What is the treatment for maxillary polyp with post nasal drip?

Treatment of Maxillary Polyp with Post Nasal Drip

Start with intranasal corticosteroids as first-line therapy, using mometasone furoate 200 μg twice daily for 16 weeks, which significantly improves postnasal drip, nasal obstruction, and reduces polyp size. 1

First-Line Medical Management

Intranasal Corticosteroids (Primary Treatment)

• Mometasone furoate nasal spray (MFNS) 200 μg twice daily is the optimal regimen, showing significant improvement in postnasal drip specifically at 4-8 weeks, along with reductions in nasal obstruction and polyp size at 4,8,12, and 16 weeks. 1

• The twice-daily dosing is superior to once-daily for postnasal drip relief—only the b.i.d. dose significantly improved postnasal drip at 4 weeks in controlled trials. 1

• Alternative intranasal corticosteroids with proven efficacy include fluticasone propionate 400 μg twice daily or budesonide, though mometasone has the strongest evidence for postnasal drip specifically. 1

• Continue treatment for at least 12-16 weeks to achieve maximal polyp reduction and symptom control, as benefits accumulate over time. 1

Short-Course Oral Corticosteroids (For Moderate-Severe Disease)

Add oral prednisolone 25-50 mg daily for 14 days when intranasal steroids alone provide insufficient relief, followed by maintenance with intranasal corticosteroids. 1, 2

• This combination provides significantly greater improvement in all nasal symptoms including postnasal drip, nasal airflow, and polyp size at 2 weeks compared to intranasal steroids alone. 1

• The prednisolone-treated group maintains superior improvements in most symptoms and polyp size through 7 weeks, with persistent benefits in smell and polyp reduction at 12 weeks. 1

• Use prednisolone 25 mg daily for 2 weeks in patients with diabetes to minimize glycemic fluctuations, rather than higher doses. 2

• Limit oral corticosteroid courses to 1-2 per year to minimize systemic adverse effects including adrenal suppression, insomnia, mood changes, and gastrointestinal disturbances. 1, 2

Adjunctive Therapies

Nasal Saline Irrigation

• Add high-volume saline irrigation (240 mL per nostril) to enhance medication delivery and mechanical clearance of secretions causing postnasal drip. 1

• Saline irrigation improves the penetration of intranasal corticosteroids into the maxillary sinus region where polyps originate. 1

Temporary Nasal Decongestants (For Severe Obstruction)

• Consider adding oxymetazoline for 4 weeks combined with MFNS when severe nasal blockage prevents adequate steroid delivery, as this combination significantly improves nasal blockage and polyp size without causing rebound congestion. 1

• The oxymetazoline-MFNS combination shows significantly greater improvement in blocked nose, smell, nasal mucociliary clearance, and total polyp score at both 4 and 6 weeks compared to MFNS alone. 1

• Do not use nasal decongestants beyond 4 weeks or as monotherapy—always combine with intranasal corticosteroids to prevent rebound swelling. 1

Surgical Intervention

Reserve endoscopic sinus surgery for patients who fail 12-16 weeks of maximal medical therapy or have severe obstruction causing recurrent sinusitis. 3, 4

• Maxillary sinus polyps can be excised via endoscopic surgery through the inferior meatus using minimally invasive techniques with low recurrence rates. 4

• After surgery, immediately start MFNS 200 μg once daily for at least 8 weeks to significantly prolong time to polyp recurrence compared to placebo. 1

• Postoperative oral corticosteroids (prednisone 30 mg for 7 days) do not provide additional benefit beyond topical steroids and surgery alone in most patients. 1

Treatment Algorithm

1. Weeks 0-4: Start MFNS 200 μg twice daily + high-volume saline irrigation
2. Week 4 assessment: If postnasal drip persists with severe obstruction, add oxymetazoline for up to 4 weeks
3. Week 8-12 assessment: If inadequate response, add oral prednisolone 25-50 mg daily for 14 days, then continue MFNS maintenance
4. Week 16 assessment: If symptoms persist despite maximal medical therapy, refer for endoscopic sinus surgery
5. Post-surgery: Resume MFNS 200 μg daily indefinitely to prevent recurrence

Critical Pitfalls to Avoid

• Never use oral corticosteroids as monotherapy—always combine with intranasal corticosteroids for maintenance after the short course. 1, 2

• Do not prescribe once-daily MFNS when postnasal drip is the primary complaint—twice-daily dosing is required for this specific symptom. 1

• Avoid extending oral corticosteroid treatment beyond 14 days, as adverse effects increase with longer duration without additional benefit. 1, 2

• Do not delay treatment for 12-16 weeks before considering surgery in patients with severe obstruction or recurrent sinusitis—these patients need earlier surgical referral. 3

• Postoperative patients require long-term intranasal corticosteroid maintenance, as polyp recurrence occurs in 10-30% without prophylaxis. 1, 5