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BackTable / ENT / Article
Eosinophilic vs Neutrophilic Nasal Polyps: Treatment, Recurrence & Long-Term Maintenance
Sam Strauss • Updated Jul 11, 2025 • 35 hits
Effective management of chronic nasal polyps often goes far beyond the initial diagnosis or surgical plan. In many patients, the disease is marked by recurrence and shaped by underlying inflammatory profiles. Recognizing the subtypes of nasal polyps can help guide both prognosis and response to intervention, particularly in cases where standard steroid-based regimens fall short.
Eosinophilic and neutrophilic phenotypes, while not always apparent on initial exam, often reveal themselves over time through patterns of steroid response and endoscopic changes. Tracking these changes with serial imaging and recorded scope exams offers valuable insight into treatment efficacy. Even when nasal polyp treatment is successful and inflammation is well-managed, patients should be counseled on the chronic nature of their condition, and how effective long-term management often relies on longitudinal treatment.
This article features excerpts from the BackTable ENT Podcast and features practical guidance from otolaryngologist Dr. Martin Citardi. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Inflammatory subtype (eosinophilic vs neutrophilic) can impact steroid efficacy and recurrence risk, but symptoms are often only apparent through longitudinal observation.
• Longitudinal tracking of polyps can help differentiate phenotype more reliably than single exams taken in isolation.
• Patients should be counseled on the chronic nature of nasal polyps, to dispel the common misunderstanding that treatment is a one-time solution.
• Long-term maintenance with topical steroids should be emphasized strongly and early in the treatment process to encourage adherence.
Table of Contents
(1) Identifying Inflammatory Subtypes of Chronic Nasal Polyps
(2) Nasal Polyp Recurrence & Long-Term Steroid Maintenance
Identifying Inflammatory Subtypes of Chronic Nasal Polyps
Recognizing the inflammatory phenotype of nasal polyps – particularly distinguishing eosinophilic from neutrophilic subtypes – can have important implications for treatment efficacy and symptom recurrence. While the phenotype is rarely confirmed from a single visit, physicians can monitor certain visual cues over time to help guide diagnosis. Color and texture are particularly telling: eosinophilic polyps often present with golden-yellow crusting, while neutrophilic polyps may appear more hyperemic or fleshy. These features should be tracked longitudinally, as relying on one-time impressions can lead to incorrect assumptions about disease behavior.
For lots of patients, eosinophilic polyps are the default. These cases tend to respond well to steroids—at least initially—but show a higher risk of recurrence if maintenance care lapses. Neutrophilic polyps, while less common, often resist standard steroid regimens and may only be recognized retrospectively after treatment failure. Because of this, many providers will record the initial endoscopy so that they can re-watch the procedure later on. This can help identify subtle signs missed in real-time. This kind of longitudinal review becomes especially important when a patient’s response to therapy is inconsistent or unexpectedly poor.
The need to track these changes over time highlights the limits of snapshot diagnostics. Even with good technique, phenotype-based decision-making often requires multiple visits, serial scopes, and a willingness to reexamine assumptions. While inflammatory subtype may not dictate initial therapy, it can guide escalation, steroid delivery strategies, and patient counseling about expected outcomes. In a disease this chronic, the subtype isn't just a label—it can be a roadmap for predicting which patients are most likely to need surgical or biologic escalation.
[Dr. Gopi Shah]
What are you seeing on your scope exams in the nasal polyp patients?
[Dr. Martin Citardi]
We try to categorize the type of polyp, okay? A lot of that, I think, is hand-waving, and you go back retrospectively and you can say, "Well, this is a neutrophilic polyp versus the eosinophilic polyp." We try to make a pass at that. Sometimes you can get clues by the colors of the secretion. If there's sort of that golden yellow crusting, that's going to be more eosinophilic. If your polyp is more hyperemic, that's going to give you a clue. Sometimes I'll talk about cystic polyps, which are sort of like grapes. They're just fluid-filled, and other ones are more fleshy. All those things I think are helpful data points, but not in the instant in which you're doing the exam. You have to collect the observations across time and then put it together into something that makes sense. That's why recording the video is so helpful because it allows you to do that pretty easily.
