first hand experience: I've used corticosteroid spray for years, but only became free of headaches and frequent infections after surgical removal of the polyps. Would like to have done this years ago.

The best treatment is medical therapy with 1-2 week systemic prednisolone for acute bouts combine with fluticasone nasal drops. Continuous prophylactive therapy with nasal steroid spray to reduce recurrence. When medical therapy fails resort to surgery. I suggest endoscopic sinus surgery but WITHOUT bone or mucosal membrane removal where polyps are removed with shaver and paranasal sinuses are opened with pressure methods (balloon catheters). This retains normal anatomic conditions in the nose. If surgeon is removing the bony walls (f.ex. ethmoidectomy) it allways leaves too wide air space in the nose. No matter what surgical method is used polyps may grow again and demand removal f.ex. each 8.years.

It is important that an predisposing or offending agents be stopped before ocmmencing such therapy. Several commonly used over the counter drugs can cause nasal polyposis.

The main reason for polyps is genetic predisposition. Ove the counter drugs can cause only nasal obstruction due to 'rhinits medicamentosa'.

I totally agree that the main treatment should start medically with topical treatment in the form of steroid drops and possibly anthististamines for at least 6 weeks with 2 weeks of oral steroids and incase this is not successful then surgery might be the next step. There is a very nice paper Eurpeon position paper for managing rhinsinusitis and nasal polyposis that has the answer in more details

http://www.rhinologyjournal.com/supplement_20.pdf

I start with local steroid spray accompay with systemic prednisolon for 2 weeks plus zaferleukast 10 mg or 20 mg then shift to edoscopic removal if thia treatment falied

I recommend cone beam tomography of the nose and sinuses before surgery as nasal polyps are often only the tip of an iceberg. The sinuses are often blocked as well and symptoms may continue or polyps grow faster back if sinuses are not addressed.

The updated EPOS study offers very clear guidence regarding medical management, which is always worth trying before undertaking surgery.

I wonder how could get rid of polyps (Stage III) without removing bony walls as happens performimng ethmoidectomy. We know that some patients (same stage, same comorbilities, same age, etc.) resolve only temporarily after "extensive" surgery, and recur, while others miss controls, do not assume any kind of drugs, simply forget their condition but show perfect reepithelized sinus cavityies, no sign of recurrence, and get perfectly well after surgery. We still have to unfold this apparent nonsense

Chronic rhinosinusitis with nasal polyps is a condition classically defined as a subtype of chronic rhinosinusitis; however, experience and contemporary evidence suggest that this may eventually prove to be a condition on its own. (attached is an excellent review of CRS)

There are numerous theories put forth that seeks to explain the etiology of CRSwNP, from genetic predisposition, to fungi, to staph superantigen, however, there is no consensus at present.

The natural history is one of recurrence, regardless of the method by which you treat it, either by medical polypectomy or surgical polypectomy. Since it is just a matter of time before it recurs, you have to qualify what you mean by BEST treatment? Do you mean a decrease in SNOT scores? Shrinkage or total absence of the polyps? Non-recurrence (and for how long?)? Decreased need for intranasal steroid spray (no maintenance medication)? Resolution of nasal obstruction? Return of sense of smell?

I subscribe to the EPOS guidelines released this 2012, however, my region of the world (South East Asia) may have different kinds of polyps compared to Western countries, so the recommendations may not be spot on all the time.

Personally, especially for grade 3 polyps, I start them off on concurrent oral and intranasal steroids and augmented penicillins for 2 weeks, re-assess the patient's status and SNOT score, proceed with PNS CT and FESS if with poor response, or if with patient-reported satisfactory response and undecided on surgery, discontinue oral meds and just continue with intranasal steroids, with the caveat that symptoms may recur.

In terms of extent of surgery, I never do just a polypectomy (unless if it is just an antrochoanal polyp, a different story altogether), but, rather, remove the uncinate, open up the ethmoid bulla, make sure the ostiomeatal unit is patent. If there is still gross polyps, I will open up the ground lamella and posterior ethmoids, but if it is just diseased mucosa, I will let my post-operative intranasal steroid spray do the work.

Antihistamines for me are only given in the presence of systemic allergy, otherwise, I don't routinely prescribe them. There are some studies supporting the use of anti-leukotrienes for recurrent nasal polyps, but the evidence is not consistent, and the studies are not robust.

