Nonsurgical Treatment of Nasal Polyps Treatment & Management

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 medical treatment for nasal polyps. ^{[1, 2, 3]} The 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]}

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 Sino-Nasal Outcome Test 22 (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. ^[13]

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.