Expanding the evidence base for the medical treatment of nasal polyposis

Abstract

Individuals with nasal polyposis continue to present a clinical challenge to the treating physician: we do not yet completely understand the underlying inflammatory and infectious pathways of the condition and the intricacies of the relationship with chronic rhinosinusitis, nor have we yet established the best means of producing long-lasting improvements in polyp size and associated symptoms. Strategies for nasal polyposis management usually involve surgical treatment, medical treatment, or a combination of both, often depending on the preference and experience of the individual physician. To date, the evidence base has lacked adequately powered studies to direct either the specialist or the primary care practitioner to the most appropriate method of treatment. Surgery is generally carried out endoscopically to relieve nasal blockage and to allow greater aeration of the sinus mucosa, thereby promoting recovery of the diseased tissue. Although the benefits of surgery include improvements in symptoms and health-related quality of life, incremental effects over medical therapy have not been well established. Indeed, recurrence rates after endoscopic sinus surgery are as high as 60% after a median of 2 years, with the likelihood of a successful outcome being influenced by a number of factors. These include aspirin sensitivity, asthma, or patient-specific anatomic obstructions, such as lateralization of the middle turbinate. In addition, major adverse events of endoscopic sinus surgery, such as cerebrospinal fluid leakage or periorbital hematoma, occur in approximately 1% of patients, with minor events occurring in 5% to 6% of patients. Given the invasive nature of any form of surgery, in combination with its inherent risks and required recovery time, the recently published ‘‘European position paper