eMedicine Specialties > Pediatrics: Surgery > Otolaryngology
Nasal Polyps: Treatment & Medication
Updated: Oct 22, 2008
- Overview
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Treatment
Medical Care
Oral and topical nasal steroid administration is the primary medical therapy for nasal polyposis. Antihistamines, decongestants, and cromolyn sodium provide little benefit. Immunotherapy may be useful to treat allergic rhinitis but, when used alone, does not usually resolve existing polyps. Administer antibiotics for bacterial superinfections.Corticosteroids are the treatment of choice, either topically or systemically. Direct injection into the polyp is not approved by the US Food and Drug Administration (FDA) because of reports of unilateral vision loss in 3 patients after intranasal steroid injection with Kenalog. Safety may depend on specific drug particle size; large molecular weight drugs such as Aristocort are safer and less likely to be transferred to the intracranial area. Avoid direct injection into blood vessels.
Oral steroids are the most effective medical treatment for nasal polyposis. In adults, most authors use prednisone (30-60 mg) for 4-7 days and taper the medicine for 1-3 weeks. Dosage varies for children, but the maximum dose is usually 1 mg/kg/d for 5-7 days, then taper over 1-3 weeks. Responsiveness to corticosteroids appears to depend on the presence or absence of eosinophilia; thus, patients with polyps and allergic rhinitis or asthma should respond to this treatment.
Patients with polyposis not dominated by eosinophilia (eg, patients with cystic fibrosis [CF], primary ciliary dyskinesia syndrome, or Young syndrome) may not respond to steroids. Long-term use of oral steroids is not recommended because of the numerous potential adverse effects (eg, growth retardation, diabetes mellitus, hypertension, psychotropic effects, adverse GI effects, cataracts, glaucoma, osteoporosis, and aseptic necrosis of the femoral head).
Many authors advocate topical nasal steroid administration for nasal polyps, either as the primary treatment or as a continual secondary treatment immediately following oral steroids or surgery. Most nasal steroids (eg, fluticasone, beclomethasone, budesonide) effectively relieve subjective symptoms and increase the nasal airflow when measured objectively (primarily in double-blind placebo-controlled studies).5 Some studies indicate fluticasone has a faster onset of action and possible mild superiority to beclomethasone.6
Topical corticosteroid administration generally causes fewer adverse effects than systemic corticosteroid use because of the former's limited bioavailability. Long-term use, especially at high dosages or in combination with inhaled corticosteroids, presents a risk of hypothalamic-pituitary-adrenal axis suppression, cataract formation, growth retardation, nasal bleeding, and, in rare cases, nasal septal perforation.
As with any long-term therapy, monitor use of topical corticosteroid sprays. However, long-term (>5 y) studies evaluating the use of beclomethasone have shown no degradation of the normal respiratory epithelium to squamous epithelium seen in chronic atrophic rhinitis. Additionally, the newer generation of systemic steroids (eg, fluticasone, Nasonex) appears to have less bioavailability than older nasal steroids, such as beclomethasone.
Surgical Care
Surgical intervention is required for children with multiple benign nasal polyposis or chronic rhinosinusitis who fail maximum medical therapy. Simple polypectomy is effective initially to relieve nasal symptoms, especially for isolated polyps or small numbers of polyps. In benign multiple nasal polyposis, polypectomy is fraught with a high recurrence rate.Endoscopic sinus surgery (ESS) is a better technique that not only removes the polyps but also opens the clefts in the middle meatus, where they most often form, which helps decrease the recurrence rate. The exact extent of the surgery needed, whether complete extirpation (ie, Nasalide procedure) or simple aeration of the sinuses, is not entirely known, simply because of the dearth of studies. Rare comparisons show that complete extirpation procedures are as effective or superior to aeration of the sinuses; complication rates are low with experienced surgeons. The use of a surgical microdebrider (see Media file 34) has made the procedure safer and faster, providing precise tissue cutting and decreased hemostasis with better visualization.