[Dr. Gopi Shah]
As you're thinking about those different types of polyps, you mentioned that maybe not in the moment, it may not necessarily change treatment options at that time. You're saying that if, as you look at it over time, that the type of polyps might dictate treatment options, at the second or third visit, is that what you mean?
[Dr. Martin Citardi]
Basically, in particular. Okay. In Southeast Texas, most of the polyps are going to be eosinophilic. Occasionally, we'll have patients who we do all the usual things for, and they just do not do well. I'll go back and look at video from the OR, from the clinic, and then it'll be, "Oh, this is a neutrophilic polyp." We just completely missed it, and it gets treated differently. That's why steroids don't seem the same way. It's just a different picture. In a busy clinic, it can be difficult to realize that.
I think, on a phenotypic level, there's a lot of overlap in how their endoscopies look at any one moment in time. For those patients who are not doing well, I'll try to correlate, again, across time, what each treatment does and how their endoscopic appearance changes across time. That's why the recording is helpful.
[Dr. Gopi Shah]
Yes. For sure. The picture is worth more than a thousand words, for sure.
[Dr. Ashley Agan]
With your hat of vice dean of clinical technology, do a role? Are we already using AI for some of this longitudinal endoscopy or imaging or videos, and response to medications, and then fitting that with some of the immune, like the type of, are they responses?
[Dr. Martin Citardi]
I know there are companies looking at an AI endoscopy for sinusitis. They're mostly aimed, I think, at primary care docs, actually. Not really us. The idea is you have an AI algorithm reading an image that says, yes, this patient has sinus disease or not. That's really the limit of it. Because the problem is doing an AI model for something that is your training dataset. It's only as good as your training data set. You would need thousands to be able to come across with this longitudinal journey of what an endoscopy looks like. It's too much right now to do that.
[Dr. Ashley Agan]
Moving on to iWorkUp. Can you tell us a little bit about sort of next steps when you consider imaging or other testing?
[Dr. Martin Citardi]
Yes. I'll get a CBC with differential, mostly looking for peripheral eosinophil counts to see if they have a systemic eosinophilia. For a while, I was using peripheral eosinophil counts to sort of guide my steroid treatment. Don't really use that as much these days, but it is a data point that helps us confirm a little bit about what's going on. I'll check a total IgE level as well. Again, high IgE levels are associated with allergic fungal sinusitis. Then I also will check a RAST inhalant panel, mostly looking for evidence of type one hypersensitivity against fungal aeroallergens.
Not so much concerned about the standard aeroallergens in this patient population, but it's part of the panel and it's sort of baked into it. That's not really going to help us much for these patients.
[Dr. Gopi Shah]
You send them to the lab for that?|
[Dr. Martin Citardi]
Yes. It's just a blood draw. We try to get it the same day before we start treatment. Just drop down the quest or whatever labs in the building and get that done.
[Dr. Ashley Agan]
Do they need imaging right off the bat? Do you get a CT scan the first time?
[Dr. Martin Citardi]
Typically, it depends if they've been treated or not. If they've been quote unquote maximally treated, we'll just jump to a scan and get that done. If they've not been treated, we'll start some type of treatment and then bring them back, typically in a month, with a scan. I think they all need a scan, even if they get a-- Even a polyp patient has a good response to the initial medical treatment needs a scan because you need to know if there's a mucocoele, if there's a high load of eosinophilic debris. Those patients are set up for failures and complications.
I've treated patients who've had vision loss from allergic fungal sinusitis, and it's because it wasn't picked up soon enough. You can't tell just by looking in their nose with a scope. You're looking at the tip of the iceberg. You have no idea what's going on in depth.
[Dr. Ashley Agan]
Got it. Everybody gets a scan eventually.
