What are the optimal intranasal sprays and treatments for an adult with chronic nasal congestion and nasal polyps?

Optimal Treatment for Chronic Nasal Congestion and Nasal Polyps

Intranasal corticosteroids delivered via spray, drops, or irrigation are the first-line treatment for chronic nasal congestion and nasal polyps, with twice-daily dosing superior to once-daily administration. 1

Primary Treatment Approach

Intranasal Corticosteroids (First-Line)

Start with intranasal corticosteroid spray (e.g., mometasone, fluticasone, budesonide) at twice-daily dosing rather than once-daily, as this optimizes effectiveness in reducing nasal congestion and improving sense of smell 1. The European Position Paper on Rhinosinusitis (2020) provides Grade A evidence supporting intranasal corticosteroids for symptom relief 1.

Delivery method matters significantly:

• Nasal drops may be more effective than sprays for reaching the middle meatus where polyps originate, with fluticasone propionate nasal drops reducing the need for surgery in 48% of patients versus 22% with placebo 2
• Nasal irrigation (e.g., mometasone 2000μg in 240mL saline) shows superior improvement compared to nasal spray in nasal blockage, drainage, endoscopy scores, and CT scores at 12 months 1
• Exhalation delivery systems (EDS) and corticosteroid-eluting stents demonstrate moderate-to-high certainty evidence for improving nasal obstruction 1, 3

The 2022 network meta-analysis found that INCS via stent, spray, and EDS appear beneficial across the widest range of outcomes 3.

Corticosteroid-Eluting Implants (Office-Based Option)

For recurrent polyposis after surgery, bioabsorbable mometasone furoate-eluting stents (1350μg over 90 days) placed in-office significantly reduce nasal obstruction, polyp size, and the need for subsequent surgery (OR 0.37 for surgery indication versus placebo) 1. These implants improved sense of smell (MD -0.46) without increasing adverse events 1.

Severe Disease Management

Short-Course Oral Corticosteroids

For severe nasal polyposis, prescribe a short course of oral prednisone (e.g., 35mg reducing by 5mg every second day over 14 days) to rapidly reduce polyp size and symptoms, then maintain with intranasal corticosteroids 1. This approach is effective in reducing symptoms and improving nasal flow 1.

Biologic Therapy (Refractory Cases)

For patients with uncontrolled symptoms despite 4+ weeks of intranasal corticosteroids, consider biologic therapy:

• Dupilumab (300mg subcutaneously every 2 weeks) significantly improves SNOT-22 scores, nasal congestion, smell (UPSIT), nasal polyp scores, and CT scores at 24-52 weeks 1. The 2023 Joint Task Force guidelines suggest biologics for patients with high disease burden despite INCS 1.
• Tezepelumab (210mg subcutaneously every 4 weeks) demonstrated superior efficacy in a 2025 trial, reducing total nasal polyp score by -2.07 and nasal congestion score by -1.03 versus placebo, with only 0.5% requiring surgery versus 22.1% in placebo group 4
• IL-4 receptor alpha inhibitors (stapokibart, dupilumab) show the largest and most consistent benefits across outcomes in network meta-analysis 5

The 2023 guidelines make conditional recommendations for biologics based on moderate certainty evidence, emphasizing shared decision-making 1.

Adjunctive Therapies

Leukotriene Modifiers

Add montelukast, zafirlukast, or zileuton as adjunctive therapy to intranasal corticosteroids for subjective improvement in nasal polyp symptoms 1. Post-surgical recurrence rates with montelukast were equivalent to nasal beclomethasone 1.

Saline Irrigation

Recommend saline nasal irrigation for symptom relief as a safe, effective over-the-counter intervention 1. This provides mechanical removal of mucus and inflammatory products 1.

Nasal Decongestants (Limited Use)

Avoid routine use of nasal decongestants, though one study showed oxymetazoline combined with mometasone spray for 4 weeks improved nasal blockage and polyp size without rebound congestion 1. However, the EPOS2020 steering group generally advises against decongestants in chronic rhinosinusitis 1.

Special Populations

Aspirin-Exacerbated Respiratory Disease (AERD)

For patients with nasal polyposis and AERD (asthma + aspirin sensitivity), consider aspirin desensitization followed by long-term daily aspirin therapy to reduce nasal symptoms, sinus infections, and need for polypectomies 1.

Common Pitfalls to Avoid

• Underdosing intranasal corticosteroids: Twice-daily dosing is superior to once-daily 1
• Using only nasal spray when drops or irrigation may be more effective for reaching polyp origins 1, 2
• Delaying biologic therapy in patients with severe, uncontrolled disease despite adequate INCS trial 1, 4
• Prescribing probiotics: Two studies showed no benefit versus placebo 1
• Prolonged nasal decongestant use without corticosteroids risks rebound congestion 1