First-Line Treatment for Sinonasal Polyps
Intranasal corticosteroids are the first-line treatment for sinonasal polyps, significantly reducing inflammation, nasal polyp size, and improving symptoms including nasal congestion and sense of smell. 1
Treatment Algorithm
Initial Therapy
- Intranasal corticosteroids twice daily + saline irrigation as the cornerstone of treatment 1
- Twice-daily dosing of intranasal corticosteroids is more effective than once-daily dosing for optimizing treatment effects 1, 2
- Nasal saline irrigation is recommended as an adjunctive therapy to help clear mucus and improve medication delivery 1
For Moderate to Severe Symptoms or Inadequate Response to Initial Therapy
- Short course of systemic corticosteroids (7-21 days) followed by maintenance intranasal corticosteroids 3, 1
- Typical regimen: oral prednisolone 25-60 mg daily for 7-14 days 1, 4
- A 14-day course of 50 mg prednisolone has been shown to be safe and effective for symptomatic nasal polyposis 4
- Systemic corticosteroids significantly reduce total symptom scores and nasal polyp scores within 2-4 weeks of treatment initiation 3
Evidence for Efficacy
Intranasal Corticosteroids
- Mometasone furoate nasal spray is the only once-daily corticosteroid spray approved for the treatment of nasal polyposis in the EU and the only intranasal corticosteroid approved in the US for nasal polyposis 5
- Fluticasone propionate and beclomethasone dipropionate at 200 μg twice daily have demonstrated effectiveness in treating nasal polyp symptoms 2
- For patients with inadequate response to standard dosing, doubling the dose of intranasal corticosteroids may be effective for recurrent nasal polyps 6
Systemic Corticosteroids
- Short courses of systemic corticosteroids (7-21 days) are highly effective for severe nasal polyposis 3, 4
- The prednisolone-treated group shows significantly greater improvements in nasal symptoms, nasal airflow, and polyp size at 2 weeks compared to placebo 3
- Benefits include improved sense of smell, which is often not adequately addressed by intranasal corticosteroids alone 3, 4
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, polyp grade, and the need for surgery (OR 0.34) 3, 1
- Leukotriene modifiers (montelukast, zafirlukast, zileuton) may provide subjective improvement as add-on therapy to intranasal corticosteroids 3, 1
- For patients with aspirin-exacerbated respiratory disease (AERD) and nasal polyps, aspirin desensitization followed by long-term daily aspirin therapy may be beneficial 3, 1
Special Considerations
- Patients with AERD and nasal polyps typically have worse outcomes with functional endoscopic sinus surgery (FESS) compared to aspirin-tolerant patients 3, 1
- Functional endoscopic sinus surgery is recommended when medical treatment fails to adequately control symptoms 1, 7
Common Pitfalls and Caveats
- Relying solely on short courses of systemic corticosteroids without maintenance therapy leads to symptom recurrence 3, 1
- Using nasal decongestants alone without intranasal corticosteroids can lead to rebound congestion 1
- Failing to identify and address comorbid conditions such as asthma, AERD, or allergic fungal rhinosinusitis can lead to suboptimal treatment outcomes 3, 1
- Intranasal corticosteroids have limited effect on improving sense of smell compared to systemic corticosteroids 7