[Dr. Martin Citardi]
Yes, they all do. We run a high-resolution scan that's good for navigation on everybody, one protocol. I try to work with the same imaging center as well, consistently. We have a printed-out sheet. Whenever we go someplace else, half the time they do it incorrectly, even if we give them printed instructions. I tell that to patients point blank, and even if it's a pain for them to come back to get our scan done at the regular place, most of them will come back for it.
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Nasal Polyp Recurrence & Long-Term Steroid Maintenance
Chronic nasal polyps require a management strategy that extends beyond immediate symptom control. While medical or surgical treatment may provide initial relief, long-term success depends on consistent maintenance and a clear understanding that the condition is recurrent by nature. Many patients assume nasal polyps can be permanently resolved through surgery or medication. It is essential to reframe this expectation early in the treatment process by presenting polyps as a chronic inflammatory disease requiring ongoing care.
Postoperative improvement can be misleading and sometimes provide a false sense of “being in the clear”. Even in the absence of symptoms, polyp regrowth may already be underway, especially in anatomically open sinus cavities. As a result, regular follow-up during the first two years is recommended, usually every three to four months to identify early signs of recurrence. Maintenance with topical therapies, such as steroid irrigations or exhalation-delivered corticosteroids, should be continued even when patients report feeling well. The absence of symptoms does not necessarily reflect disease resolution and should not be used as a basis for tapering treatment prematurely.
To reinforce adherence and long-term engagement, analogies can be useful. For example, just as antihypertensive medications must be continued even when blood pressure is stable, steroid maintenance should not be interrupted simply because nasal breathing has improved. Framing treatment in this way helps establish realistic expectations and encourages sustained compliance with topical therapies and follow-up visits, which are key to preventing symptomatic relapse. As is always the case, clear and compassionate communication with patients will set them up for the best chance at feeling satisfied with their treatment.
[Dr. Gopi Shah]
In terms of your follow-up, Dr. Cirtadi, going back to our patient, you've seen them operate on the patient. When do they see you back, and then how do you follow these patients? Is it every three weeks, and then three months type of thing?
[Dr. Martin Citardi]
Yes, so the typical ground rule after sort of a conventional image-guided FESS for nasal polyps is two visits in the first two to three weeks after surgery, and then at that second visit, I can get a sense of who's going to be a frequent flyer versus not. At that point, we start them on the steroid irrigations or exhalational delivery of fluticasone if the cavity is not crusty or dirty in a sense. If I think they're a frequent flyer, I'll bring them back in two months. If I think they're going to do okay, I'll say three to four months. For the first couple years, most patients are coming back every three to four months for just routine checks.
I encourage them to come back early, regularly during that early period, because they will feel great, but they could have a significant relapse and not have symptoms because the cavity is wide open. You only get symptoms when things fill in to that extreme level again. I encourage them to come back, and I tell them about that, too, because it's an incentive then to tell them, "Even though you're feeling good, you got to stay on the irrigation. It's super important."
I'll use the analogy of, blood pressure medicine. When you take your blood pressure medicine, your blood pressure is good, but that doesn't mean you stop your blood pressure medicine. Most people get that. If they don't, then they're going to do whatever. Most people get that. I do want to see them early in that first year or two when they're doing well, because if there's a smoldering infection, if they have cystic polyps, those are all things that we can intervene with in the office that I think prevents a progression to a full-blown symptomatic relapse.
[Dr. Ashley Agan]
In patients who, in that small population who are on a biologic because they just had severe disease that wasn't controlled with topical steroids, are they coming in at the same frequency? Is there anything special or anything additional to think about in that group of patients?
[Dr. Martin Citardi]
No. I try to use the same frequency, basically. I try to be consistent. At that two or two-and-a-half-year mark when they're doing well, I may start both groups stretching them out to six months. The reality is there's a certain amount of attrition because people move. I also think over a long period of time, the disease process sort of burns itself out. Nobody ever really talks about that. I think that certainly happens if you have someone who has polyps at age 18. They don't have the same polyps 20 years later. Those adult patients who develop polyps, their natural history is different. We don't really have much information, that longitudinal follow-up.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2025, April 29). Ep. 220 – Managing Nasal Polyps: Treatments & Insights [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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