Management of nasal polyps (CRSwNP)

1. Confirm the diagnosis first

• Bilateral, soft, mobile, insensitive polyps are usually inflammatory. These are chronic rhinosinusitis with nasal polyps (CRSwNP), mostly driven by type 2 (IL-4, IL-5, IL-13, IgE, eosinophilic) inflammation. - Goldman-Cecil Medicine
• Unilateral polyp: treat it with suspicion, especially in older patients or those exposed to wood dust. The differential is antrochoanal polyp, inverted papilloma, or sinonasal malignancy. CT and biopsy are indicated. - Scott-Brown's ORL-HNS, Vol 1
• Biopsy caution: avoid biopsy of a polyp arising superiorly in the nose, or from the back of the nose in a juvenile male, until you have excluded encephalocele or angiofibroma. - Scott-Brown's ORL-HNS, Vol 1
• Children: exclude meningocele or encephalocele. Also think of cystic fibrosis in a child with polyps. - Bailey & Love, Goldman-Cecil
• Bleeding polyps may indicate malignancy. - Bailey & Love
• Look for associated conditions:
  • Asthma and aspirin sensitivity (AERD).
  • Allergic fungal rhinosinusitis. This shows thick eosinophilic mucin, high IgE, Charcot-Leyden crystals, and a double-density pattern on CT.
  • Cystic fibrosis.
  • Eosinophilic granulomatosis with polyangiitis (EGPA).

2. Medical therapy (first line)

• A systematic review of 34 placebo-controlled studies found INCS improve symptoms, especially nasal blockage. About half of patients report better smell and smaller polyps. - Scott-Brown's ORL-HNS, Vol 1
• Polyp size tends to fall only after several weeks of use.
• Fluticasone 400 μg/day and beclomethasone 400 μg/day both improved nasal volume and flow. Fluticasone worked faster. - Scott-Brown's ORL-HNS, Vol 1
• Delivery matters. Drops or high-volume rinses (budesonide) reach the sinuses better, particularly after surgery.

• In a trial in Scott-Brown, prednisolone 60 mg daily for 4 days, then tapered by 5 mg/day over 12 days, gave symptom improvement in 72% of patients and CT improvement in 52%. - Scott-Brown's ORL-HNS, Vol 1
• Benefits are temporary, and repeated courses carry systemic risks (bone, glucose, mood, adrenal suppression). Limit the number of courses.

• Saline irrigation.
• Antihistamine or allergen avoidance if allergic.
• Antibiotics only for acute bacterial exacerbation. Long-term low-dose macrolide is optional, and the evidence is weaker in high-IgE, type 2 disease.
• Intrapolyp steroid injection. A 2025 network meta-analysis exists (PMID 39707800), but this is not routine practice and carries a rare risk of visual complications.
• Aspirin desensitisation for AERD.

3. Surgery

• Polyps are removed with a powered microdebrider, and the sinuses are opened (ethmoidectomy at minimum). - Bailey & Love
• Unilateral polyps should be sent for histology. - Bailey & Love
• Continue INCS after surgery. Polyps recur often, especially with asthma, AERD, or allergic fungal rhinosinusitis.

4. Biologics for severe, uncontrolled disease

1. Evidence of type 2 inflammation.
2. Need for systemic steroids, or a contraindication to them.
3. Significantly impaired quality of life.
4. Significant loss of smell.
5. Comorbid asthma.

• Dupilumab (anti-IL-4Rα).
• Omalizumab (anti-IgE).
• Mepolizumab (anti-IL-5).
• Tezepelumab (anti-TSLP). One review states these four are FDA approved for refractory CRSwNP. A NICE appraisal of tezepelumab appeared in my search as a draft, which I haven't verified.

5. Practical pathway

1. Endoscopy, then CT if symptoms persist or the polyps are unilateral, atypical, or complicated.
2. Start INCS with saline irrigation, and treat any allergy or asthma.
3. Add a short oral steroid course if symptoms are severe.
4. If there is no control after about 3 months, go to FESS.
5. If recurrent and severe despite surgery, assess for a biologic.
6. Lifelong maintenance INCS and regular review.

Recent evidence