Nonsurgical Treatment of Nasal Polyps

Nasal polyposis results from chronic inflammation of the nasal and sinus mucous membranes. Chronic inflammation causes a reactive hyperplasia of the intranasal mucosal membrane, which results in the formation of polyps. The precise mechanism of polyp formation is incompletely understood.

In 1990, Tos reported 10 pathogenic theories of nasal polyp formation:[4]

• Adenoma and fibroma theories

• Necrosing ethmoiditis theory

• Glandular cyst theory

• Mucosal exudate theory

• Cystic dilatation of the excretory duct and vessel obstruction theory

• Blockade theory

• Periphlebitis and perilymphangitis theory

• Glandular hyperplasia theory

• Gland new formation theory

• Ion transport theory

Multiple chemical mediators have been identified in nasal polyps but their significance has not been completely elucidated. Some of these mediators may be released by the polyps themselves and others by the eosinophils found in certain subsets of polyps. Cysteinyl leukotriene receptors and interleukin-5 (IL-5) appear to be the most well studied.

Frequency

United States

Nasal polyps are present in 5% of nonallergic people and only 1.5% of people with allergic rhinitis. No racial or sexual predilection is reported. The prevalence is increased in patients with cystic fibrosis and aspirin-hypersensitivity triad.

Mortality/Morbidity

Morbidity from polyps is directly related to their location and size.

• Obstruction of the sinus ostia frequently occurs and may lead to acute or chronic sinus conditions. With increased growth, polyps can cause bony destruction because they can exert pressure on bone. Polyps may cause destruction of the nasal bones or other facial bones.

• Nasal obstruction due to polyposis can also lead to hyposmia or even anosmia.

• Nasal polyps are not known to be premalignant. However, they may be confused with papillomas, including inverting papillomas, which are known to be precursors of malignant lesions. In addition, polyps can sometimes arise from inflammation caused by malignant or premalignant nasal lesions. These polyps can obstruct visualization of the more concerning lesions and sometimes cause delay in diagnosis.

Patients with massive nasal polyposis typically present with increasing nasal congestion, hyposmia to anosmia, changes in sense of taste, and persistent postnasal drainage. Headaches and facial pain and discomfort are not uncommon and are found in the periorbital and maxillary regions. On occasion, a patient with completely obstructing nasal polyposis presents with symptoms of obstructive sleep apnea.

Patients with solitary polyps frequently present with only symptoms of nasal obstruction, which may change with a shift in position. For example, while lying supine, the polyp may swing posteriorly, opening up the nasal cavity. In an upright position, the polyp has a more obstructive effect.

Whether 1 or more polyps are present, patients may have symptoms of acute, recurrent, or chronic rhinosinusitis if the polyps obstruct the sinus ostia.

Intranasal examination reveals a fleshy translucent mass or masses in the nasal cavity, usually originating in the superior nasal vault. Polyps can be observed originating in the ethmoid region, from the maxillary sinus ostium (antral choanal polyps), the turbinates, or the septum. Obstructing polyps may make thorough intranasal examination difficult. See the images below.

Nasal polyposis, right nasal passage.

Nasal polyposis, right nasal passage.

Mucopurulent discharge occasionally emanate from the ethmoid region or the superior nasal vault, suggesting an underlying rhinosinusitis. Septal deformities may make the examination more difficult.

See the list below:

• Allergy[5]

• Chronic sinusitis

• Chronic inflammation of indeterminate etiology

See the list below:

• Allergy testing in patients who have polyps and are not clinically allergic is controversial.

  • Many clinicians think that the expense is not justified.

  • On the contrary, a thorough allergy evaluation should be considered in patients with a history of environmental allergies or a strong family history of allergies.

• Children who present with nasal polyposis should be tested for cystic fibrosis with either a sweat chloride test or with hematologic genetic testing.

See the list below:

• Coronal sinus CT scanning is the imaging study of choice in the evaluation of patients with nasal polyposis.

  • Coronal CT scanning of the paranasal sinuses is best for delineating the underlying pathology, the extent of disease, and possible bony destruction.

  • Nonenhanced CT scanning with 2- to 3-mm sections helps to delineate the location and origin of the visible polyps, evaluate the underlying condition of all of the sinuses, and assess the anatomy of the paranasal sinuses in the event of surgical intervention.

• Magnetic resonance imaging (MRI) is not an appropriate imaging modality for nasal polyposis unless intracranial extension is suspected. Bony details of the paranasal sinus anatomy are poorly visualized on MRI.

• Radiography with Waters views may show opacification of the sinuses.

