What is the recommended treatment for nasal polyps?

Nasal Polyp Treatment

Intranasal corticosteroids are the cornerstone of nasal polyp treatment and should be initiated as first-line therapy, with twice-daily dosing being more effective than once-daily administration. 1

First-Line Medical Management

Initiate intranasal corticosteroids twice daily plus saline nasal irrigation for all patients with nasal polyps. 2, 1

• Fluticasone propionate 400 μg twice daily or budesonide 256 μg twice daily significantly reduces polyp size, improves nasal airflow, and decreases nasal congestion compared to placebo 2, 3
• Twice-daily dosing demonstrates superior efficacy over once-daily regimens in reducing polyp size and improving peak nasal inspiratory flow 1, 3
• Saline nasal irrigation serves as essential adjunctive therapy to clear mucus and enhance medication delivery 2, 1
• Treatment duration should be at least 8-12 weeks to achieve optimal polyp reduction 2, 3, 4

Proper Administration Technique

Patients must use correct intranasal steroid technique to maximize efficacy and minimize adverse effects. 2

• Look downward by bending the neck toward the floor 2
• Use the right hand for the left nostril and left hand for the right nostril 2
• Aim toward the outer nasal wall, not the septum, to prevent epistaxis and irritation 2
• Avoid sniffing hard after administration 2

Escalation for Severe or Refractory Disease

For patients with severe symptoms or inadequate response to intranasal corticosteroids after 8-12 weeks, add a short course of systemic corticosteroids (7-21 days) at 25-60 mg oral prednisolone daily, followed by mandatory maintenance with intranasal corticosteroids. 1, 5

• Systemic corticosteroids significantly reduce total symptom scores and polyp scores within 2-4 weeks 1
• This approach serves as "medical polypectomy" for severe obstruction 6
• Critical pitfall: Relying on systemic corticosteroids alone without maintenance intranasal therapy leads to rapid symptom recurrence 1, 6

Additional Medical Options

• Leukotriene modifiers (montelukast, zafirlukast, zileuton) may provide subjective improvement when added to intranasal corticosteroids 1
• Corticosteroid-eluting sinus implants placed in the ethmoid sinus reduce nasal obstruction, polyp grade, and surgical need (OR 0.34) for patients failing standard therapy 1
• Short-term combination of oxymetazoline plus intranasal corticosteroids (4-6 weeks) may be more effective than intranasal corticosteroids alone without causing rebound congestion 1

Special Population: Aspirin-Exacerbated Respiratory Disease (AERD)

For patients with AERD and nasal polyps, consider aspirin desensitization followed by long-term daily aspirin therapy after initial medical management. 1, 5

• Aspirin desensitization reduces nasal symptoms, frequency of sinus infections, and need for polypectomies 1, 5
• These patients have worse surgical outcomes and higher recurrence rates compared to aspirin-tolerant patients 1, 7

Surgical Intervention

Functional endoscopic sinus surgery (FESS) is indicated when medical treatment fails to adequately control symptoms after appropriate trials of intranasal corticosteroids, systemic corticosteroids, and adjunctive therapies. 1, 7, 8

Surgical Indications

• Severe nasal polyposis causing complete obstruction despite comprehensive medical management 7, 8
• Patients requiring repeated courses of systemic corticosteroids (risks exceed surgical risks) 7
• Unilateral polyps or atypical presentations requiring tissue diagnosis 2
• Extension of polyps outside the nasal cavity 2

Critical Surgical Considerations

• Correction of anatomic obstruction (septal deviation, turbinate hypertrophy) should be performed concurrently to optimize outcomes 7
• Major complications occur in less than 1% of cases 7
• Mandatory post-operative management: Continue intranasal corticosteroids twice daily indefinitely to prevent recurrence 7, 8
• 60-70% of patients maintain polyp control at 18 months with continued post-operative medical therapy 7
• Revision surgery is required in approximately 10% of patients within 3 years 7

Treatment Algorithm Summary

1. Initial therapy (all patients): Intranasal corticosteroids twice daily + saline irrigation for 8-12 weeks 2, 1
2. If inadequate response: Add short course systemic corticosteroids (7-21 days) followed by maintenance intranasal corticosteroids 1, 5
3. If still inadequate: Consider corticosteroid-eluting implants or leukotriene modifiers 1
4. If medical failure: Proceed to FESS with mandatory post-operative intranasal corticosteroids 1, 7, 8

Common Pitfalls to Avoid

• Failing to use twice-daily dosing of intranasal corticosteroids reduces treatment efficacy 1, 3
• Improper administration technique (aiming toward septum) causes epistaxis and poor drug delivery 2
• Discontinuing intranasal corticosteroids after systemic steroid course or surgery leads to rapid recurrence 1, 7, 6
• Using nasal decongestants alone without corticosteroids causes rebound congestion 1
• Not identifying comorbid asthma, AERD, or allergic fungal rhinosinusitis results in suboptimal outcomes 1, 5
• Assuming surgery alone will cure the condition—nasal polyposis is a chronic inflammatory disease requiring lifelong medical management 8, 5