First-Line Management of Nasal Polyps
Intranasal corticosteroids administered twice daily are the definitive first-line treatment for nasal polyps. 1
Mechanism and Efficacy of Intranasal Corticosteroids
Intranasal corticosteroids work by reducing inflammation through multiple mechanisms: decreasing vascular permeability, inhibiting inflammatory mediator release, and limiting infiltration of eosinophils, T-cells, and mast cells into polyp tissue. 1
Key clinical benefits include:
- Reduction in polyp size 1
- Relief of nasal congestion and rhinorrhea 2, 1
- Improvement in olfaction 1
- Prevention of post-surgical recurrence 1
Twice-daily dosing is significantly more effective than once-daily administration for optimal polyp control, making this the preferred regimen. 1, 3
When to Escalate Beyond First-Line Therapy
Reserve short courses of oral corticosteroids (prednisone 40-60 mg daily for 5-7 days, then taper over 7-14 days) for severe nasal polyposis when intranasal therapy alone proves insufficient. 1
Critical point: Oral corticosteroids must always be followed by maintenance intranasal corticosteroids, as benefits are not sustained after the oral course ends without continued topical therapy. 1, 3
Limit systemic corticosteroids to 1-2 courses per year maximum to avoid cardiovascular, metabolic, and musculoskeletal complications. 3
Adjunctive Therapies
Saline nasal irrigation should be recommended alongside intranasal corticosteroids for symptom relief, as it improves mucociliary clearance and sinus ostia patency. 2, 3
Montelukast 10 mg daily provides subjective symptom improvement when added to intranasal corticosteroids and shows comparable efficacy to postoperative nasal beclomethasone in controlling recurrence after endoscopic sinus surgery. 1, 3
Special Populations Requiring Modified Management
Patients with asthma or aspirin-exacerbated respiratory disease (AERD):
- AERD accounts for 13-40% of all nasal polyposis cases and requires more aggressive management due to higher recurrence rates. 4, 1
- The presence of asthma is NOT a contraindication to short-term oral corticosteroids for severe nasal polyposis. 4
- Consider aspirin desensitization followed by long-term daily aspirin therapy in AERD patients, as this reduces nasal symptoms, frequency of sinus infections, need for polypectomies, and systemic corticosteroid requirements. 4, 1, 3
Children with nasal polyps should be evaluated for cystic fibrosis. 5
What NOT to Do: Common Pitfalls
Do not prescribe antibiotics for nasal polyps themselves—they have no proven effect on polyps and should only be used when purulent nasal secretions indicate bacterial superinfection. 1, 6
Pooled analysis of double-blind trials showed no significant benefit of long-term macrolide therapy over topical corticosteroids (standardized mean difference 0.21, p = 0.83). 1
Do not use nasal decongestants for chronic management despite any perceived benefit, as they cause rebound congestion and rhinitis medicamentosa. 4, 3
Do not discontinue intranasal corticosteroids prematurely—patients may require 3-5 days before perceiving improvement, and long-term maintenance is essential to prevent recurrence. 1
Do not use oral corticosteroids as monotherapy without concurrent intranasal therapy, as this fails to maintain benefits after the systemic course ends. 4, 1
Confirming the Diagnosis
The American Academy of Otolaryngology-Head and Neck Surgery guideline emphasizes that clinicians should confirm the presence or absence of nasal polyps in patients with chronic rhinosinusitis, as this modifies management. 2
Nasal polyps appear as semitranslucent, pale gray growths in the nasal cavity, contrasting with pink or erythematous adjacent mucosa. 5