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BackTable / ENT / Article
Nasal Polyps Treatment: From Symptom Recognition to Surgical Strategy
Sam Strauss • Updated Jun 24, 2025 • 33 hits
Effective management of nasal polyps begins with recognition of the oft-muted symptoms that accompany the chronic inflammatory condition. Many patients find ways to adjust to the progressive obstruction, anosmia and poor nasal airflow without fully understanding the severity of their disease, and this often makes initial diagnosis difficult. Subtle signs—combined with a proper and full nasal exam—can help identify polyp burden early and guide the decision-making process for medical or surgical intervention.
Nasal polyp treatment is typically tiered, beginning with oral steroids and topical irrigation, and progressing to surgical removal or steroid-implant therapy if those initial measures fail. The decision to escalate care hinges not only on imaging and polyp load but also on the patient’s ability to sustain long-term topical therapy.
Read on to learn how to make nasal polyp treatment decisions, and when a patient should be referred for interventional therapy. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel here, and you can listen to the full episode below.
The BackTable ENT Brief:
• Patients with severe polyp burden often report only mild symptoms and require specific prompting to identify anosmia and chronic obstruction.
• Rigid endoscopy using a 3mm, 30-degree scope is typically preferred for initial evaluation, with video capture enabling longitudinal review.
• Initial treatment typically includes a short course of oral prednisone, topical budesonide irrigation, and antibiotics as required.
• Surgical interventions in this area aim for complete polyp clearance to clear the airway, and enable effective steroid delivery to reduce inflammation and reduce recurrence rate.
• Steroid implants may be used during or after a polypectomy to prolong symptom relief and delay biologic escalation.
Table of Contents
(1) Nasal Polyp Symptoms: Recognizing Airway Obstruction
(2) Nasal Polyp Evaluation & Assessment
(3) When & How to Initiate Medical Treatment for Nasal Polyps
(4) When to Escalate: Nasal Polyp Surgery, Steroid Implants & Biologics
Nasal Polyp Symptoms: Recognizing Airway Obstruction
Patients with nasal polyps often present with a disconnect between objective findings and reported symptoms. Even when polyps obstruct nearly the whole nasal passage, patients frequently describe their symptoms as minor—“a little stuffy” or “a little congested.” This underreporting may delay referral or mask the severity of inflammation and obstruction. For clinicians, this makes a compelling case for proactive assessment when patients report nonspecific nasal complaints, particularly if symptoms have persisted beyond what would be expected from typical rhinitis or allergies.
For more proactive polyp management, clinicians should develop a high level of suspicion, especially in patients who present with other conditions—like outer ear complaints or facial pain—and coincidentally reveal obstructive polyps during routine nasal examination. It is critical to prompt patients about sense of smell, mouth breathing, or poor sleep, as these can be more telling than their self-reported nasal congestion.
One proposed physiologic reason for muted symptom reporting is sensory adaptation over time. Patients with long-standing obstruction may develop a form of desensitization that reduces trigeminal nerve signaling. This may explain their tolerance for both chronic obstruction and in-office procedures like endoscopic debridement.
[Dr. Martin Citardi]:
Most patients with sinusitis with nasal polyps, they report congestion, obstruction, but they are not horribly vocal about their symptoms, which is interesting. The nose will be swollen shut with polyps, and they say, "Oh, I'm a little bit stuffy. I'm a little bit congested. I wheeze a little bit," but they're not vocal about it. To me, that's always been fascinating. Many of them have decreased sense of smell, but they usually don't lead with that symptom. You have to sort of elicit it from them.
They're relatively minimally symptomatic compared to the other patients we see in rhinology.
[Dr. Gopi Shah]:
Yes. I noticed that too. I think that's, it's really interesting just in general, how we think of sensation of nasal obstruction and nasal airflow, because you're right. You can look in there, and you can't even fit the scope anywhere. It's like, "You can breathe through your nose or you can't breathe through your nose?" They're here for the outer ear. They're here for something completely different. It's like, and I don't know, is it a reflection on the slow growth of polyps? I feel like they grow so fast after certain-- Sometimes you're like, "Hey, how did that reappear so fast? How does their nose get so--" How do they accommodate to their mouth breathing or get used to their symptoms? Why do you think it is?
[Dr. Martin Citardi]:
The best explanation I heard, I don't know if this has actually been validated, is they get substance P depletion. Just by over-sensory stimulation, eventually the trigeminal innervation just sort of attenuates itself. That makes sense. I don't know if it's actually true, but it does make sense.
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Nasal Polyp Evaluation & Assessment
The physical exam for a nasal polyp assessment begins long before a scope enters the nasal cavity. Observe the patients facial symmetry and nasal tone when they first speak, or the way they breathe when they enter the room. These subtle findings can guide the exam before any instruments are used. Once the exam moves to the nasal cavity, rigid endoscopy is preferred – typically with a 30-degree, 3mm scope for optimal visualization and patient comfort.
Nearly every patient with suspected or known nasal polyps should receive an endoscopic evaluation. Video capture during these exams allows for longitudinal tracking and surgical planning. Clinicians often use polyp appearance—cystic, fleshy, hyperemic, or crusted—as part of a broader pattern recognition model over time rather than a single visit.
