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🫁 NASAL POLYPS — Complete ENT Guide

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1. DEFINITION

Cummings Otolaryngology Head and Neck Surgery — Nasal polyps represent a subgroup of chronic rhinosinusitis characterized by Th2-driven eosinophilic mucosal inflammation.

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2. ETIOPATHOGENESIS CHART

A. Predisposing Conditions / Risk Factors

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B. Pathogenesis Flowchart

TRIGGER (allergen / infection / environmental irritant)
          ↓
Epithelial barrier dysfunction
(↑ permeability, ↓ tight junction proteins)
          ↓
Innate lymphoid cells type 2 (ILC2) activation
Epithelial cytokines: TSLP, IL-25, IL-33 released
          ↓
Th2-polarized immune response (predominantly in Western populations)
  ↓ IL-4, IL-5, IL-13 released
  ↓ IgE ↑ (mast cell / basophil activation)
  ↓ Eosinophil recruitment & activation (↑ IL-5)
  ↓ Tissue eosinophilia
          ↓
Chronic mucosal edema → pseudocyst formation
(Accumulation of albumin-rich fluid in subepithelial stroma)
          ↓
Stromal remodeling → polyp growth
(Fibroblast activation, ↑ vascular permeability)
          ↓
NASAL POLYP

────────────────────────────────────────
NOTE: In Asian populations / children with CF:
Th1/Neutrophilic endotype predominates
(TNF-α, IFN-γ driven; less eosinophilic; 
more fibrotic; corticosteroid-resistant)
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C. Samter's Triad (AERD)

• Aspirin / NSAID sensitivity + Asthma + Nasal polyps
• Mechanism: Arachidonic acid shunted to lipoxygenase pathway → excess leukotrienes (LTC4, LTD4)

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3. TYPES OF NASAL POLYPS

Classification 1: By Etiology (Sturman & Hughes)

Classification 2: By Distribution

Classification 3: By Histology

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4. CLINICAL FEATURES

Symptoms

Signs

Associated Features

• Asthma (30–50%)
• Allergic rhinitis
• Aspirin sensitivity
• In children: suspect cystic fibrosis (sweat chloride test mandatory)

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5. DIAGNOSIS

Clinical Diagnosis

• Based on history + anterior rhinoscopy / nasal endoscopy (gold standard for visualization)
• Presence of polyps + ≥2 cardinal CRS symptoms (obstruction, discharge, facial pain/pressure, olfactory loss) lasting >12 weeks confirms CRSwNP

Investigations

Grading / Staging

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6. DIFFERENTIAL DIAGNOSIS

⚠️ Red flags for malignancy: Unilateral polyp, epistaxis, bony erosion on CT, facial deformity, proptosis, cranial nerve palsy → biopsy mandatory

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7. MANAGEMENT

A. MEDICAL MANAGEMENT

Step 1: Topical (Intranasal) Corticosteroids — First-Line

• Drugs: Mometasone furoate, Fluticasone propionate, Budesonide, Beclomethasone
• Mechanism: Reduce eosinophilic inflammation, decrease polyp size
• Dose: 2 sprays each nostril OD/BD — long-term maintenance
• Evidence: Strongest evidence base; reduces polyp size, improves smell and nasal airflow
• Works best when polyp does not completely block access

Step 2: Saline Nasal Irrigation

• Isotonic or hypertonic saline rinses
• Clears secretions, improves mucociliary function, enhances delivery of topical steroids

Step 3: Systemic (Oral) Corticosteroids — For acute control / pre-op reduction

• Prednisolone 0.5–1 mg/kg/day × 10–14 days ("medical polypectomy")
• Rapidly reduces polyp burden before surgery or when topically inadequate
• Repeated courses with caution — risk of adrenal suppression, osteoporosis

Step 4: Antibiotics

• Doxycycline (low-dose, 20 mg BD × 3 weeks) — anti-inflammatory/anti-Staphylococcal effect, reduces polyp size short-term
• Systemic antibiotics for acute exacerbations (amoxicillin-clavulanate, clarithromycin)
• Long-term macrolides (azithromycin) — immunomodulatory effect, especially in non-eosinophilic/Th1 phenotype

Step 5: Antihistamines / Leukotriene Receptor Antagonists

• Antihistamines (cetirizine, loratadine) — for allergic component
• Montelukast (leukotriene antagonist) — especially useful in AERD/aspirin-sensitive patients; reduces relapse

Step 6: Aspirin Desensitization (AERD)

• Indicated in Samter's triad when surgery and steroids inadequate
• Gradual oral aspirin challenge under supervision → maintained on aspirin 325–650 mg BD
• Reduces polyp recurrence, improves nasal symptoms

Step 7: Biologics — For Severe Refractory CRSwNP (uncontrolled despite maximal medical/surgical treatment)

• Refractory to ≥2 courses oral steroids or contraindication
• NPS ≥5/8 (bilateral), SNOT-22 ≥40
• At least 2 of: tissue eos ≥10/hpf, blood eos ≥250/μL, IgE ≥100 IU/mL, anosmia, comorbid asthma

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B. SURGICAL MANAGEMENT

Indications for Surgery

• Failed adequate medical therapy (≥3 months intranasal steroids + oral steroid courses)
• Massive polyposis with complete obstruction
• Complications (sinusitis, orbital/intracranial extension)
• Unilateral polyp (rule out malignancy — diagnostic excision)
• Antrochoanal polyp (does not respond to medical therapy)

Surgical Procedures

Principles of FESS

1. Restore mucociliary drainage (not just remove polyps)
2. Open osteomeatal complex (OMC) — the key drainage pathway
3. Conservative mucosa preservation
4. Aimed at sinus ventilation, not radical resection
5. Post-op care: Saline rinses + intranasal corticosteroids mandatory to prevent recurrence

Post-Surgical Medical Therapy (Mandatory)

• Intranasal steroids — lifelong in most patients; prevents recurrence
• Saline irrigation — daily to remove debris and crusts
• Short oral steroid courses for early recurrence
• Biologics — if recurrence despite FESS + medical therapy (biologics now rival surgery for controlled disease)

Complications of Surgery

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8. ENDOSCOPIC / CLINICAL IMAGES

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9. QUICK SUMMARY TABLE

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Recent Evidence (PubMed 2024–2025)

• Dupilumab vs Surgery [PMID: 39149992] — A 2024 systematic review and meta-analysis in Am J Rhinol Allergy found dupilumab comparable or superior to FESS for polyp score reduction and symptom control in CRSwNP
• Biologics in pediatric CRS [PMID: 38488239] — 2024 systematic review supports emerging role of biologics in pediatric refractory CRSwNP
• Biologic treatment landscape [PMID: 40861204] — 2025 bibliometric review confirms dupilumab as the dominant biologic, with growing evidence for mepolizumab and omalizumab

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