What is the most effective treatment for a patient with bilateral nasal polyps, Chronic Rhinosinusitis (CRS), and smell problems?

Treatment of Bilateral Nasal Polyps with CRS and Anosmia

For a patient with bilateral nasal polyps, chronic rhinosinusitis, and smell problems, the most effective treatment among the options listed is either mometasone spray (option d) or fluticasone spray (option c), as intranasal corticosteroids are the first-line, evidence-based treatment for this condition. 1

Why Intranasal Corticosteroids Are the Answer

• Intranasal corticosteroids are specifically recommended as first-line treatment for nasal polyps by the American Academy of Allergy, Asthma, and Immunology, with proven efficacy in improving sense of smell and reducing nasal congestion. 1

• Both mometasone and fluticasone are effective intranasal corticosteroids that significantly decrease polyp size, nasal congestion, and rhinorrhea while increasing nasal airflow and improving olfactory function. 2, 3

• Twice-daily dosing is more effective than once-daily dosing for optimal control of nasal polyps, so either mometasone or fluticasone should be administered twice daily. 1

• Long-term treatment with intranasal corticosteroids reduces inflammation and nasal polyp size while improving nasal symptoms including loss of smell, which directly addresses this patient's anosmia. 4

Why the Other Options Are Incorrect

Acyclovir (Option a)

• Acyclovir is an antiviral medication with no role in treating nasal polyps or CRS, as this is an inflammatory condition, not a viral infection.

Decongestant Spray Containing Zinc (Option b)

• Nasal decongestants are NOT recommended for chronic use in nasal polyps despite one small study showing benefit with oxymetazoline, due to concerns about rebound congestion and rhinitis medicamentosa. 1
• The EPOS2020 steering group specifically advises against using nasal decongestants in chronic rhinosinusitis with nasal polyps. 1
• Zinc-containing nasal sprays have been associated with permanent anosmia and should be avoided, particularly in a patient already experiencing smell problems.

Oral Steroid (Option e)

• While oral corticosteroids are effective, they are reserved for severe cases and represent second-line treatment, not first-line therapy. 1
• Short courses of oral prednisone (25-60 mg daily for 5-20 days) are used for severe nasal polyposis to achieve rapid symptom reduction, but must be followed by maintenance intranasal corticosteroids. 1, 5
• Systemic corticosteroids should be limited to 1-2 courses per year maximum due to cardiovascular, metabolic, and musculoskeletal risks. 5
• The benefit from oral corticosteroids is lost within 3-6 months, making them unsuitable as monotherapy. 6

Treatment Algorithm

Initial approach:

• Start with intranasal corticosteroids (mometasone or fluticasone) twice daily as first-line therapy. 1, 4
• Continue treatment long-term as intranasal corticosteroids have minimal systemic absorption (<0.5% bioavailability for second-generation formulations). 6

If intranasal spray fails:

• Consider intranasal corticosteroid drops (such as fluticasone propionate nasal drops), which may better reach the middle meatus where polyps originate. 4, 3
• Fluticasone propionate nasal drops reduced the need for surgery in 48% of patients versus 22% with placebo in patients awaiting functional endoscopic sinus surgery. 3

For severe disease only:

• Add a short course of oral corticosteroids (prednisone 25-60 mg daily for 5-20 days) followed by maintenance intranasal corticosteroids. 1, 5
• The European Position Paper on Rhinosinusitis recommends 1-2 courses of systemic corticosteroids per year maximum as a useful addition to nasal corticosteroid treatment in patients with partially or uncontrolled disease. 1

Common Pitfalls to Avoid

• Do not use oral corticosteroids as monotherapy—always transition to or continue maintenance intranasal corticosteroids. 1, 5
• Avoid chronic use of nasal decongestants, which cause rebound congestion despite any perceived short-term benefit. 1
• Do not prescribe zinc-containing nasal products to patients with smell problems, as zinc can cause permanent anosmia.
• Patients with comorbid asthma may have less favorable responses to combination oral and topical corticosteroid therapy, requiring more aggressive management. 7