Control of other conditions should also be undertaken, since non-allergic asthma also correlates with nasal polyps. Patients with aspirin sensitivity should be considered as special cases and treated appropriately.

If the case is a nasal polyposis without complications, I prescribe steroid nasal sprays (2 puffs BID for 3 months, saline nasal irrigation, Klarithromycine low dose daily for 1 month +/- short cure of systemic corticotherapy & reassessment by endoscopy + CT-scan sinus: if no significant improvement, FESS is indicated. On the other hand, if nasal polyposis is associated with complication (ocular or IC extension), FESS is indicated from the start followed by the above mentioned medical treatment.

best treatment for nasal polyps, DNS, sinussitis is Yoga's Shuddi kriya called Jalaneti and sutraneti. no operation and medicine reqd.

Chavan , please more explain about Yoga for nasal polyposis

I disagree with Shanti Chavan because no published article said that Yoga can treat nasal polyps, DNS or sinusitis. The EPOS 2012 guidelines of sinusitis treatment did not mention Yoga.

i don't know about any guidelines what you talking about. but surely, yoga does cure all above condition without any intervention of surgery or steroid, provided sinus not infected or conditioned worsened where one do need medically operated.

many of my students with Sinusitis and DNS, got cured through application of Yoga. and till date many of them practising yoga. among them are some of ENT doctors. you people may find this is fantasy, but its true. our rishis don't need any scientific lab or scientific journal to published or proof it. yoga is experiential science. one need to practice and experienced.

The EPOS 2012 guidelines of sinusitis treatment did not mention Yoga as an evidence based treatment of polyposis, sinusitis or DNS.

Mr Chavan, please plublish your experince or if you have any paper , give references.

Well proved drugs firm Vitorgan and Sanum(Germany)

Mis Olga, would you present the article about Vitorgan & Sanum (in english).

Dear Mr. Hazem Abdelwahed! These are preparations of the German company, here is their website www.vitorgan.de. www.sanum.de. If you have questions, write. All the best. With respect Olga Shn

Mis Olga Shnaybel !! I saw www.vitorgan.com - www.sanum.com but I did not find any article which can prove the efficacy of vitorgan or sanum in treatment of sinusitis or polyposis. Also, EPOS 2012 did not mention that. please send me an article, English or Germany.

Why not bungee jumping then?

This is a reference to the Institute http://www.regbiomed.com/en/about.shtml . Must be addressed to Professor Rolik Ivan Stanislavovich. They have a lot of works on research of these drugs. With respect Olga Shn

I feel nasal polyps are irreversibly edematous nasal mucosa resulting from persistent nasal inflammation . I would address the underlying cause than to primarily concentrate on removing the polyps. steroids are of good help in treating patients symptoms. with through investigations and functional endoscopic surgery, my recurrence rates have been around 15%

To add on to Dr Kiruba Manoharan, Polyps are obviously a medical disorder caused among other rarer things,by allergy. FESS helps in refractory polyps in most patients. The trick is to do a meticulous surgery leaving no bony overhangs and residual cells. Chronic inflammation and crusting in these nooks definitely cause recurrence. Also we should not underestimate the use of irrigation of the sinuses after surgery. Too many patients suffer a life time of ultra-conservative treatments with poor results affecting their quality of life.

About yoga, This works more on the psychological acceptance than physical reversion of polyps. I see a lot of patients undergoing yoga as there is a hub of yoga teaching near this place. The satisfaction levels of the patients are some how much more than what their nasal exams would sometimes reveal!! I wonder why?

thank you very much for your good response. I think , the Yoga has a psychological affects. this is an additional treatment after or associate classic therapy.

Dear colleagues, what are your comments about intra nasal intra polyp injection of steroid?

Personally I have no experience on intranasal intrapolyp steroid injection.. I think its a food for thought, as I could not find good references for this. However in the absence of contraindications, systemic steroids are very useful and can cause complete regression of polyps in many cases. But this need to be followed by a prolonged course of intranasal steroid sprays for preventing recurrence. Yes, when the polyp is very small, even steroid sprays can cause regression of polyps. However, for this treatment both the patient and the treating doctor should require lot of patience. otherwise a short course of oral steroid, followed by endoscopic sinus surgery, followed by intranasal steroid should be the good practice, in my opinion..