Direct surgery at diseased tissue that is apparent on the CT scan at the time of surgery. Patients with diseases such as CF, primary ciliary dyskinesia syndrome, or Young syndrome may proceed to surgery without extensive medical treatment because these diseases usually do not respond well to corticosteroid treatment. Once diseased tissue has been removed from the nasal cavity and sinuses, the pulmonary systems usually improve. Consider use of an image-guided system to define the exact location of intranasal, sinus, orbital, and intracranial structures for massive polyposis or revision surgery because surgical landmarks may be absent or altered. For specific techniques in pediatric sinus surgery, with and without polyps, see Pediatric Sinusitis, Surgical Treatment.
Nasal polyposis occurs in 6-48% of children with CF. Surgery is performed when children become symptomatic. Recurrence of polyps in CF is almost universal, requiring repeated surgeries every few years. In fact, recurrence is typical for many diseases that cause nasal polyps; patients should receive preoperative counseling about this possibility.
For lesions other than benign nasal polyps that result in a nasal polyp, the polyp should be biopsied or removed, depending on the disease process.
Consultations
First notify a pediatric otolaryngologist, especially if medical therapy has failed or if the origin or diagnosis of the underlying pathology of the nasal polyp is unknown.
Consider consultation with a pulmonary specialist when benign nasal polyps are identified because they could result from asthma, allergy, or CF. Patients with these diseases often have associated pulmonary problems.
Diet
Treatment of nasal polyps involves no special diet.
Activity
No activity restrictions are necessary for a child with nasal polyps. The child's activity level may decrease because of diminished ability to breath through the nose, decreasing sport or physical activity performance. After sinus surgery, activities are limited; these limitation recommendations vary from surgeon to surgeon. Most surgeons specifically restrict nose blowing because it may increase intranasal pressure and cause potential problems in areas of already thinned bony dividers in patients with nasal polyposis.
Medication
See Medical Care.
Corticosteroids
Corticosteroids have potent anti-inflammatory action and relieve rhinorrhea, sneezing, itching, and congestion.
Prednisolone (Prelone, Orapred, Pediapred)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Adult
Dosage varies: for nasal polyps short course (ie, 5-7 d), 1 mg/kg/d PO up to 40-80 mg/d, depending on weight; for >5-7 d, taper to smaller doses/d over time
Pediatric
1 mg/kg/d PO for 5-7 d in preparation for ESS; occasionally, dose can be used to try to shrink polyps for temporary relief; if used >5-7 d, taper to smaller doses/d over time
Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects of corticosteroids
Documented hypersensitivity; fungal or tubercular skin lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis
Prednisone (Deltasone, Orasone, Meticorten, Sterapred)
May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
Dosage varies: for nasal polyps short course (ie, 5-7 d), 1 mg/kg/d PO up to 40-80 mg/d, depending on weight; for >5-7 d, taper to smaller doses/d over time
Pediatric
1 mg/kg/d PO for 5-7 d in preparation for ESS; occasionally, dose can be used to try to shrink polyps for temporary relief; if used >5-7 d, taper to smaller doses/d over time
Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Dexamethasone (Decadron)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Adult
6-8 mg IV/IM q6h prn for inflammation for short course of a few d; taper over time if longer than a few d, as in pediatric dose
Pediatric
1-2 mg/kg/d IV divided q6h prn for inflammation; if used >2 d, taper quickly to lowest possible dose
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; active bacterial or invasive fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use
Nasal corticosteroids
These agents induce a nonspecific anti-inflammatory response that should theoretically reduce the size of polyps and prevent regrowth when continuously used. Available nasal steroid sprays appear to be similarly effective and relatively safe for both short-term and long-term use.
Mometasone (Nasonex)
Nasal spray; demonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic activity in preclinical trials. Studies concerning bioavailability are established; should be considered first-line when treating pediatric patients. Not systemically absorbed like other nasal steroids (ie, beclomethasone). Studies concerning bioavailability are established; should be considered first-line when treating pediatric patients. Not systemically absorbed like other nasal steroids (ie, beclomethasone).