Nasal endoscopy in an office setting can sometimes be helpful in the diagnosis and evaluation of nasal polyps. This technique helps illuminate and improves visualization of the dark recesses of the nasal cavity. Endoscopy may allow the examiner to see beyond an obstructing nasal septal deviation, an enlarged turbinate, or an obstructing polyp.

Biopsy is not always required for the diagnosis of nasal polyps. Nasal masses that do not have the classic appearance of nasal polyps (translucent to gray, fleshy and pedunculated) or that do not respond to conservative medical treatment should be biopsied for confirmatory diagnosis. The histologic appearance of nasal polyps varies from edematous tissue with a few glands to an increase in glandular elements. Eosinophils may be present, indicating an allergic component.

Many factors play a role in the formation of nasal polyp. Epithelial damage has been implicated in the pathogenesis of polyps. Epithelial cells can undergo activation in response to allergens, pollutants, and infectious agents. The cells release various factors that play a role in the inflammatory response and subsequent repair. The epithelium of nasal polyps shows goblet cell hyperplasia and mucous hypersecretion that may play a role in nasal obstruction and rhinorrhea.

Mucin synthesis and goblet cell hyperplasia are thought to be under control of epidermal growth factors (EGF). Inhibitors may block mucous production and goblet cell hyperplasia. Free radicals are highly reactive molecules with an unpaired electron in the outer orbit and may also play a role in polyp formation. The body produces endogenous oxidants as a result of the leakage of electrons from electron transport chains, phagocytic cells and endogenous enzyme systems (MAO, P450, etc).

Exogenous factors include radiation, air pollutants, tobacco smoke, sun exposure, ozone, and others. A certain physiologic level of reactive oxygen species is necessary for proper regulation of cell functions. Exposure to oxidants can initiate free radical-mediated reactions and lead to oxidative stress. Free radicals can result in cellular damage or death and subsequent tissue damage.

Several inflammatory factors have been isolated and are proven to be expressed by nasal polyps. These factors include endothelial vascular cell adhesion molecule (VCAM)-1, nitric oxide synthase, granulocyte-macrophage colony–stimulating factor (GM-CSF), eosinophil survival enhancing activity (ESEA), cys-leukotrienes (Cys-LT) and many other cytokines.

The management of nasal polyps should be based on the causative factors. Unfortunately, most cases of nasal polyps have an unclear etiology. Even if the patient is allergic, no clinical evidence shows that the management of allergies reduces or eliminates polyps. Because the underlying etiology in most cases is inflammatory, medical management is aimed at nonspecific treatment of this inflammatory disorder.

Oral corticosteroids are the most effective short-term medical treatment for nasal polyps.[1, 2, 3] These nonspecific anti-inflammatory agents quickly and substantially reduce the size of inflammatory polyps and improve symptoms. Patients whose polyps respond to oral corticosteroids may be re-treated safely 3-4 times a year, especially if they are not candidates for surgery. The mechanism of action of corticosteroids is unclear. One study showed that corticosteroids induce apoptosis in inflammatory cells in human nasal polyps in vitro.

Intranasal steroid sprays may reduce or retard the growth of small nasal polyps, but they are relatively ineffective in massive nasal polyposis. Intranasal corticosteroid sprays reduce the growth of small intranasal polyps and are most effective in the postoperative period to prevent or retard regrowth of the polyps.

Rudmik et al conducted a meta-analysis that reviewed the effect of topical steroids (low-dose administration methodology) on symptoms in patients with nasal polyps. Results suggest topical nasal steroid therapy improves nasal symptoms in patients with chronic rhinosinusitis and nasal polyposis. The study did not look specifically at the effect on polyp size or regression, but rather only on whether or not the patients' symptoms improved. Readers should be cautioned to recognize that since the studies reviewed did not measure polyp mass, no statement can be made about the mechanisms underlying the observed symptomatic improvements, as they may be due to improvement in associated rhinitis, rather than an effect on the nasal polyps. In addition, most of the studies reviewed were from outside of North America.[6]

Intrapolyp steroid injections have been shown to reduce polyp growth and nasal symptom scores compared with intranasal medical therapy and appear to be a safe alternative to surgery in select patients. More studies are necessary.[7]

A study by Moss et al indicated that although visual complications can occur following steroid injections for nasal polyps, the likelihood is small. The study involved 78 patients with chronic rhinitis or sinusitis who were treated with a total of 237 injections of triamcinolone acetonide. The injections were either intraturbinate (152 injections) or intrapolyp (85 injections). One patient experienced a visual change following an intrapolyp injection, but it was transient and resolved spontaneously. The investigators also conducted a review of nine case series encompassing a total of 117,669 intranasal steroid injections, of which only three (0.003%) caused visual complications; all of these all resolved spontaneously without permanent visual deficit.[8]

