REFRACTORY NASAL POLYPOSIS TREATED WITH OMALIZUMAB IN A CHILD

Abstract

Introduction Current treatment of inflammatory nasal polyposis consists of nasal/oral glucocorticoid therapy and surgical management if unresponsive to pharmacotherapy. The etiology is often multifactorial and requires combination management with both pharmacotherapy and surgery. We present a case of refractory nasal polyposis in a child treated with omalizumab, preventing the need for repeat surgical intervention. Case Description A 12-year old male with history of severe asthma, allergic rhinitis and allergic fungal sinusitis requiring functional endoscopic sinus surgery, developed worsening nasal polyposis despite maximal medical therapy. Physical and endoscopic exam revealed left sided nasal polyps, bilateral inferior turbinate hypertrophy, vocal cord nodules and hoarse voice. FeNO was uptrending, ranging from 98-175 ppb over the past year. Management included allergen immunotherapy, oral leukotriene-receptor antagonist, high-dose inhaled corticosteroid/long-acting beta agonist, oral antihistamine, intranasal antihistamines, high-dose intranasal steroid rinses, and oral steroids. His asthma was well controlled. Repeat surgical intervention was anticipated. Given his rising FeNO levels despite oral steroids, omalizumab was initiated in an attempt to decrease his nasal inflammatory process. Significant symptomatic improvement was noted after two omalizumab injections and his FeNO decreased to 65 ppb, the lowest value in the previous 3 years. Six months later, his FeNO has declined further to 29 ppb. Endoscopic exam showed polyp regression. This has prevented need for nasal surgery with continued use. Discussion Off-label use of omalizumab for atopic nasal polyposis should be considered in patients nonresponsive to traditional pharmacotherapies.