An exception for the routine treatment for nasal polyposis, is the nasal polyposis due to allergic fungal sinusitis. Here surgical clearance should take precedence, of course following a short course of systemic steroid if possible. Fungal debris need to be chased to clear even a little bit, to prevent recurrence. even these patients need topical steroid for a short period of one or two months after surgery.

Thanks, for good information. I know that surgery is not the solution for permanent cure of nasal polyps. Regular Jala net and Sutra neti help in curing nasal polyp permanently.

The use of yoga techniques for nasal conditions. You may refer the following papers-

http://www.ncbi.nlm.nih.gov/pubmed/20509333

http://www.ncbi.nlm.nih.gov/pubmed/23354530

intranasal steroid injection may be effective than oral steroid with a little side effects

For class 1 and II type of polyps I have use a combination of Clarithromycin 500 mg daily, Montelukast 10 mg daily, Levocetirizine 5 mg daily and Mometasone nasal spray one puff bid to each nostril till the polyps disappear (I try to avoid giving oral steroids if I can help it) and once the polyps disappear I maintain them on the ICS with or without the Levocetirizine.   It does not work that well for class 3 polyps which eventually require FESS.  However recurrence is seen in about 50% of the patients.   No I don't have a proper organised DBRPC studies to prove this.   

As a patient with nasal polyps my MD has prescribed me pulmicort in saline nasal wash instead of nasal spray corticosteroid and I have to admit it works better than spray. However, the best "treatment" for me was to avoid any alcohol and any coffee and take probiotics. 

I am practicing Jal neti as well as Sutraneti, But, pollyps reappear. What to do?

Sorry I am unfamiliar with Jal Neti and Sutraneti.  What are those?

In my opinion there is no permanent solution for nasal polyps. I am regularly practicing jal-neti as well as sutra neti for last five years. Till date it has not been cuted. But, it is under control.

Thanks Mandal

Ok

What about the cost of long lasting (and most often unefficient) medical treatment with nasal steroids, systemic steroids, antihistamines, antileukotriens, nasal douches prescribed in CRSwNP not preceeded by surgery? In my country not all patients couls afford this approach, while surgery is provided for free.

Yes medical control is expensive. It works in about 50% of the patients and not in the other 50% who will then be offered surgery. Surgical option is much more expensive owing to the high cost of hospitalisation in Malaysia. Medicine is cheaper and not every one has health insurance. So medication may be cheaper for some.

Greetings dear colleagues, I was operated on for 8 months of nasal polyposis, however despite that I do polyps formation and therefore sinusitis .. I have been treated with many antibiotics, penicillins, quinolones, mupirocin, etc ... I have been given corticoids orally for 2 weeks the polyps completely remit but one to two months and I go back to form .. What would be the ideal management to avoid that these polyps appear again .. Someone told me to use budesonide 500mcg in each nostril .. Has someone experience with this..?

And someone who has experience with the use of baby shampoo with the formula of Dr Takashima for chronic sinusitis plus recurrent nasal polyposis .. Because despite having received multiple antibiotics the infectious disease reappears and therefore the circle of nasal polyps formation ..

trial of medical polypectomy in form of intranasal cortecosteriod for one month if failed FESS according to the extent of the polyps. Polyposis due to Fungal rhinosinusitis should treated surgically from start as diagnosed by Ct .

I am patient of nasal polyps, one thing I observed is I am almost normal during summers but as winter comes it swells for unknown reasons and causes too much difficulty while breathing.

Does anyone knows the reason behind this?

Is it change in humidity or temperature or pressure or other factor?

And does it happens with every other patients in winters only?

Yes, the weather variability has affects on your disorder, especially the cold weather. Therefore, you are sensitive to the cold weather.

But at the same time sitting in low temperature air conditioned room do not trigger the swelling of the nasal polyps. So if drop in temperature is not the reason then what could it be?

Thanks for the reply.

other reasons may be contributed in severity of nasal polyposis, recurrent viral infections, indoor allergens such as mites,molds and pets ( of course, they have a little effects). however I think, the cold weather ( both indoor or outdoor) is the most important factor in severity of nasal polyposis.