Nasal Polyps — Treatment Overview

1. Medical Management

A. Intranasal Corticosteroids (INCS) — First-line

• Sprays and drops (e.g., mometasone, fluticasone, budesonide) are the cornerstone of long-term management
• Reduce polyp size, improve nasal airflow, and decrease symptoms
• Should be used continuously; drops (in head-down position) may reach more posterior polyps than sprays
• Evidence-based guidelines from the Allergy-Immunology Joint Task Force strongly support INCS use for CRSwNP

B. Systemic (Oral) Corticosteroids

• Short courses of oral corticosteroids (e.g., prednisolone) can significantly reduce polyp size and relieve obstruction
• Provide short-term relief but polyps typically recur after stopping treatment
• Not suitable for long-term continuous use due to systemic side effects (adrenal suppression, osteoporosis, hyperglycemia, etc.)
• Often used as a "medical polypectomy" before surgery or to manage severe flares

C. Nasal Saline Irrigation

• Adjunct therapy — improves mucociliary clearance and symptom control
• Well-tolerated with no significant side effects; can be used daily

D. Biologics (Monoclonal Antibodies) — Emerging/Advanced

E. Long-course Low-dose Macrolide Antibiotics

• Used in CRS without nasal polyps (CRSsNP) in patients with normal IgE levels
• Anti-inflammatory (immunomodulatory) rather than purely antimicrobial effect
• Example: Azithromycin or clarithromycin for 3+ months

2. Surgical Management

Functional Endoscopic Sinus Surgery (FESS)

• The standard surgical approach (Bailey & Love's, p. 792)
• Endoscopic nasal polypectomy is performed using a powered nasal microdebrider
• Opens sinus drainage pathways, removes polyps, and improves ventilation
• Preceded by CT scan of the sinuses to:
  • Confirm extent of disease
  • Delineate bony anatomy (especially skull base and lamina papyracea)

Pre-operative Assessment

• CT imaging is mandatory to assess:
  • Level and symmetry of the anterior skull base
  • Integrity of the lamina papyracea (medial orbital wall)

Serious Complications of FESS

Polyps commonly recur after surgery; long-term medical therapy (INCS ± biologics) post-operatively is essential.

3. Aspirin Therapy After Desensitization (ATAD)

• For patients with NSAID-exacerbated respiratory disease (AERD / Samter's triad): asthma + nasal polyps + aspirin sensitivity
• Aspirin desensitization followed by daily aspirin can reduce polyp recurrence and improve quality of life
• Requires specialist supervision

4. Treatment Algorithm Summary

Diagnosis of CRSwNP
        ↓
Saline irrigation + Intranasal corticosteroids (INCS)
        ↓
Inadequate response?
   ├─ Add short course oral corticosteroids
   ├─ Consider ATAD if NSAID-sensitive
   └─ Consider biologics (dupilumab, mepolizumab, omalizumab)
        ↓
Still refractory? → FESS + continue INCS post-op
        ↓
Recurrence after FESS? → Biologics strongly considered

5. Special Considerations

• Bailey and Love's Short Practice of Surgery, 28th Ed., p. 792
• Medical Management of Chronic Rhinosinusitis with Nasal Polyposis — Allergy-Immunology Joint Task Force Guidelines, p. 1