According to a report by Shen et al, clinical evidence indicates that, following endoscopic sinus surgery, recurrent chronic rhinosinusitis with nasal polyps can be safely and effectively treated via bioabsorbable, steroid-eluting sinus implants. With localized delivery of mometasone furoate providing an alternative to systemic steroids and revision surgery, the authors stated that this modality shows promise in shrinking polyp size and reducing symptom burden.[9]

Leukotrienes are formed during the breakdown of arachidonic acid by the enzyme 5-lipoxygenase. They are inflammatory mediators and have been implicated in the pathogenesis of asthma, allergic rhinitis, and nasal polyposis. As a result, they have become targets for therapeutic modulation. Early studies of leukotrienes synthesis inhibitors have shown improvements in nasal airflow and reduction in nasal polyps on endoscopy and imaging studies. Benefits appear to be greatest in patients with concomitant allergic rhinitis and eosinophilic infiltration of the nasal polyps on histology.

Research indicates that monoclonal antibodies can also be effective against nasal polyps.[10] For example, in a randomized, double-blind, placebo-controlled parallel-group study, Bachert et al found that adding subcutaneous dupilumab to mometasone furoate nasal spray reduced the endoscopic nasal polyp burden in patients with corticosteroid-refractory nasal polyposis. The study included 51 patients with symptomatic chronic sinusitis and nasal polyposis that had proved refractory to intranasal corticosteroids, with those receiving the dupilumab/mometasone furoate combination experiencing better results against nasal polyps after 16 weeks than those receiving mometasone furoate plus placebo.[11]

In June 2019, the US Food and Drug Administration (FDA) approved dupilumab for treatment in adults with inadequately controlled, severe chronic rhinosinusitis with nasal polyps (CRSwNP). Dupilumab is a humanized monoclonal antibody that inhibits IL-4 and IL-13 signaling by specifically binding to the IL-4 receptor-alpha subunit shared by the IL-4 and IL-13 receptor complexes. Blocking the IL-4 receptor-alpha subunit inhibits IL-4 and IL-13 cytokine-induced responses, including the release of proinflammatory cytokines, chemokines, and immunoglobulin E (IgE). Approval was supported by phase 3 clinical trials (eg, SINUS-24, SINUS-52), which demonstrated significant improvement in nasal congestion/obstruction, the nasal polyp score, sinus opacification, and sense of smell when dupilumab was added to standard-of-care mometasone furoate nasal spray.[11, 12]

A study published in 2023 also found dupilumab to be effective against chronic rhinosinusitis with nasal polyps. The median Sino-Nasal Outcome Test 22 (SNOT-22) score was 70 at baseline and 33 and 20 at 6- and 12-month follow-up, respectively. The median nasal polyps score at baseline and at 6- and 12-month follow-up was 6, 3, and 2, respectively. The adverse event rate was considered minimal; for example, at 3-month follow-up, 12.7% of patients reported having had an adverse drug reaction at the injection site, while 11.1% developed transient hypereosinophilia during follow-up.[13]

In a study of omalizumab treatment in 23 adult patients with recalcitrant chronic rhinosinusitis with nasal polyps, as well as comorbid mild asthma, Armengot-Carceller et al found that all subjects experienced significant and sustained reductions in the total nasal endoscopic polyp score. As measured using the SNOT-22, quality-of-life improvement was also achieved. Therapy was effective even in the 19 patients (83%) with aspirin-exacerbated respiratory disease (AERD). The investigators determined that therapeutic success was associated with treatment time.[14]

Antifungal agents have no role in the management of nasal polyposis, but these agents may be useful in cases of allergic fungal sinusitis with polyposis.

Other agents with a possible role in management of nasal polyposis are macrolides antibiotics, topical diuretic therapy, and intranasal lysine–acetylsalicylic acid.

See Nasal Polyps, Surgical Treatment.

See the list below:

• Consultation with an allergist is beneficial for patients with a history of environmental allergies.

• Allergy pharmacotherapy or immunotherapy is beneficial for patients with allergy symptoms.

• Consultation with a pulmonologist is helpful for patients with lower airway allergy, asthma, or cystic fibrosis.

