Corticosteroids

• Intranasal corticosteroids are effective in improving sense of smell and reducing nasal congestion in patients with nasal polyps 1
• Twice-daily dosing is more effective than once-daily dosing for optimal control of nasal polyps 1
• Intranasal corticosteroids work by reducing inflammation through multiple mechanisms, including decreasing the number of antigen-presenting cells, T cells, mast cells, and eosinophils 2
• Patients may start to feel relief on the first day of using intranasal corticosteroids, but it takes several days to build up to full effectiveness 3

Second-Line Treatment: Oral Corticosteroids

• For severe nasal polyposis, a short course of oral prednisone is effective in reducing symptoms, polyp size, and improving nasal flow 1
• After the initial reduction with oral steroids, maintenance therapy should be continued with intranasal corticosteroids 1
• Oral corticosteroids can serve as a "medical polypectomy" but should only be used for short-term improvement due to risk of adverse effects 4

Adjunctive Therapies

• Leukotriene modifiers (montelukast, zafirlukast, zileuton) have shown subjective improvement in nasal polyp symptoms when used as add-on therapy to intranasal corticosteroids 1
• After endoscopic sinus surgery, montelukast has shown similar efficacy to postoperative nasal beclomethasone in controlling recurrence rates 1
• For patients with Aspirin-Exacerbated Respiratory Disease (AERD) and nasal polyps, aspirin desensitization followed by long-term daily aspirin therapy may reduce nasal symptoms, frequency of sinus infections, requirement for nasal polypectomies, and need for systemic corticosteroids 1

Special Considerations

• Nasal polyps are more difficult to control in patients with asthma and AERD 1
• Patients with AERD and nasal polyps have worse outcomes with functional endoscopic sinus surgery than aspirin-tolerant patients 1
• Chronic nasal polyposis is associated with reduced quality of life and greater risk of sleep disturbances 1, 5
• Nasal polyps have a prevalence of 2-4% in the general population and usually occur after age 40 years 1

Treatment Algorithm

1. Initial Assessment:

   • Evaluate polyp size (grades 1-3) and symptom severity 2
   • Assess for comorbidities: asthma, AERD, cystic fibrosis 6

2. Small to Medium Polyps (Grades 1-2):

   • Start with intranasal corticosteroids twice daily 1
   • Monitor response over 2-4 weeks 7

3. Large Polyps (Grade 3) or Inadequate Response:

   • Short course of oral corticosteroids (e.g., prednisone) 1
   • Follow with maintenance intranasal corticosteroids 1
   • Consider adding leukotriene modifier if response is suboptimal 1

4. For Patients with AERD:

   • Consider aspirin desensitization followed by long-term daily aspirin therapy 1

5. When Medical Management Fails:

   • Consider referral for functional endoscopic sinus surgery 1
   • Resume intranasal corticosteroids post-surgery to prevent recurrence 2, 8

Common Pitfalls and Caveats

• Intranasal corticosteroids may cause minor nosebleeds, bad taste/smell, or nasal irritation, but serious side effects are rare 3
• Unlike nasal decongestant sprays, intranasal corticosteroids do not cause a "rebound effect" and can be used for up to six months in patients age 12 or older 3
• Patients should be advised that while they may feel some relief on the first day, full effectiveness of intranasal corticosteroids takes several days to develop 3
• If severe sinus pain or thick nasal discharge develops, patients should stop using intranasal corticosteroids and see a doctor as they may have an infection 3
• If symptoms don't improve after one week of treatment, patients should consult their doctor as they may have an infection requiring different treatment 3