What is the primary treatment for nasal polyps?

Primary Treatment for Nasal Polyps

Intranasal corticosteroids administered twice daily are the primary treatment for nasal polyps, serving as the cornerstone of medical management to reduce polyp size, improve nasal breathing, and control symptoms. 1, 2, 3

First-Line Medical Management

Intranasal Corticosteroids

• Topical corticosteroids (fluticasone propionate, budesonide, beclomethasone dipropionate) are the medical treatment of choice for nasal polyps, with proven efficacy in reducing polyp size and rhinitis symptoms in multiple randomized controlled trials 4, 5
• Twice-daily dosing is superior to once-daily administration for optimal therapeutic effect 2, 3
• These agents work by reducing inflammatory cells including eosinophils, mast cells, and T cells in polyp tissue 4
• Treatment typically requires several days to achieve maximum effect, though symptom improvement may begin within 12 hours 6

Adjunctive Saline Therapy

• Nasal saline irrigation should be used alongside intranasal corticosteroids to clear mucus and improve medication delivery 2, 3

Treatment Algorithm for Escalation

For Small to Medium Polyps (Grades 1-2)

• Start with intranasal corticosteroids twice daily as monotherapy 4
• Continue as long-term maintenance therapy 7, 8

For Severe or Large Polyps (Grade 3)

• When polyps are large and obstruct nasal passages, a short course of oral corticosteroids (prednisone 25-60 mg daily for 7-21 days) is required to rapidly reduce polyp size and improve airflow 1, 2, 3
• This "medical polypectomy" allows effective delivery of topical medications 7
• After the short course of systemic steroids, maintenance with intranasal corticosteroids twice daily is essential to prevent recurrence 1, 2, 3

Add-On Therapies for Inadequate Response

• Leukotriene modifiers (montelukast) may provide subjective improvement when added to intranasal corticosteroids, though evidence is mixed 1, 2, 3
• For aspirin-exacerbated respiratory disease (AERD) patients with nasal polyps, aspirin desensitization followed by long-term daily aspirin therapy can reduce the need for polypectomies and systemic corticosteroids 1, 2, 3

Surgical Considerations

• Functional endoscopic sinus surgery should be reserved only for patients who fail to respond adequately to medical treatment 1, 2
• Surgery does not eliminate the need for ongoing medical therapy; intranasal corticosteroids must be continued postoperatively to prevent recurrence 1, 8
• In the majority of chronic rhinosinusitis patients, appropriate medical treatment is as effective as surgical treatment 1

Critical Pitfalls to Avoid

• Never rely on oral corticosteroids alone without transitioning to maintenance intranasal corticosteroids, as this leads to rapid symptom recurrence 2, 3
• Avoid nasal decongestants for chronic use in nasal polyps, as they can cause rebound congestion and are not recommended by current guidelines 3
• Do not use topical corticosteroids once daily when twice-daily dosing is indicated for active disease 2, 3
• Recognize that patients with AERD and asthma have more difficult-to-control polyps and worse surgical outcomes 1, 3

Dosing Specifics

• Adults: Start with 200 mcg daily (two 50-mcg sprays per nostril once daily or one spray per nostril twice daily) 6
• After 4-7 days of control, some patients may be maintained on 100 mcg daily 6
• Pediatric patients (≥4 years): Start with 100 mcg daily, reserve 200 mcg for inadequate responders 6