Approach

Treatment options for chronic rhinosinusitis with nasal polyps (CRSwNP) include topical medications, principally intranasal corticosteroids, nasal irrigations, systemic medications including biologics, and surgery.[2][4]​​​​​

Nasal polyposis in children is rare, and should prompt additional investigations to exclude cystic fibrosis.[2] Nasal polyps may also be a feature of the nasal and sinus inflammation seen in primary ciliary dyskinesia. Management of nasal polyposis in children is similar to that for adults; surgery is reserved for severe CRSwNP resistant to medical treatment.

Intranasal corticosteroids

Intranasal corticosteroids are the first-line treatment for patients with chronic rhinosinusitis. They are well tolerated and effectively reduce nasal polyp size, reduce symptoms, improve quality of life, and prevent polyp recurrence after endoscopic sinus surgery.[2][4]​​​​

For patients with mild to moderate symptoms (visual analogue scale [VAS] score 0-7), the first-line treatment is a 3-month course of an intranasal corticosteroid spray, such as fluticasone or mometasone. There is insufficient evidence to suggest one type of corticosteroid over another.[2] The patient is reviewed at 3 months and, if there has been satisfactory improvement, the patient may continue to use the intranasal corticosteroid spray, at the lowest effective dose, with review every 6 months. Intranasal corticosteroid delivery using stents and exhalation delivery systems has also shown promise.[4]

For patients with severe symptoms (VAS score >7 to 10), the first-line treatment is an intranasal corticosteroid spray, plus consideration of a short course of an oral corticosteroid.[2] [ Cochrane Clinical Answers logo ] ​ A short course (7-21 days) of a systemic corticosteroid, with or without local corticosteroid treatment, results in a significant reduction in total symptom score and nasal polyp score in patients with CRSwNP.[2][36][37] One to two courses of systemic corticosteroids can be given every year along with intranasal corticosteroid treatment in patients with partial or uncontrolled disease.[2]  Following completion of the oral corticosteroid course, the patient then continues on the intranasal corticosteroid. The patient is reviewed at 1 month and, if there has been satisfactory improvement, the patient should continue on the intranasal corticosteroid with review at 3 months.

Adjunctive therapies

Doxycycline may have a modest effect in addition to intranasal corticosteroids when used for 3-12 weeks.[38][39]​​ Nasal saline irrigation with isotonic saline or Ringer’s lactate can also be beneficial.[2][40]​ Adding xylitol, sodium hyaluronate, and xyloglucan to nasal saline irrigation may have a positive effect.[2]

Leukotriene receptor antagonists (e.g., montelukast) are sometimes used as an adjunct to intranasal corticosteroids, particularly in patients with aspirin/non-steroidal anti-inflammatory drug (NSAID) hypersensitivity; however, clinical trial evidence for their efficacy is lacking, and they are not routinely recommended.​[2]

Biologics

Biologics (e.g., dupilumab, mepolizumab, omalizumab) target specific inflammatory pathways which are important in disease pathophysiology. As most patients with CRSwNP have type 2 inflammation, biologics for managing CRSwNP are designed to modify the type 2 inflammatory response.[4]

​The American Academy of Allergy, Asthma & Immunology (AAAAI)/American College of Allergy, Asthma & Immunology (ACAAI) Joint Task Force guideline panel suggests using biologics over no biologics, depending on the preferences of patients and/or their carers for individual outcomes, disease severity, and availability of other treatment options.[4] Consider biologics in patients on intranasal corticosteroids for at least 4 weeks who do not show symptom improvement.[4] Biologics may be preferred over other therapies in patients with high disease severity at presentation.[4]

Dosing for biologics for CRSwNP varies based on the type of biologic and may depend on patient’s weight, laboratory tests, or severity of disease.[4]

Do not use biologics in patients in whom symptoms improve with intranasal corticosteroids, surgery, or aspirin therapy after desensitisation (ATAD).[4]

Individuals with symptoms impairing quality of life despite regular use of intranasal corticosteroids may be considered for treatment, while taking additional factors into consideration (e.g., previous sinus surgery, need for oral corticosteroids, comorbid asthma).[41] Biologics are recommended in patients with bilateral polyps who have had sinus surgery or are not fit for surgery and who have three of the following characteristics:[2] 

  • Evidence of type 2 hypersensitivity (tissue eosinophils ≥10/high-power field or blood eosinophils ≥250 cells/microlitre or total IgE ≥100 IU/mL)

  • Contraindication to systemic corticosteroids, need for systemic corticosteroids or continuous use of systemic corticosteroids (≥2 courses per year or long term [>3 months] low-dose corticosteroids)

  • Significantly impaired quality of life (SNOT-22 score ≥40)

  • Anosmic on smell test, and/or

  • A diagnosis of comorbid asthma needing regular inhaled corticosteroids

Intranasal corticosteroid therapy should be continued in patients when biologics are introduced. If the biologic is sufficiently effective and symptoms become almost negligible/very mild, corticosteroid dose could be reduced and even stopped.

