Breathing a sigh of relief: Improving the treatment journey for patients with nasal polyps
Patients with nasal polyps often have a slow, frustrating path to therapy. Symptoms initially manifest as congestion or a runny nose, which may be attributed to allergies and treated with over-the-counter medications.
In fact, many patients may self-medicate with over-the-counter allergy medications for months or years without achieving symptom relief, and most patients only discuss these symptoms with their primary care provider once they have lost their sense of smell or taste or developed significant nasal congestion.
Diagnosis, treatment journey
PCPs typically assess nasal congestion and runny nose by shining a light in the nasal passage or using an otoscope, but these approaches only visualize the first inch of the nasal passage. Unless the nasal polyps are very large, they will not be visible with these exams.
This may result in missed diagnosis and use of medication to treat presumed allergies. When these patients inevitably fail to respond to these medications, sinus infections can be suspected, resulting in prescriptions for antibiotics and/or nasal steroids.
A diagnosis of nasal polyps usually is not made until the patient is evaluated by an ear, nose and throat specialist and undergoes a nasal endoscopy to visualize the area where the sinuses drain into the nasal cavity. Sinus CT scans also can show the presence of nasal cavity masses, such as nasal polyps.
Once nasal polyps have been diagnosed, medication is typically used for first-line therapy. This can include antibiotics, including a macrolide-type antibiotic or doxycycline for 2 to 3 weeks. Additionally, a tapering dose of oral prednisone can be prescribed over 1 to 2 weeks. Clinicians can also prescribe twice-daily sinus irrigations with saline and a corticosteroid additive, such as budesonide or mometasone.
Polyps that block the sinuses inhibit proper sinus drainage, which can make the patient prone to developing sinus infections. Patients with significant sinus infections may be treated with alternative steroid formulations, such as those that enable delivery higher and deeper into the nasal passages compared with conventional steroid nasal sprays.
In some cases, these patients may also warrant treatment with biological agents that target inflammation throughout the respiratory system, including the lungs and sinuses. However, biological therapies are normally administered twice monthly via self-injection or an IV infusion. Additionally, these can be lifelong therapies that are expensive, making them a less attractive option for the medical management of most nasal polyps.
Despite the availability and use of multiple first-line medical therapies, about 80% of patients with nasal polyps fail aggressive medical management and proceed to surgery. Just as asthma medications reduce constrictions that impede airflow to the lungs, surgical removal of obstructing nasal polyps allows the sinuses to drain properly and facilitates delivery of nasal steroid medications to the sinuses.
However, sinus surgery is not a cure for nasal polyps, and almost all patients will require additional postsurgical medical treatment or subsequent surgery if polyps recur.
An alternative treatment
In many cases, postsurgical medical management is similar to first-line therapy and is generally designed to deliver steroids to the sinuses. This can include steroid nasal spray or sinus irrigation with steroid-containing saline.
The efficacy of these medications often depends on patients’ compliance with their treatment regimens. Some patients may forget to use their nasal spray as prescribed, and others may find sinus irrigation uncomfortable.
The Sinuva steroid-releasing sinus implant (Intersect ENT), which has been approved for use in adults who have undergone ethmoid sinus surgery, can improve patient compliance with steroid therapy. It is placed in the ethmoid sinus and releases mometasone furoate over a period of 3 months. This ensures complete patient compliance because the implant releases the steroid in a time-released fashion without the patient having to do anything, such as irrigate or spray.
An ENT surgeon places the implant in the office under local anesthesia, and the procedure takes about 15 minutes per side. The implant can be replaced as needed based on the patient’s response to therapy.
A randomized, sham-controlled phase 3 clinical trial of Sinuva in 300 patients with chronic rhinosinusitis with nasal polyps found that patients receiving the implant experienced significant reductions in their nasal obstruction/congestion score (P = .0074) and their polyp size (P = .0248) compared with controls.
Patients receiving the implant also had significant reductions in multiple secondary endpoints compared with patients in the control group: proportion of patients still indicated for repeat sinus surgery (P = .0004), percent ethmoid sinus obstruction (P = .0007), nasal obstruction/congestion (P = .0248) and decreased sense of smell (P = .047).
There was no significant difference between the implant and control groups with respect to facial pain/pressure. Patients in the implant group had a 61% reduction in the need for further sinus surgery.
As with all therapies, the choice of treatment should be based on the best medical evidence in the context of patients’ needs and priorities. Patients who adhere to nasal steroid spray or sinus irrigation regimens may not require alternative approaches.
However, compliance with these therapies is frequently suboptimal, which may compromise their ability to provide optimal long-term outcomes. Patients who struggle with adherence and those who prefer a postsurgical management regimen that does not require daily medication may find that an implant is a simple therapeutic alternative.
Timely and proper diagnosis of nasal polyps is also essential for helping patients achieve optimal outcomes as quickly as possible. Toward this end, patients and primary care providers should consider evaluation by an ENT when congestion or runny nose persists following standard courses of allergy medications or antibiotics.
Nasal endoscopy and/or a maxillofacial CT scan are usually required for a definitive diagnosis of nasal polyps, and the latter is essential for determining patients’ need for sinus surgery. The growing arsenal of medications and surgical procedures that can provide relief of nasal polyp symptoms can only be effective if the patients who stand to benefit from them are diagnosed appropriately.
In addition to facilitating accurate diagnosis of nasal polyps, continued advancement of innovative anti-inflammatory agents and delivery systems will be crucial for further improving patient outcomes. Following the data and evolving clinical practice in an evidence-based manner should help patients and physicians breathe a little easier.
For more information:
Greg Davis, MD, is an otolaryngologist at Ear, Nose, Throat & Allergy Associates in Puyallup, Washington. He can be reached at 253-770-9000, email@example.com, 104 27th Ave SE, Puyallup WA 98374.