What is the treatment for nasal polyps?

Treatment of Nasal Polyps

Intranasal corticosteroids are the first-line treatment for nasal polyps, used twice daily for optimal control, with short courses of oral corticosteroids reserved for severe disease, followed by surgical intervention for patients who fail medical therapy. 1

First-Line Medical Management: Intranasal Corticosteroids

• Intranasal corticosteroids should be administered twice daily rather than once daily for superior efficacy in reducing polyp size, improving nasal congestion, and restoring sense of smell 1, 2

• Fluticasone propionate, budesonide, beclomethasone dipropionate, and mometasone furoate are all effective options, with demonstrated efficacy in multiple randomized controlled trials 3, 4

• Topical steroids work by reducing activated eosinophils, mast cells, T cells, and antigen-presenting cells at the cellular level 3

• These medications do not cause rebound congestion and can be used for up to 6 months continuously in patients age 12 and older 5

• Avoid nasal decongestants (oxymetazoline, xylometazoline) for chronic use despite limited evidence of benefit, due to concerns about rebound congestion 1

Second-Line Treatment: Oral Corticosteroids for Severe Disease

• For severe nasal polyposis with significant obstruction, prescribe oral prednisone 25-60 mg daily for 5-20 days to provide rapid symptom reduction, decreased polyp size, and improved nasal airflow 1, 2

• Oral methylprednisolone (32 mg/day tapering over 20 days) reduces symptoms for 4 weeks and polyp scores for 55 days 1

• After oral steroid-induced reduction, transition immediately to maintenance therapy with twice-daily intranasal corticosteroids to prevent recurrence 1

• The European Position Paper on Rhinosinusitis recommends limiting systemic corticosteroids to 1-2 courses per year as adjunctive therapy in patients with partially controlled disease 1

Adjunctive Medical Therapies

• Montelukast 10 mg daily may be added to intranasal corticosteroids for subjective improvement in total symptoms, headache, sense of smell, and sneezing at 8-12 weeks 1, 2

• Saline nasal irrigation improves mucociliary clearance and sinus ostia patency, serving as useful adjunctive therapy 1

• For patients with Aspirin-Exacerbated Respiratory Disease (AERD), aspirin desensitization followed by long-term daily aspirin therapy reduces nasal symptoms, frequency of sinus infections, and requirement for repeat polypectomies 1, 6

Surgical Intervention

• Surgery is indicated when patients fail appropriate medical therapy (minimum 1-3 months of intranasal corticosteroids, with or without oral steroids) or require repeated courses of oral corticosteroids 7

• Functional endoscopic sinus surgery is superior to simple polypectomy and should include full exposure of affected sinuses, removal of diseased tissue, and correction of anatomic obstruction (septal deviation, turbinate hypertrophy) 7

• Patients requiring surgery must continue twice-daily intranasal corticosteroids indefinitely post-operatively to prevent recurrence (60-70% maintain polyp control at 18 months with continued medical therapy) 7

• Major complications occur in less than 1% of cases, with revision surgery required in approximately 10% within 3 years 7

Special Populations and Considerations

Pediatric Patients

• Screen all pediatric patients with nasal polyps for cystic fibrosis, as up to 50% of children with CF develop nasal polyposis 2, 6

• Consider evaluation for immotile cilia syndrome in children with nasal polyps 2

• Use the same treatment algorithm as adults: intranasal corticosteroids twice daily first-line, oral steroids for severe disease, with surgical referral for refractory cases 2

Patients with Asthma and AERD

• Nasal polyps are more difficult to control in patients with asthma and AERD, who have worse surgical outcomes than aspirin-tolerant patients 1

• These patients benefit most from aspirin desensitization post-operatively if AERD is present 7

Treatment Algorithm

1. Initiate twice-daily intranasal corticosteroids for all patients with nasal polyps 1

2. If severe obstruction or inadequate response after 1-3 months, add oral prednisone 25-60 mg daily for 5-20 days, then return to intranasal steroids 1, 7

3. Consider adding montelukast 10 mg daily for additional symptom control 1

4. If requiring more than 1-2 courses of oral steroids per year or persistent severe symptoms, refer for functional endoscopic sinus surgery 1, 7

5. Post-operatively, continue twice-daily intranasal corticosteroids indefinitely 7

6. Evaluate for AERD and consider aspirin desensitization in appropriate candidates 1, 7

Common Pitfalls to Avoid

• Do not use nasal decongestants chronically, as they cause rebound congestion despite one small study showing benefit 1

• Do not delay surgery in patients requiring repeated oral steroid courses, as the risks of repeated systemic steroid use exceed surgical risks 7

• Do not perform simple polypectomy alone; functional endoscopic sinus surgery with full sinus exposure is superior 7

• Do not discontinue intranasal corticosteroids after surgery, as this leads to high recurrence rates 7

• Patients with higher BMI may require higher doses of experimental therapies like verapamil for adequate effect 8