Dupilumab is directed against the interleukin-4 receptor alpha subunit, thereby blocking the activity of interleukin-4 and interleukin-13. It has been shown to reduce polyp size and improve symptoms, computed tomography (CT) appearances, and sense of smell in patients already on an intranasal corticosteroid.[22]​ Dupilumab is approved in the US as add-on maintenance treatment in adults with inadequately controlled CRSwNP. It is also approved in Europe as an add-on therapy with intranasal corticosteroids for adults with severe CRSwNP for whom therapy with systemic corticosteroids and/or surgery do not provide adequate disease control. Ocular adverse reactions have been reported; healthcare professionals should review new onset or worsening ocular symptoms and refer patients for ophthalmological examination as appropriate.[42]

Mepolizumab blocks the activity of the pro-eosinophilic cytokine interleukin-5.[20]​ It has been shown to reduce the need for repeat surgery in those already taking an intranasal corticosteroid.[21]​ Mepolizumab is approved in the US and Europe for four eosinophil-driven diseases, including CRSwNP.[22]

Omalizumab inhibits IgE binding to the high-affinity IgE receptor on mast cells and basophils. It is approved in the US as add-on maintenance treatment for CRSwNP in adults with an inadequate response to intranasal corticosteroids, and in Europe as add-on therapy with intranasal corticosteroids for adults with severe CRSwNP in whom intranasal corticosteroids do not provide adequate disease control.

Aspirin therapy after desensitisation (ATAD)

ATAD can be considered in patients with CRSwNP with a convincing history of a respiratory reaction to aspirin/NSAIDs (as judged by the clinician) or the development of respiratory symptoms during an aspirin challenge.[2][4]​​​ ATAD has been recommended for treating patients with CRSwNP and NSAID-exacerbated respiratory disease (NERD) who agree to comply with the therapy.[2] The AAAAI/ACAAI Joint Task Force guideline panel suggests using ATAD over no ATAD in patients with NERD but not in those without NERD.[4] Intranasal corticosteroid therapy should be continued in patients when ATAD is introduced. If ATAD is sufficiently effective and symptoms become almost negligible/very mild, corticosteroid dose could be reduced and even stopped.

ATAD is preferred in patients who are unable to tolerate NSAIDs but need them for other indications such as cardiovascular disease.[4] In patients with NERD who do not require NSAIDs to manage other conditions and who wish to avoid the desensitisation procedure, biologics are preferred over ATAD.[4]

ATAD involves desensitising patients with NERD to aspirin, followed by daily aspirin therapy. Desensitisation itself does not provide immediate clinical benefit for patients with NERD but is necessary to allow patients to take aspirin daily, which in turn may lead to improvement in chronic rhinosinusitis symptoms. Oral ATAD is effective in improving quality of life and total nasal symptom score in patients with NERD.[2] Appropriate preventive measures (i.e., Helicobacter pylori eradication, proton-pump inhibitors, H2 antagonists) should be introduced and continued during ATAD to prevent adverse effects following aspirin treatment.[2]

Refractory to medical therapy

If there is no or minimal improvement in symptoms at the initial 3-month follow-up, most clinicians suggest surgery for removal of polyps. This necessitates a preoperative CT scan to examine the local anatomy and the extent and location of the polyps, in order to make an accurate surgical plan.

Whichever surgical technique is employed, patients usually receive follow-up saline douching and intranasal corticosteroids.[43] The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis and nasal polyps is of very low quality. The evidence thus far does not show that one treatment is better than another in terms of patient-reported symptom scores and quality-of-life measurements.[44] Patients with CRSwNP and comorbid asthma are at a higher risk of undergoing revision surgery, and many of these patients experience poor symptom control, the need for repeated systemic corticosteroids and multiple surgeries.[45]

Postoperative doxycycline for 3 weeks or 12 weeks may have a beneficial effect.[38][39]​​ Clinicians may also use a macrolide antibiotic.

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