Highlights
- Effective management of nasal polyps requires ongoing monitoring and tailored treatment strategies.
- Biologic therapies offer new hope for patients with severe nasal polyps unresponsive to traditional treatments.
Summary and Overview
Nasal polyps are benign growths from the nasal and sinus linings, commonly linked to chronic inflammation such as chronic rhinosinusitis with nasal polyposis (CRSwNP). They cause nasal obstruction, reduced smell, facial pressure, and recurrent infections, often coexisting with asthma, allergic rhinitis, and aspirin-exacerbated respiratory disease (AERD). Treatment includes intranasal corticosteroids as first-line therapy, oral corticosteroids for severe cases, and functional endoscopic sinus surgery (FESS) for refractory polyps. Biologic therapies targeting specific inflammatory pathways (e.g., dupilumab, mepolizumab, omalizumab) have shown promise for severe or recurrent disease. Despite treatments, recurrence is common, requiring ongoing management balancing efficacy and safety. Guidelines recommend a stepwise approach from medical therapy to surgery and biologics.
Pathophysiology, Diagnosis, and Symptoms
Nasal polyps develop bilaterally due to persistent mucosal inflammation, immune dysregulation, and epithelial barrier dysfunction. Risk factors include asthma, allergic rhinitis, and genetics. Patients often experience nasal blockage, loss of smell, postnasal drip, and facial pressure. Diagnosis involves history, nasal endoscopy for direct visualization, and CT imaging to assess polyp extent and sinus anatomy. Polyps are a key feature of CRSwNP and can range from asymptomatic to severely impairing quality of life.
Treatment Options
Treatment aims to reduce polyp size, relieve symptoms, and prevent recurrence, using medical and surgical methods based on severity and response.
Medical Management
Intranasal corticosteroids are first-line due to efficacy and low systemic absorption, with mild side effects like nasal irritation or epistaxis. Oral corticosteroids are reserved for severe or refractory cases but carry systemic risks and should be used cautiously. Saline irrigation supports medication delivery and reduces mucosal edema. Biologics such as dupilumab, mepolizumab, and omalizumab target inflammatory mediators and improve symptoms in severe CRSwNP, with generally mild side effects. Other agents like antileukotrienes and clarithromycin have limited evidence.
Surgical Management
FESS is the standard surgery to remove polyps and restore sinus drainage, often after medical therapy fails. Alternatives include balloon sinuplasty and endoscopic polyp excision. Surgery is generally safe but carries risks like bleeding and rare serious complications, requiring careful patient selection and postoperative care.
Adjunctive Therapies
Management also addresses associated systemic diseases (e.g., AERD, eosinophilic granulomatosis with polyangiitis, cystic fibrosis). Aspirin desensitization benefits AERD patients. Antibiotics are used only for acute bacterial infections; antifungal use remains controversial. Regular follow-up is important to monitor treatment response and recurrences.
Factors Influencing Treatment Choice
Treatment depends on disease severity, comorbidities, prior response, and underlying inflammation type. Intranasal corticosteroids are first-line for symptom control, with oral steroids and surgery considered for refractory cases. Biologics are indicated for severe CRSwNP with type 2 inflammation and significant symptoms. Management of systemic conditions and tailored approaches are critical.
Treatment Effectiveness and Outcomes
Topical corticosteroids effectively reduce symptoms and polyp size with low risk. Oral corticosteroids provide short-term benefits but have limited long-term impact and systemic risks. FESS improves symptoms in many patients, with recurrence rates up to 20% within five years; newer surgical techniques show lower recurrence. Biologics significantly reduce polyp size and symptoms, decreasing the need for surgery or systemic steroids, though cost and long-term safety limit widespread use.
Safety and Side Effects
Intranasal corticosteroids have minimal systemic absorption and mild local side effects. Oral corticosteroids risk systemic adverse effects and should be used sparingly. Biologics are generally well tolerated, with injection site reactions as the most common side effect. Surgery risks include bleeding and rare serious complications. Other investigated drugs require further safety validation.
Living with Nasal Polyps
Due to frequent recurrence, ongoing management is necessary. Consistent use of corticosteroid nasal sprays is key to controlling inflammation and preventing polyp regrowth, especially following surgery. Patients benefit from tailored, long-term treatment plans to maintain symptom control and quality of life.
Guidelines and Recommendations
Clinical guidelines recommend a stepwise approach starting with intranasal corticosteroids, progressing to oral steroids, enhanced topical delivery methods, surgery, and biologics for refractory cases. Surgery is reserved for those unresponsive to medical therapy. Biologics are considered after failure of conventional treatments, reflecting their role as advanced options.
Future Directions
Ongoing research aims to optimize treatment protocols and evaluate long-term outcomes of medical, surgical, and biologic therapies. High-quality trials are needed to standardize care and improve patient selection. Biologics show promise for durable benefits in severe cases. Studies on optimized steroid regimens and personalized management are encouraged to enhance efficacy and safety.
The content is provided by Harper Eastwood, Scopewires