Adult
2 sprays (50 mcg/spray) each nostril qd; supplement with saline nasal spray
Pediatric
Not FDA-approved for nasal polyps in children <18 y; dose listed below is FDA-approved dose for allergic rhinitis in children
<2 years: Not established
2-11 years: 1 spray (50 mcg/spray) each nostril qd
>12 years: Administer as in adults
None reported
Documented hypersensitivity; nasal septal perforation; nasal surgery; nasal trauma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use with caution in patients with active or quiescent tuberculosis of the respiratory tract, ocular herpes, or untreated fungal, bacterial, systemic viral infections; rare instances of decreased growth velocity in pediatric patients have been reported; rare instances of nasal septum perforation and increased IOP have also been reported; nasal and inhaled corticosteroids have been associated with development of glaucoma and/or cataracts
Fluticasone propionate (Flonase)
Topical nasal steroid. Has extremely potent vasoconstrictive and anti-inflammatory activity. Has a weak hypothalamic-pituitary-adrenocortical axis inhibitory potency when applied topically. Studies concerning bioavailability are established; should be considered first line when treating pediatric patients. Not systemically absorbed like other nasal steroids (ie, beclomethasone).
Should use nasal steroid spray with fluticasone propionate to help buffer the nose and prevent complications from the spray, such as nasal drying, epistaxis, and, in long-term use, septal perforation.
Adult
2 sprays/nostril qd (50 mcg/spray); supplement with saline nasal spray
Pediatric
<4 years: Not established
4-11 years: 1-2 sprays/nostril qd (50 mcg/spray); supplement with saline nasal spray
>12 years: Administer as in adults
None reported
Documented hypersensitivity; viral, fungal, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to abort asthma attack; may cause hoarseness, burning, epistaxis, pruritus; caution in glaucoma or cataracts
Budesonide (Rhinocort Aqua)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
2 sprays/nostril bid (32 mcg/spray); not to exceed 256 mcg/d (8 sprays/d); supplement with saline nasal spray
Pediatric
<6 years: Not established
6-12 years: 1 spray/nostril qd initially; may increase if needed, not to exceed 128 mcg/d (4 sprays/d)
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Gets absorbed into the body so be cautious in children
Triamcinolone (Nasacort AQ)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
2-4 sprays/nostril qd (55 mcg/spray); supplement with saline nasal spray
Pediatric
<2 years: Not established
2-5 years: 1 spray/nostril/d (55 mcg/spray)
6-12 years: 1-2 sprays/nostril qd; supplement with saline nasal spray
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use at higher than recommended doses, gets absorbed into the body so be cautious or do not use in children
Beclomethasone (Beconase AQ)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Delivers 42 mcg/actuation.
Adult
1-2 sprays/nostril bid with saline nasal spray
Pediatric
<6 years: Not established
6-12 years: 1 spray/nostril bid; may increase if needed to 2 sprays/nostril
>12 years: Administer as in adults
Coadministration with ketoconazole may increase plasma levels, but levels do not appear clinically significant
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Intranasal bioavailability is 44% and reports have shown a slowing of growth curves when beclomethasone inhaled sprays are administered to children
Weight gain, increased bruising, cushingoid features, acneiform lesions, mental disturbances, and cataracts may occur (taper medication slowly if these changes occur)
More on Nasal Polyps |
| Overview: Nasal Polyps |
| Differential Diagnoses & Workup: Nasal Polyps |
 Treatment & Medication: Nasal Polyps |
| Follow-up: Nasal Polyps |
| Multimedia: Nasal Polyps |
| References |
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References
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Further Reading
Keywords
nasal polyps, nasal polyposis, nasal mucosa, paranasal sinuses, nasal lesion, chronic sinusitis, allergic rhinitis, cystic fibrosis, CF, allergic fungal sinusitis, AFS, antral-choanal polyp, encephaloceles, gliomas
hemangiomas, papillomas, juvenile nasopharyngeal angiofibromas, rhabdomyosarcoma, lymphoma, neuroblastoma, sarcoma, chordoma, nasopharyngeal carcinoma, inverting papilloma, multiple nasal polyposis, asthma
chronic rhinosinusitis, primary ciliary dyskinesia, Churg-Strauss syndrome, Young syndrome, nonallergic rhinitis with eosinophilia syndrome, NARES, nasal obstruction, anosmia, snoring, postnasal drainage, rhinorrhea, hyposmia, proptosis, hypertelorism, diplopia, nasolacrimal duct cyst
