Transcript
Announcer:
Welcome to Clinician’s Roundtable on ReachMD. On this episode, Dr. Amber Luong will share her insights on the management of chronic rhinosinusitis with and without nasal polyps. Dr. Luong is a Professor of Otorhinolaryngology Head and Neck Surgery at the McGovern Medical School at UTHealth Houston.
Here she is now.
Dr. Luong:
Once you have a patient who presents with symptoms—so you have a scan or a nasal endoscopy confirming chronic rhinosinusitis without nasal polyps or with nasal polyps—the first thing you want to do is try some topical anti-inflammatory medicines and some saline irrigation. So saline irrigations help move the mucus to clear things that may be triggering the inflammation and the anti-inflammatory, because we know this is an inflammatory process. It helps to reduce inflammation.
We usually will start there, and if there's signs of pus, meaning, on nasal exam, you see purulent material, then you may consider them a candidate for oral antibiotics. But oftentimes, we don't need to use oral antibiotics—it's only when you actively see pus noted.
And then, once in a while, you may want to consider oral steroids. So in patients with severe polyps, some people will try oral steroids, because, as you can imagine, the topical steroids aren't going anywhere with all those polyps in place. The problem is that you have to consider the side effects associated with oral steroids, so that's really important.
If they respond to and are happy with those medicines, then that's all you need to do. But oftentimes, patients end up having just temporary relief with these medications, especially in an unoperated patient. So then you may need to offer a surgery. The surgery doesn't cure the patient, but what it does is it may reduce the inflammatory load. So it removes the polyps, and then it also, more critically, opens up the sinus cavity, so that topical therapies can more effectively get to the inflamed mucosa. And so for the post-op with surgery, I often tell patients, listen, this is just the first step. Surgery is just the first step in this. Then you have to maintain it with these saline irrigations and topical steroids.
Then, if for some reason patients with polyps don't respond to that regimen because their polyps came back, then they may be candidates for these type 2 targeted biologics which we now have. In patients with aspirin-exasperated respiratory disease and in patients with polyps and asthma, if their polyps come back immediately after surgery—meaning within the first three to four months—then you know that they're generally not going to do well with the post-op regimen of saline, irrigations, or saline with some anti-inflammatories in it.
In that situation, we used to just offer—especially if the polyps came back—revision surgery, even if everything is wide open. The idea was just to quote-unquote “mow the grass” or reduce the inflammatory burden to help with their symptoms. But nowadays, since biologics have been approved for patients with polyps, then in that situation, we can now consider a biologic for them. So in the past, sometimes some patients would have four or five sinus surgeries, and nowadays it's maybe one, maybe two, just to really address all the sinuses. Those are the typical numbers of sinus surgery. If they have recurrent polyps, then we start considering whether or not they're a candidate for a biologic therapy.
Announcer:
That was Dr. Amber Luong discussing how to effectively treat chronic rhinosinusitis with and without nasal polyps. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
