What are the management options for nasal polyps?

Management of Nasal Polyps

Intranasal corticosteroids are the first-line treatment for nasal polyps, with oral corticosteroids reserved for severe cases, and biologics or aspirin therapy after desensitization as additional options for specific patient populations. 1

First-Line Treatment

• Intranasal corticosteroids (INCS) are the cornerstone of nasal polyp management, effectively reducing polyp size, nasal congestion, and rhinorrhea while improving nasal airflow 1, 2
• Twice-daily dosing of INCS is more effective than once-daily dosing for optimal control of nasal polyps 1
• Different delivery methods include nasal spray, rinse/irrigation, exhalation delivery system, drops, and stents/dressing, with varying levels of medication penetration into the sinuses 3
• INCS are particularly effective for small to medium-sized polyps (grades 1 and 2) 2

Second-Line Treatment

• Short courses of oral corticosteroids are effective for severe nasal polyposis or when polyps are too large (grade 3) for topical medication to penetrate effectively 1, 2
• Oral corticosteroids can serve as a "medical polypectomy," rapidly reducing symptoms, polyp size, and improving nasal flow 4
• After initial reduction with oral steroids, maintenance therapy should be continued with intranasal corticosteroids to prevent recurrence 1, 4

Surgical Management

• Surgery is indicated when:
  • Polyps cause severe obstruction 5
  • Medical therapy has failed 5
  • Recurrent sinusitis occurs 5
• The goal of surgery is to restore physiological function of the nose by removing polyps and allowing drainage of infected sinuses 6
• Complementary medical treatment with INCS is always necessary after surgery, as the procedure cannot treat the underlying inflammatory component 6

Adjunctive Therapies

• Leukotriene modifiers (e.g., montelukast) can provide subjective improvement when used as add-on therapy to intranasal corticosteroids 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 and frequency of sinus infections 1
  • Decrease requirement for nasal polypectomies 1, 5
  • Reduce need for systemic corticosteroids 1
• Biologics are emerging as an important treatment option for CRSwNP, particularly for patients with severe disease 3
• Saline irrigation may help improve mucociliary clearance and secondarily improve the patency of the sinus ostia 3

Special Considerations

• Nasal polyps are more difficult to control in patients with asthma and AERD 1
• Children with nasal polyps should be evaluated for cystic fibrosis 5
• Nasal polyps occur more frequently in patients with:
  • Persistent asthma 5
  • Aspirin-exacerbated respiratory disease 5
  • Chronic rhinosinusitis 5
  • Cystic fibrosis 5

Treatment Algorithm

1. Initial Assessment:

   • Evaluate polyp size and associated conditions (asthma, AERD, etc.) 3, 5
   • Check for complications requiring urgent referral (orbital swelling, diplopia, forehead swelling) 3

2. First-Line Therapy:

   • Begin with intranasal corticosteroids twice daily for all patients 1
   • For small to medium polyps (grades 1-2), INCS may be sufficient as primary treatment 2

3. For Severe/Large Polyps:

   • Short course of oral corticosteroids (e.g., prednisone) followed by maintenance with INCS 1, 4

4. For Inadequate Response to Medical Therapy:

   • Consider surgical intervention (endoscopic sinus surgery) 5, 6
   • Continue INCS after surgery to prevent recurrence 6, 2

5. For Patients with AERD:

   • Consider aspirin desensitization followed by daily aspirin therapy 1, 5

6. For Refractory Cases:

   • Consider biologics targeting type 2 inflammation 3
   • Add leukotriene modifiers as adjunctive therapy 1

Common Pitfalls and Caveats

• Failure to continue INCS after surgical intervention often leads to polyp recurrence 6, 2
• Large polyps (grade 3) may not respond to INCS alone due to poor medication penetration; consider oral steroids or surgery first 2
• Nasal polyps are rarely "curable" in the true sense and typically require ongoing management 2
• Patients with AERD have worse outcomes with functional endoscopic sinus surgery than aspirin-tolerant patients 1
• Overlooking comorbid asthma may lead to suboptimal treatment outcomes 3, 5