What is the best course of treatment for a 43-year-old male patient with persistent bilateral nasal congestion and bimaxillary pain, diagnosed with nasal polyps, a deviated septum, and a history of nasal fracture, who has not responded to previous medications, including nasal sprays and oral medications, and is considering surgical intervention?

Treatment Approach for Bilateral Nasal Polyps with Failed Medical Therapy

This patient requires a short course of oral corticosteroids (prednisone 25-60 mg daily for 5-20 days) followed by CT sinus imaging and referral to otolaryngology for functional endoscopic sinus surgery, as he has extensive bilateral nasal polyposis that has failed topical intranasal corticosteroid therapy. 1, 2

Immediate Medical Management

Oral Corticosteroid Course

• Initiate a 2-week oral corticosteroid taper immediately (as already prescribed by the provider), which is the appropriate first-line intervention for severe nasal polyposis causing complete nasal obstruction. 1, 3
• The standard regimen is prednisone 25-60 mg daily for 5-20 days, or methylprednisolone 32 mg/day tapering over 20 days. 3
• This will provide rapid symptom reduction, decrease polyp size, and improve nasal airflow before transitioning to maintenance therapy. 3

Maintenance Intranasal Corticosteroids

• After completing the oral steroid course, prescribe twice-daily intranasal corticosteroids indefinitely to prevent rapid recurrence. 1, 3
• Intranasal corticosteroids are recommended for symptom relief of chronic rhinosinusitis with nasal polyps based on high-quality systematic reviews of randomized controlled trials. 1
• Patients should aim the spray toward the outer nasal wall (not the septum) using the contralateral hand to optimize delivery and minimize epistaxis risk. 1

Adjunctive Saline Irrigation

• Add nasal saline irrigation to the regimen for additional symptomatic relief. 1
• This provides benefit through mechanical clearance and is supported by Grade A evidence. 1

Diagnostic Imaging

CT Sinus Without Contrast

• CT of the paranasal sinuses without IV contrast is mandatory before surgical planning. 1
• Multidetector CT provides excellent bony detail to confirm chronic rhinosinusitis, evaluate the extent of disease, identify anatomic variants that narrow sinus drainage pathways, and assess critical structures like the lamina papyracea and skull base. 1
• CT is critical for surgical planning because it identifies anatomic variants and abnormalities that increase the risk for intracranial, intraorbital, and vascular injury during functional endoscopic sinus surgery. 1
• The bilateral nature of the polyps makes malignancy unlikely, but CT will definitively characterize the disease extent. 4

Specialist Referral and Surgical Planning

Otolaryngology Referral

• Refer to otolaryngology immediately given the extensive bilateral polyposis filling both nasal cavities with inability to visualize the middle meatus or sphenoethmoid recess. 2
• The American Academy of Otolaryngology-Head and Neck Surgery recommends referring patients with nasal polyps who fail to respond adequately to medical therapy with intranasal corticosteroids. 2
• Patients with extensive polyposis causing severe nasal obstruction warrant expedited referral to avoid unnecessary delays and disease progression. 2

Functional Endoscopic Sinus Surgery

• Functional endoscopic sinus surgery is indicated as the standard of care for restoring patency of paranasal sinus outflow tracts, with postoperative improvement in symptoms and quality of life reported in over 75% of patients. 1
• Surgery should be performed after the oral corticosteroid course and CT imaging are complete. 1
• The deviated septum noted on examination may be addressed during the same surgical procedure if it contributes to obstruction or limits surgical access. 1

Assessment for Associated Conditions

Screen for Asthma

• Evaluate this patient for asthma, as nasal polyps occur in 7-15% of adults with asthma, and the combination significantly impacts treatment strategy. 1
• Document whether asthma, aspirin sensitivity, cystic fibrosis, or immunocompromised state are present, as these are modifying factors for chronic rhinosinusitis with nasal polyps. 1
• If aspirin-exacerbated respiratory disease (AERD) is present, the patient may benefit from aspirin desensitization after surgery, which reduces nasal symptoms, frequency of sinus infections, and need for repeat polypectomies. 3

Consider Allergy Evaluation

• Although the patient reports no history of allergies, allergy does not appear to predispose to polyp formation, and only 10-15% of patients with allergic rhinitis have nasal polyps. 1
• Referral to allergist-immunologist may be considered for evaluation of underlying allergic factors or immunodeficiency states if clinically indicated. 2

Critical Management Points

Avoid Repeated Systemic Steroids

• Limit oral corticosteroids to 1-2 courses per year maximum to avoid cardiovascular, metabolic, and musculoskeletal risks. 3
• Patients requiring more than 2-3 courses per year should proceed to surgery, as the risks of repeated systemic steroid use surpass the risks of endoscopic sinus surgery. 2

No Role for Biopsy in Bilateral Disease

• Routine histological confirmation is not required for bilateral nasal polyps with typical clinical presentation, as the misdiagnosis rate is less than 1% in large retrospective studies. 4
• Biopsy would be indicated only if the polyps were unilateral, had atypical appearance (brick red, black necrotic areas, firm lobulated masses), or the patient had concerning demographics (pediatric age). 4

Address Past Nasal Drug Use

• The patient's admission of past nasal drug use should be documented, though this is not a contraindication to treatment. 1
• Ensure the patient is not currently using nasal decongestants chronically, as these cause rebound congestion and rhinitis medicamentosa. 3

Expected Outcomes and Follow-Up

• Oral corticosteroids provide significant reduction in nasal symptoms for 4 weeks and decreased polyp size lasting 55 days. 3
• Functional endoscopic sinus surgery combined with postoperative medical therapy (intranasal corticosteroids) provides the best long-term outcomes. 1
• Recurrence of nasal polyps is common, and lifelong medical therapy after surgery is often necessary. 5
• The patient should follow up after CT completion to review imaging and finalize surgical planning with otolaryngology. 1