While many practices still use quality-of-life questionnaires, Dr. Citardi notes that they often introduce noise rather than clarity. Direct questioning about functional goals, alignment between patient expectations and treatable pathology, and symptom progression is more informative in practice. For example, a patient seeking relief from occipital headaches may not benefit from aggressive nasal treatment. If the patients don’t understand the purpose behind the questions they are being asked, it can “muddy the waters” of their answers, making it more difficult to provide an accurate diagnosis.
[Dr. Gopi Shah]:
In these appointments, let's pretend we're talking about the patient that didn't know they had nasal polyps and they were just coming to you because they're like, "I'm a little congested. I think my allergies are flaring up." Then, how does the rest of that visit go?
[Dr. Martin Citardi]:
We try to get a detailed history in terms of the onset and fighting factors. These days, many patients will report some prior treatment with over-the-counter nasal steroids. There's a lot of different things patients will try before they get to us. Since this is mostly a quality-of-life disease, I think it's important for the patient to define what their objective is, because we could achieve our objective as physicians. If it doesn't align with the patient wants and it's all about quality of life, that there's a problem there.
Now, sometimes when their objective is completely misaligned to the things we can help them with, I think we need to have that conversation as well. The patient who comes in with a little bit stuffy, but their main complaint is pain in the back of their head. No amount of things we're going to do to improve their nasal air flow is going to change the pain in the back of their head. We need to have that conversation up front. I think that's really important.
[Dr. Gopi Shah]:
Yes. Sometimes patients have a constellation of things going on, and they can just assume that they're all connected. Then, the nose is better, and they're like, "Yes, but I'm still having these headaches, these sinus headaches that point to the back," and you're like, "Oh, yes, that's not part of it. That's a really good point." Do you like to use questionnaires when you validate questionnaires, as far as determining quality of life impact and things like that?
[Dr. Martin Citardi]:
We do have them on paper currently. We're exploring moving to a digital format. Personally, I don't think they're terribly helpful because it doesn't give me what I need to understand what's driving the patient's behavior and what gives them the most trouble. There's a lot of noise in the questionnaires that's not directly disease-related. It's more behavioral, and that clouds the picture. I also think there's a problem with the quality of life questionnaires in that we tend to use them for diagnosis, and that's not their intent. They assume that the population who's taking the questionnaire has the confirmed disease process and then it gets valid too. I think it's very easy to misuse them. We do do it, but again, practically, I don't think it's super helpful in most patients.
When & How to Initiate Medical Treatment for Nasal Polyps
First-line medical therapy for nasal polyps typically includes a short oral steroid taper combined with topical budesonide irrigation. This combination reduces mucosal inflammation, improves airflow, and facilitates deeper penetration of topical agents. Antibiotics are often prescribed alongside, although their benefit may be limited to addressing secondary infection or protocol completeness prior to surgery.
Oral prednisone tapers generally begin at 40 mg and decrease every three days over a 12-day period. This approach is well tolerated in most patients unless contraindicated by comorbidities, such as uncontrolled diabetes. In those cases, treatment may rely on topical delivery alone, which is still effective when inflammation is sufficiently controlled to allow absorption.
Patient counseling is key during this phase. It’s important to clarify that oral steroids serve as a “jumpstart” rather than a long-term solution. Many patients continue to improve for weeks beyond the steroid course due to enhanced delivery of topical agents to now-accessible sinus mucosa. However, some patients don’t show enough improvement, which typically leads to surgery being the next option. It is also important to communicate the relatively benign nature of nasal polyps to patients, especially those who experience more anxiety about the diagnosis.
[Dr. Ashley Agan]:
As far as your treatment for patients who are treatment naive, is there a particular go-to treatment?
[Dr. Martin Citardi]:
If they have significant polyp burden on one side or both sides, I will give them a round of oral prednisone unless there is a strong contraindication. Depending on the polyp burden, it could just be a 12-day course of prednisone, starting at 40 milligrams and then dropping by 10 milligrams every three days. I'll pair that with antibiotics. I don't think the antibiotics do very much in many patients.
If you're thinking that there's a possibility of surgery, that's one of the checkboxes you got to go hit. We'll do that. Then typically, we add on a topical steroid as well, particularly as the prednisone is coming down because the prednisone will open things up and then allow budesonide irrigations or exhalational delivery of fluticasone to get in. I'll prescribe that to start and then they'll come back, typically within a month, maybe six weeks, with that scan and we kinda see how they're doing at that point.
[Dr. Gopi Shah]:
What antibiotic, how long are they on it for? 30 days, two weeks? What do you usually use?
[Dr. Martin Citardi]:
Three weeks is typical. I think it's arbitrary, but I say three weeks. Then what's interesting is with that regimen, most of the patients will feel better. It's just a question of how sustainable the improvement is when the prednisone is off.
They can actually improve for weeks, maybe even months, after initiating the topical steroid, after the sinuses have been opened by the round of the prednisone.
[Dr. Ashley Agan]:
Which antibiotic do you like to use?
