Initial Treatment for Nasal Polyps
Intranasal corticosteroids are the first-line treatment for nasal polyps, used twice daily to reduce polyp size, decrease inflammation, and improve nasal congestion and sense of smell. 1, 2
First-Line Medical Management
Start with intranasal corticosteroids twice daily as the cornerstone of therapy, which significantly reduces inflammation, polyp size, and improves symptoms including nasal obstruction and olfaction 1, 2
Twice-daily dosing is superior to once-daily dosing for optimizing treatment effects 2
Specific agents with proven efficacy include:
Add nasal saline irrigation as adjunctive therapy to help clear mucus and improve medication delivery 2
Expect gradual improvement: Patients may notice some relief within the first day, but full effectiveness requires several days of consistent use 4
Duration of therapy: Intranasal corticosteroids can be used for up to 6 months in adults (age 12+) or up to 2 months per year in children (age 4-11) before requiring physician reassessment 4
When Initial Treatment Fails (Severe or Uncontrolled Symptoms)
Add a short course of oral corticosteroids (7-21 days) for severe nasal polyposis or when rapid symptomatic improvement is needed 1, 2
Specific oral corticosteroid regimens with proven efficacy:
Meta-analyses demonstrate that short courses of systemic corticosteroids significantly reduce total symptom scores and nasal polyp scores within 2-4 weeks of treatment initiation 2
Critical caveat: After completing the short course of oral corticosteroids, maintenance with intranasal corticosteroids is essential to sustain beneficial effects and prevent recurrence 1, 2
Treatment Algorithm
Initial therapy: Intranasal corticosteroids (mometasone, fluticasone, or budesonide) twice daily + nasal saline irrigation 2
If inadequate response after 1-2 weeks: Add short course (7-21 days) of oral prednisolone 25-60 mg daily 1, 2
Maintenance phase: Continue intranasal corticosteroids twice daily long-term 1, 2
If medical therapy fails: Consider functional endoscopic sinus surgery (FESS), followed by maintenance intranasal corticosteroids to prevent recurrence 2, 5
Important Clinical Considerations
Topical corticosteroids work locally in the nose with minimal systemic absorption, making them safe for long-term use 4, 5
No rebound effect occurs with intranasal corticosteroids, unlike nasal decongestants 4
Direct spray away from the nasal septum to minimize local side effects such as nasal irritation and bleeding 1
Monitor for severe sinus pain or thick nasal discharge, which may indicate bacterial sinusitis requiring antibiotic therapy 4
Children with nasal polyps should be evaluated for cystic fibrosis, as this is an important underlying cause in the pediatric population 6
Common Pitfalls to Avoid
Do not rely solely on short courses of oral corticosteroids without maintenance intranasal therapy, as this leads to rapid symptom recurrence 2
Do not use nasal decongestants as primary therapy, as they can cause rebound congestion (rhinitis medicamentosa) and do not address the underlying inflammation 1
Do not delay treatment while waiting for complete diagnostic workup in obvious cases—empiric treatment with intranasal corticosteroids is appropriate and safe 1, 5
Do not prescribe long-term or repeated courses of systemic corticosteroids due to significant risks including immunosuppression, metabolic changes, osteoporosis, and cardiovascular complications 7
Special Populations
Aspirin-exacerbated respiratory disease (AERD): Consider aspirin desensitization followed by long-term daily aspirin therapy, which may reduce nasal symptoms and need for polypectomies 2, 6
Comorbid asthma: Monitor total corticosteroid burden from both intranasal and inhaled corticosteroids 5
Postoperative patients: Intranasal corticosteroids prevent polyp recurrence significantly better than placebo (RR 0.73), with even greater benefit in patients with previous sinus surgery (RR 0.31) 2