Dietary modifications should be considered in patients with food allergy and nasal polyposis. Controlling allergy in these patients is important, and recording a food diary or undergoing tests for food allergy may help control symptoms and slow polyp growth.

The only medications effective in shrinking polyps are corticosteroids. Available both orally and topically, they provide a nonspecific anti-inflammatory response that reduces the size of the polyps and improves symptoms related to nasal obstruction. Other medications currently undergoing evaluation affect the nasal inflammatory pathway in different ways and specificity, but they have not shown great promise.

Class Summary

The time-tested medical treatment for obstructing nasal polyps is oral corticosteroids. This nonspecific anti-inflammatory agent significantly reduces the size of the inflammatory polyps and improves symptoms quickly. Unfortunately, the effects are short lasting, and polyps frequently regrow and cause similar symptoms within weeks to months.

Prednisone (Prednisone Intensol)

Immunosuppressant to treat autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Potent anti-inflammatory, generically available, and cost effective.

Class Summary

These induce a nonspecific anti-inflammatory response that should theoretically reduce the size of polyps and prevent regrowth when used continuously. Available nasal steroid sprays appear to be similarly effective and relatively safe for both short- and long-term use.

Fluticasone (Flonase Allergy Relief, Xhance)

Potent vasoconstrictive and anti-inflammatory activity; weak inhibitory potency on HPA when applied topically. Nasal drying, epistaxis, and, in long-term use, septal perforation have been reported. Advise patients to administer spray toward lateral nasal wall, avoiding irritation to septum or having drug run down back of pharynx.

Mometasone (Nasonex)

Nasal spray; elicits anti-inflammatory activity. Indicated for nasal polyposis treatment. Demonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic activity in preclinical trials. Decreases rhinovirus-induced up-regulation in respiratory epithelial cells and modulates pretranscriptional mechanisms. Reduces intraepithelial eosinophilia and inflammatory cell infiltration (eg, eosinophils, lymphocytes, monocytes, neutrophils, plasma cells). Before initial use, prime pump by actuating 10 times or until a fine spray appears; if stored unused for > 1 wk, reprime. Advise patients to administer spray toward lateral nasal wall, avoiding irritation to septum or having drug run down back of pharynx.

Budesonide inhaled (Rhinocort, Rhinocort Allergy)

Potent vasoconstrictive and anti-inflammatory activity. Budesonide is indicated for nasal polyposis management. Advise patients to administer spray toward lateral nasal wall, avoiding irritation to septum or having drug run down back of pharynx.

Class Summary

These agents prevent or reverse some of the pathologic features associated with the inflammatory process mediated by leukotrienes.

Montelukast (Singulair)

Potent and selective antagonist of leukotriene D4 (LTD4) at the cysteinyl leukotriene receptor, CysLT1. Prevents or reverses some of the pathologic features associated with the inflammatory process mediated by leukotrienes C4, D4, and E4.

Class Summary

Inhibition of interleukins 4 and 13 with dupilumab in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) has shown to decrease polyp burden and improve symptoms.

Dupilumab (Dupixent)

Monoclonal antibody that inhibits IL-4 and IL-13 signaling by specifically binding to the IL-4 receptor-alpha subunit shared by the IL-4 and IL-13 receptor complexes. Blocking the IL-4 receptor-alpha subunit inhibits IL-4 and IL-13 cytokine-induced responses, including the release of proinflammatory cytokines, chemokines, and IgE. It is indicated for adults with inadequately controlled, severe CRSwNP.

See the list below:

• Patients with nasal polyposis can easily be monitored as outpatients, and they should be examined by an otolaryngologist.

  • Patients with limited symptoms may be monitored once or twice a year.

  • Patients with severe obstructive symptoms may need closer follow-up, especially if they are receiving high-dose oral corticosteroids or using nasal steroid sprays long term.

• Consider surgical intervention for nasal polyps after appropriate medical therapy is unsuccessful and for patients with recurrent sinus infections that need treatment with multiple antibiotics.

See the list below:

• Intranasal

  • Recurrent sinusitis

  • Chronic sinusitis

  • Acquired nasal deformity

• Orbital

  • Proptosis

  • Diplopia

• Intracranial

  • Meningitis

  • Encephalitis

See the list below:

• Medical therapy for nasal polyposis is usually reserved for patients who are not surgical candidates or who require temporization of symptom relief.

• Rarely do the polyps resolve, but they occasionally shrink enough to provide symptomatic relief.

See the list below:

• For excellent patient education resources, visit eMedicineHealth's Ear, Nose, and Throat Center. Also, see eMedicineHealth's patient education article Sinus Infection.