[Dr. Martin Citardi]:
Amoxicillin, clavulanate, usually, occasionally doxycycline if they're allergic, or they've been on amoxiclav recently.
[Dr. Ashley Agan]:
When you're talking to patients about just polyps in general, how do you explain nasal polyps? Because I think sometimes patients hear polyp and they think about polyps in other parts of the body. It's like a polyp in the colon, which could be precancerous, and that you can just remove. They might say like, "Can't you just take it out?" You have to have that conversation about the uniqueness of nasal polyps. What does that conversation look like for you?
[Dr. Martin Citardi]:
A lot of times, you can watch the patient's reaction if they think it's something like a colon polyp. Then I'll just say point blank, “this is not like colon polyps. It's a completely different game”, Just to take that off the table, if I get a sense that they're just super nervous. What I do explain, though, it's just basically about inflammation that is triggered for unclear reasons in a specific patient. I'll even go further and say it's like a lot of chronic diseases that everyone experiences, like hypertension. Why do some people get high blood pressure? Some combination of a genetic predisposition, some bad luck, and some ill-defined environmental trigger.
Almost any chronic illness falls into that category. It's very hard to go deeper than that in any one patient without doing these exhaustive studies that are not really clinically relevant. Most patients will accept that type of explanation.
When to Escalate: Nasal Polyp Surgery, Steroid Implants & Biologics
When polyp recurrence is frequent or symptom relief is short-lived, escalation to surgery becomes appropriate. The goal of nasal polypectomy is complete clearance—creating an anatomy that permits efficient, ongoing topical treatment. The first surgery is especially critical; a complete “polyp-zero” baseline allows topical therapies to function without obstruction or hidden indices of inflammation.
Steroid-eluting implants, such as SINUVA, may be placed intraoperatively or postoperatively in the office to sustain local steroid delivery and improve outcomes. These are particularly useful in patients hoping to avoid biologic therapy, offering a non-systemic way to maintain control. Proper counseling is essential to align patient expectations and clarify that implants are an adjunct – not a replacement – for consistent topical care.
Biologics are reserved for patients who have undergone surgery and continue to experience recurrence despite adherence to topical therapies. These agents should not be positioned as a first-line alternative to standard treatment. ENT clinicians must assess treatment history, prior surgical effectiveness, and long-term management needs before considering biologics, especially in a landscape where ENT involvement may diminish as biologic use expands across specialties. There is still limited research and data about the efficacy of biologics and its use for diagnosis under the otolaryngology specialty.
[Dr. Martin Citardi]:
I think the important thing about the surgery is that the first surgery is probably the most important one. We suspect that's true, especially for allergic fungal sinusitis patients. I think it's true really in general for all of these polyp patients. It has to be comprehensive in terms of making sure that all the sinuses on the involved side that have polyps in them are cleared out, because you really want to get them down to a true polyp-zero state. Because that's your new baseline.
You don't want to have any pockets where there is a nidus of eosinophilic inflammation just blocked off from topical treatments. The surgery, I think, needs to be comprehensive. That doesn't mean that every patient automatically gets a drill out. I think that's overkill and too dysfunctional. Most of these patients with polyps, the frontal recess is expanded by the polyp. It's almost done the work. You just have to spend the time to make sure that all the little compartments are open and cleared out.
We have the technology to do that safely, reasonably well. What the surgery does is set up the patient for post-operative steroid delivery. You can place memetazole implants at the time of surgery as well. The sustained delivery of steroids into the cavity is important. Now, for the biologics question, I think it's an interesting one. Over the past three or four years, there are a couple of patients who were sent to me by allergists in town who were started on biologics, and their request was they wanted their sinuses "cleaned out" so the biologics would work better. They were started on biologics basically the week before I would see them in the office.
In that very small number of patients, the surgery seemed a little bit different in terms of how their eosinophilic mucus looked. It was just a different consistency. It's tough to put into words, but it did look different. The problem with that approach now is there's no data to show that. You choose your favorite biologic, you give them one or two rounds, you do surgery, you're going to take it off, whether that actually improves outcomes. That study in the US will never happen because the people who fund the research do not want to fund only two rounds of a pharma treatment or one round. We're trapped there. It's an interesting idea, but I don't know how far we'll be able to take it.
[Dr. Shah]:
Can you tell us a little bit more about steroid delivery? We all think of topical budesonide. Is there a role for steroid-eluting stents at the time of surgery or in your office, or in your practice?
[Dr. Citardi]:
I'm going to say a strong yes for that because it's a way to get basically steroid to target in a very reproducible way and predictable way. You can think about the standard 370 microgram, PROPEL Mini, PROPEL Contour versus SINUVA, which is a much higher dose. The SINUVA mometasone implant was designed for recurrent polyps after ethmoidectomy for delivery in an office setting. I will offer that to patients quite a bit when they're not doing well. The conversation is basically we can do this procedure in the office, place this dissolvable device versus putting you on a biologic, which is probably an indefinite commitment.
Podcast Contributors
Dr. Martin Citardi
Dr. Martin Citardi is a rhiinologist and Professor and Chair of the Department of Otorhinolaryngology at McGovern Medical School in Houston, Texas.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
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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