What is the best management approach for nasal polyps?

Management of Nasal Polyps

Start with intranasal corticosteroids as first-line therapy for all patients with nasal polyps, using 200 mcg daily of fluticasone propionate (or equivalent) for at least 1-3 months before considering other interventions. 1, 2, 3

Initial Medical Management

First-Line: Intranasal Corticosteroids

• Intranasal corticosteroids are the cornerstone of treatment, effectively reducing polyp size, nasal congestion, rhinorrhea, and improving nasal airflow 1, 2, 4
• Fluticasone propionate 200 mcg daily (two 50-mcg sprays per nostril once daily) is the standard starting dose for adults 3
• Twice-daily dosing is more effective than once-daily dosing for optimal polyp control 2
• Maximum benefit may take several days to weeks, with some symptom improvement as early as 12 hours 3
• Continue treatment for at least 1-3 months before declaring treatment failure 5, 2

Second-Line: Oral Corticosteroids

• Reserve short courses of oral corticosteroids (prednisone 25-60 mg daily for 5-20 days) for severe polyposis causing significant obstruction 2, 6
• Oral steroids provide rapid "medical polypectomy" with reduction in polyp size, symptom improvement, and restoration of smell 2, 6
• After oral steroid course, transition to maintenance intranasal corticosteroids 2
• Limit systemic steroid use to 1-2 courses per year maximum—more frequent use (>2-3 courses annually) indicates need for surgical referral, as the risks of repeated oral steroids exceed the risks of endoscopic sinus surgery 1, 5, 2

Adjunctive Therapies

• Saline irrigation improves mucociliary clearance and may enhance medication delivery 2
• Leukotriene modifiers (montelukast 10 mg daily) show mixed evidence but may provide subjective symptom improvement when added to intranasal corticosteroids 2
• Avoid chronic nasal decongestants (oxymetazoline, xylometazoline) due to rebound congestion risk 2

When to Consider Surgery

Clear Indications for Endoscopic Sinus Surgery

• Patients with high disease burden and severe obstruction of multiple sinonasal outflow tracts benefit most from early surgery 1
• Complete opacification of sinuses on CT scan with marginal response to medical therapy warrants surgical intervention 1
• Bony erosion or neo-osteogenesis on imaging indicates worse prognosis with medical therapy alone and favors surgery 1
• Patients requiring oral steroids more than once every 2 years (or annually if concurrent asthma present) should undergo surgery rather than continued systemic steroid exposure 1, 5

Surgical Outcomes

• Functional endoscopic sinus surgery combined with medical therapy provides greater improvement in disease-specific quality of life than medical therapy alone at 1 year 1
• Early surgical intervention results in more improvement in sinonasal disease burden compared to delayed surgery 1
• Surgery is particularly beneficial for eosinophilic mucin chronic rhinosinusitis with polyps and bone erosion 1

Biologic Therapy

When to Consider Biologics

• Consider biologics (dupilumab, omalizumab, or mepolizumab) for patients who have not sufficiently benefited from intranasal corticosteroids, surgery, or both 1
• Biologics provide moderate-certainty evidence for improvement in disease-specific quality of life and nasal symptoms 1
• Dupilumab and omalizumab show the greatest magnitude of benefit across patient-important outcomes, followed by mepolizumab 1
• Patients with high baseline disease severity are most likely to value the benefits of biologics over less certain benefits from other medical therapies 1

Special Populations for Biologics

• Patients with dual indications (e.g., atopic dermatitis and nasal polyps) may benefit from dupilumab 1
• For aspirin-exacerbated respiratory disease (AERD), biologics may be preferred over aspirin desensitization in patients with increased GI bleeding risk, prednisone use, hypertension, diabetes, or lower BMI 1
• Patients with eosinophilic granulomatosis with polyangiitis (EGPA) may benefit more from mepolizumab or benralizumab rather than dupilumab 1

Special Consideration: Aspirin-Exacerbated Respiratory Disease

• Aspirin desensitization followed by daily aspirin therapy (650 mg twice daily) significantly reduces sinus infections, need for systemic corticosteroids, and requirement for repeat polypectomies in AERD patients 1, 2
• 87% of AERD patients completing ≥1 year of aspirin treatment after desensitization experience improvement 1
• Benefits include reduced nasal symptoms, improved sense of smell, and decreased frequency of short prednisone courses 1

Referral Criteria

Urgent Specialist Referral Needed

• Failure to respond to 1-3 months of appropriate intranasal corticosteroid therapy 5
• Requirement for >2-3 courses of oral corticosteroids per year 5
• Extensive polyposis causing severe nasal obstruction 5
• Inability to visualize nasal cavity adequately to confirm diagnosis 5
• Unilateral polyps, atypical appearance, or bleeding lesions (rule out malignancy) 5

Common Pitfalls to Avoid

• Do not delay referral in severe polyposis by rigidly adhering to prolonged medical trials—this allows disease progression and worsens outcomes 5
• Do not assume all nasal masses are benign inflammatory polyps—unilateral presentation requires urgent evaluation 5
• Do not continue repeated courses of oral corticosteroids beyond 2-3 per year—transition to surgery or biologics instead 1, 5
• Do not use chronic nasal decongestants despite initial symptom relief 2

Pediatric Considerations

• Start children ≥4 years with fluticasone 100 mcg daily (one spray per nostril once daily) 3
• Reserve 200 mcg daily dosing for inadequate response to 100 mcg 3
• Monitor growth velocity routinely in children on intranasal corticosteroids, as growth suppression can occur even without HPA axis suppression 3
• Evaluate children with nasal polyps for cystic fibrosis 7