Initial Treatment for Nasal Polyps
Intranasal corticosteroids administered twice daily are the first-line treatment for nasal polyps, with mometasone furoate nasal spray (MFNS) 200μg twice daily or fluticasone propionate 200μg twice daily being the most effective options based on multiple high-quality trials. 1
First-Line Medical Management
Intranasal Corticosteroids (Primary Treatment)
Twice-daily dosing is superior to once-daily dosing for reducing polyp size, improving nasal obstruction, rhinorrhea, and sense of smell 1, 2
Specific regimens with proven efficacy:
- Mometasone furoate nasal spray 200μg twice daily significantly reduces polyp grade and improves all four cardinal symptoms (nasal obstruction, anterior rhinorrhea, postnasal drip, loss of smell) at 4,8,12, and 16 weeks 1
- Fluticasone propionate nasal drops 400μg twice daily demonstrates significant polyp size reduction and symptom improvement by 12 weeks 1, 3
- Fluticasone propionate aqueous nasal spray 200μg twice daily shows efficacy by 14 weeks with evidence of faster onset than beclomethasone 4
Duration of treatment: Continue long-term as maintenance therapy, as intranasal corticosteroids reduce inflammation, decrease polyp size, and prevent recurrence 5, 6, 7
Adjunctive Saline Irrigation
- Nasal saline irrigation should be added to intranasal corticosteroids to help clear mucus and improve medication delivery 2
Second-Line Treatment for Inadequate Response
Short-Course Oral Corticosteroids
When to use: Severe nasal polyposis with significant obstruction or inadequate response to intranasal corticosteroids after 4-8 weeks 2, 5, 6
Dosing regimen: Oral prednisolone 25-60mg daily for 7-21 days 8, 2
Evidence: Meta-analyses demonstrate significant reduction in total symptom scores and nasal polyp scores within 2-4 weeks of treatment initiation 2
Critical caveat: Short courses of systemic corticosteroids must be followed by maintenance intranasal corticosteroids to sustain beneficial effects and prevent rapid recurrence 2, 6, 7
Treatment Algorithm
Step 1: Initiate intranasal corticosteroid twice daily (MFNS 200μg bid or fluticasone propionate 200μg bid) plus saline irrigation 1, 2
Step 2: Assess response at 4-8 weeks by evaluating polyp size on nasal endoscopy and symptom improvement 1
Step 3: If inadequate response, add short course of oral prednisolone 25-60mg daily for 7-21 days, then continue maintenance intranasal corticosteroids 2, 6
Step 4: If still inadequate response after 12-16 weeks of optimal medical therapy, consider referral for functional endoscopic sinus surgery (FESS) with postoperative continuation of intranasal corticosteroids 2, 7
Special Populations and Considerations
Aspirin-Exacerbated Respiratory Disease (AERD)
Patients with AERD (nasal polyps, asthma, aspirin intolerance) may benefit from aspirin desensitization followed by long-term daily aspirin therapy to reduce nasal symptoms, sinus infections, and need for polypectomies 1, 2, 5
These patients typically have worse surgical outcomes and higher recurrence rates 2
Pediatric Patients
- Children presenting with nasal polyps should be evaluated for cystic fibrosis, as this is an uncommon finding in children without underlying systemic disease 5
Common Pitfalls to Avoid
Relying on oral corticosteroids alone without maintenance intranasal therapy leads to rapid symptom recurrence once systemic steroids are discontinued 2, 6
Using once-daily instead of twice-daily intranasal corticosteroid dosing results in suboptimal polyp reduction and symptom control 1, 2
Prescribing nasal decongestants as primary therapy can lead to rebound congestion (rhinitis medicamentosa) without addressing the underlying inflammatory process 1, 2
Failing to identify comorbid conditions such as asthma, AERD, or allergic fungal rhinosinusitis leads to suboptimal treatment outcomes 2, 5
Premature surgical referral before adequate trial of medical therapy (minimum 12-16 weeks of twice-daily intranasal corticosteroids, with or without short course of oral steroids) 1, 2