Nasal Polyps Treatment: Symptoms, Medical Management and FESS Surgery

Nasal polyps are oedematous, gelatinous, pale grey-pink masses arising on the chronically inflamed sinonasal mucosa. They typically originate at the middle meatus — at the ethmoid sinus outflow — and progressively fill the nasal cavity. Histologically: oedematous stroma, basement membrane thickening, and (in Western populations) dense eosinophilic infiltration.

The mechanism is complex and under active research. Type-2 (T2) inflammation — driven by IL-4, IL-5, IL-13 — dominates most cases. This explains the frequent association with atopic asthma, allergic rhinitis and atopic dermatitis. Eosinophil-derived major basic protein (MBP) and related mediators damage the epithelium and perpetuate chronicity.

Clinically, nasal polyps define one of two major chronic rhinosinusitis phenotypes: with polyps (CRSwNP) and without polyps (CRSsNP). EPOS 2020 makes this distinction the basis for treatment. CRSwNP affects 1-4% of the general population, men twice as often as women, most commonly between 40-60. Related service: our general ENT services.

Cardinal symptoms: persistent bilateral nasal obstruction (mouth breathing, snoring), loss of smell (hypo- or anosmia) — prominent in 70-80%, postnasal drip, facial pain or pressure, recurrent sinus infections. For most patients, smell loss is the most quality-of-life-limiting symptom and a primary treatment target.

A history of asthma, allergic rhinitis, aspirin/NSAID intolerance (AERD — Samter's triad classically), or atopic dermatitis must be sought. In AERD, polyps are more aggressive and post-surgical recurrence reaches 50-70%.

Examination: anterior rhinoscopy can show pale mobile polypoid masses at the middle meatus. Flexible nasal endoscopy is the standard — polyp staging (Lund-Kennedy 0-2), extent and mucosal status are documented. Sinus CT (paranasal sinus coronal thin-section) reveals opacification, ostiomeatal complex status, and bony anomalies; Lund-Mackay (0-24) is used for surgical planning.

Differential diagnosis: a unilateral polypoid mass raises concern for malignancy (inverted papilloma, squamous cell carcinoma, lymphoma), antrochoanal polyp, mucocele, or fungal ball; biopsy is mandatory in unilateral lesions. Bilateral polyps in a child mandate workup for cystic fibrosis.

Further workup: total IgE, peripheral eosinophil count, allergy testing (skin prick or specific IgE), spirometry for asthma control. Oral aspirin provocation testing for suspected AERD is controversial but performed in selected cases by allergists.

Topical intranasal corticosteroid (INCS): the cornerstone. Mometasone furoate (200-400 mcg/day), fluticasone furoate (110 mcg/day), and budesonide sprays are standard. Low bioavailability keeps systemic side effects negligible. At least 12 weeks of regular use — do not expect a response in the first week. Correct application technique (head slightly forward, spray directed at the lateral nasal wall, not the septum) is vital; most apparent failures are technique-related.

Large-volume saline irrigation (neti pot, squeeze bottle): 240 ml of isotonic or mildly hypertonic solution once or twice daily. Improves mucociliary clearance, clears crusts and mediators. Performed before INCS spray for better penetration. Budesonide-added irrigation (1 mg per rinse) is effective off-label in difficult cases.

Short oral corticosteroid course: prednisolone or methylprednisolone 0.5-1 mg/kg/day for 5-14 days, then rapid taper. Rapid polyp shrinkage and smell recovery — used pre-operatively to "shrink" polyps or during flare. Limit to 1-2 courses per year; long-term systemic steroid toxicity (diabetes, osteoporosis, hypertension, cataract, adrenal suppression) is unacceptable.

Antihistamines and leukotriene receptor antagonist: when significant allergic rhinitis or AERD coexists, montelukast 10 mg/day adds benefit. Antibiotics are not routine; acute bacterial exacerbation calls for 10-14 days of amoxicillin-clavulanate or a macrolide. Long-term low-dose macrolide (3 months) is tried as an immunomodulator in difficult cases (off-label, debated).

Biologics — have transformed the field. Dupilumab (anti-IL-4Rα), mepolizumab (anti-IL-5), benralizumab (anti-IL-5Rα), omalizumab (anti-IgE) are approved for recurrent severe CRSwNP after surgery. They significantly improve polyp score, smell and quality of life. Cost and chronic injection are drawbacks; particularly valuable when severe asthma coexists. For the related clinical reference, see sinusitis (FESS) page.

Indications: persistent symptoms after at least 3 months of optimum medical therapy (especially obstruction and anosmia), threat of anatomic complications (orbital, intracranial extension), suspected malignancy in unilateral polyp, antrochoanal polyp, allergic fungal sinusitis. Surgery does not replace medical therapy — lifelong INCS use is advised postoperatively.

Functional endoscopic sinus surgery (FESS): under general anaesthesia, using 0° and 30°/45° rigid endoscopes plus a microdebrider, polyps are removed, ethmoid cells opened, and sphenoid, frontal and maxillary ostia widened. The "fully functional" (Messerklinger) approach is tailored to disease extent — from limited maxillary antrostomy to complete sphenoethmoidectomy.

Emerging trend: "reboot" or "full-house" surgery — in advanced CRSwNP, all sinuses are completely stripped of mucosa and widely drained in one operation. This approach significantly lowers recurrence (3-year recurrence 20% vs 50% with conventional FESS). Reversible — revision possible if needed.

Navigation systems (CT-based stereotactic navigation): in revision cases, frontal sinus disease, anatomic variants (Onodi cell, dehiscent skull base or orbit), they enhance safety — orbital and intracranial complications drop.

Postoperative care: minimal activity in the first 48 hours, saline irrigation from day 1, in-office endoscopic debridement at weeks 1, 2 and 4. INCS resumed from week 1. A short oral steroid course in selected patients with significant postoperative inflammation. Full re-epithelialisation 8-12 weeks.

Complications: rare but potentially severe — orbital haematoma/blindness (0.1%), CSF leak (0.1-0.5%), major bleeding, septal perforation, persistent anosmia, frontal-maxillary recess stenosis. Experienced surgeons and proper equipment minimise risks.

Surgery alone is not curative — the underlying inflammation persists and continuous medical therapy is required. Lifelong INCS is recommended; high dose for the first 6 months, then maintenance. Budesonide-added saline irrigation (1 mg/day) significantly reduces recurrence in selected patients.

Regular follow-up: endoscopy at 1, 3 and 6 months post-op, then every 6-12 months. Early polyp recurrence triggers intralesional steroid injection or a short oral course.

Asthma control must be optimised — uncontrolled asthma accelerates polyp recurrence. Joint care with pulmonology, inhaled corticosteroid, biologic therapy if needed.

In AERD, aspirin desensitisation (at experienced allergy centres) significantly reduces polyp recurrence and respiratory symptoms; daily 325-650 mg aspirin maintained (when not contraindicated). Alternative: biologic therapy (dupilumab particularly effective).

Lifestyle: smoking is absolutely forbidden — smoke worsens chronic inflammation and triggers recurrence. Home environment dust-free and humidified; HEPA-filtered air cleaner helps.

Nutrition: low-salicylate diet (in AERD) has debated benefit; long-chain omega-3 (fish oil) may provide anti-inflammatory benefit. Evidence is moderate. Related reading: our Istanbul ENT services.