What is the treatment for nasal polyps and concha bullosa?

Treatment of Nasal Polyps and Concha Bullosa

Intranasal corticosteroids administered twice daily are the cornerstone first-line treatment for nasal polyps, with short courses of oral corticosteroids reserved for severe cases or inadequate response to topical therapy. 1, 2

First-Line Medical Management

• Start with intranasal corticosteroids twice daily as the primary treatment, which significantly reduces polyp size, nasal congestion, and improves sense of smell 1, 2

• Twice-daily dosing is more effective than once-daily dosing for optimal polyp control 1, 2

• Specific agents with proven efficacy include:

  • Fluticasone propionate 200 mcg twice daily 3, 4
  • Mometasone furoate 200 mcg twice daily 5
  • Budesonide 128-200 mcg twice daily 5

• Add nasal saline irrigation as adjunctive therapy to improve mucus clearance and medication delivery 1

Treatment for Severe or Inadequate Response

• For severe nasal polyposis or inadequate response to intranasal corticosteroids alone, prescribe a short course of oral corticosteroids (prednisone 25-60 mg daily for 7-21 days) followed by maintenance with intranasal corticosteroids 1, 2
• Meta-analyses demonstrate that short courses of systemic corticosteroids significantly reduce total symptom scores and nasal polyp scores within 2-4 weeks 1
• Critical caveat: Maintenance therapy with intranasal corticosteroids after the oral steroid course is essential to prevent symptom recurrence 1, 2

Advanced Treatment Options

• For patients with inadequate response to standard medical therapy, consider corticosteroid-eluting sinus implants placed in the ethmoid sinus, which significantly reduce nasal obstruction, polyp grade, and need for surgery (OR 0.34) 1
• Leukotriene modifiers (montelukast 10 mg daily) may provide subjective improvement when added to intranasal corticosteroids, though evidence is mixed 1, 2
• For patients with aspirin-exacerbated respiratory disease (AERD) and nasal polyps, aspirin desensitization followed by long-term daily aspirin therapy may reduce nasal symptoms, frequency of sinus infections, and need for polypectomies 1, 2

Biologic Therapy

• Dupilumab 300 mg subcutaneously every 2 weeks is FDA-approved for chronic rhinosinusitis with nasal polyps in patients aged 12 years and older with inadequate control on standard therapy 6

Surgical Management

• Functional endoscopic sinus surgery (FESS) is indicated when medical treatment fails to adequately control symptoms 1
• Patients with AERD typically have worse surgical outcomes compared to aspirin-tolerant patients 1, 2
• Post-operative maintenance with intranasal corticosteroids prevents polyp recurrence significantly better than placebo (RR 0.73,95% CI 0.56 to 0.94) 5

Treatment Algorithm

1. Initial therapy: Intranasal corticosteroids (fluticasone 200 mcg or equivalent) twice daily + saline irrigation 1, 2
2. If inadequate response after 8-12 weeks: Add short course of oral prednisone 25-60 mg daily for 7-21 days, then continue intranasal corticosteroids 1, 2
3. If still inadequate: Consider corticosteroid-eluting implants, leukotriene modifiers, or biologic therapy (dupilumab) 1, 6
4. If medical management fails: Proceed to functional endoscopic sinus surgery with post-operative intranasal corticosteroids 5, 1

Regarding Concha Bullosa

• Concha bullosa (pneumatization of the middle turbinate) is an anatomical variant, not a disease requiring treatment unless it contributes to obstruction or recurrent sinusitis
• If concha bullosa is causing significant obstruction or contributing to chronic rhinosinusitis, surgical reduction may be considered during functional endoscopic sinus surgery
• Isolated concha bullosa without symptoms does not require treatment

Common Pitfalls to Avoid

• Do not rely on short courses of systemic corticosteroids alone without maintenance intranasal corticosteroids, as this leads to rapid symptom recurrence 1, 2
• Avoid nasal decongestants for chronic use in nasal polyps due to risk of rebound congestion 2
• Do not use once-daily dosing of intranasal corticosteroids when twice-daily dosing has superior efficacy 1, 2
• Failing to identify comorbid conditions such as asthma, AERD, or allergic fungal rhinosinusitis leads to suboptimal outcomes 1
• Patients with previous sinus surgery have significantly greater polyp size reduction with intranasal corticosteroids (RR 0.31) compared to those without prior surgery (RR 0.54) 5