Journal of Otolaryngology-ENT Research

Review Article Open Access

Steroid therapy for nasal polyp: compliance due to

cost and phobia in developing countries
Abstract Volume 10 Issue 6 - 2018

Nasal polyps are among the common conditions encountered by an otolaryngologist in

Vadisha Srinivas Bhat
routine clinical practice. It is a benign lesion, but can be troublesome due to variety of Department of Otorhinolaryngology, Deemed to be University
clinical symptoms. A condition, which can be diagnosed easily by clinical examination K S Hegde Medical Academy, India
supported by CT scan of the paranasal sinuses, poses a challenge in the treatment.
While surgical clearance with the aid of endoscopic sinus surgery can provide quick Correspondence: Vadisha Srinivas Bhat, Professor,
relief from nasal obstruction, it is frequently followed by recurrence. Medical treatment Otorhinolaryngology, K S Hegde Medical Academy, NITTE,
with systemic and intranasal steroid is increasingly used with success as reported by Deemed to be University, Mangalore 575018, Karnataka, India,
many authors around the world. Steroid has been used as a single modality of therapy Tel +919480174828, Email
or as an adjuvant to surgical therapy before and after the surgery. Considering the long
duration of treatment required with intranasal steroids, a large proportion of patients Received: July 06, 2018 | Published: November 16, 2018
discontinue the treatment after certain period of usage, due to number factors which
include the cost of therapy and phobia of steroids. This is a review about the steroid
usage in nasal polyp, with emphasis on the compliance.

Keywords: nasal polyp, steroid; phobia, cost, compliance

Introduction sinusitis, whereas allergic fungal sinusitis causes multiple bilateral

nasal polyps. Katzenstein et al.3 described the case histories of seven
Nasal polyps are benign lesions arising from the mucosa of the patients with asthma, nasal polyposis, sinusitis and allergic mucin
nasal cavity or the paranasal sinuses. It is a clinical manifestation of within sinuses. This allergic mucin contained laminated mucin,
some of the mechanisms that is present in few people. The prevalence eosinophils, Charcot-Leyden crystals, and fungal hyphae. They called
of nasal polyposis ranged from 1% to 4.3%.1 Presentations of nasal this condition as “allergic aspergillus sinusitis”.3 Later, de Shazo et al
polyps is usually after the age of 20 years. It is very rare in children. proposed diagnosed criteria for allergic fungal sinusitis.4
Common symptoms of nasal polyps are nasal obstruction, increased
nasal secretion, hyposmia or anosmia, postnasal drip with resultant Cystic fibrosis, Aspirin (ASA) intolerance, Young’s syndrome,
cough and sleep disturbance. When the polyps become larger, they Churg strauss disease, primary ciliary dyskinesia are few uncommon
obstruct the sinus ostium, causing secondary sinusitis. Some patients associations of nasal polyps. Samter’s triad or ASA triad is the
present with a visible mass in the nasal cavity with a fear of having syndrome of nasal polyposis, asthma and ASA intolerance. This triad
a tumour, after ignoring initial symptoms of nasal obstruction and has been found in 8-39% of patients with nasal polyps.5 As many
discharge. Epistaxis is a rare symptom in nasal polyp, but can occur as 10% of children with cystic fibrosis may have concomitant nasal
due to secondary rhino sinusitis, when the polyp is longstanding. Even polyps.5
though a simple disease, this can significantly affect the quality of life
Diagnosis
of the affected person.
Most of the cases of nasal polyp can be easily diagnosed with
Etiology of nasal polyp clinical examination alone. Anterior rhinoscopy will reveal multiple
Exact etiology of nasal polyp is unknown; however it is associated pale, oedematous mass which are generally bilateral (Figure 1). Nasal
with many other conditions. Factors considered in the pathogenesis mucosa is hyperaemic with various stages of oedema. Sometimes
of nasal polyp are chronic rhino sinusitis, family history and genetic posterior rhinoscopy or nasal endoscopy is needed to investigate the
predisposition, atopy and allergy to inhalant and food allergens and origin of the polyp. Smaller polyps limited to the middle meatus,
aerodynamic factors.2 ethmoidal bulla, frontal recess, and uncinate process are can be seen
endoscopically. Mucus or purulent postnasal drip is often present in
Allergy is the most common association of nasal polyp. Elevated the pharynx.2
IgE levels in these patients, and the response to steroid therapy, supports
this theory. Asthma is associated with 25% to 32.6% of patients with
nasal polyps.1 Asthmatic patient have a twofold higher risk for having
nasal polyps than individuals without asthma; however, polyps are
more common in patients with nonallergic asthma compared with
those with allergic asthma suggesting that bronchial asthma rather
than allergy may be a predisposing factor.1 Nasal polyps are present in
both atopic and nonatopic Individuals.
Chronic rhino sinusitis is another cause for nasal polyposis.
Antrochoanal polyps have been associated with bacterial rhino Figure 1 Specimen of nasal polyp.

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© 2018 Bhat. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and build upon your work non-commercially.
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Steroid therapy for nasal polyp: compliance due to cost and phobia in developing countries ©2018 Bhat 313

Plain X-rays of the paranasal sinuses are almost obsolete now. CT lamellar element.7 Tissue eosinophilia is a general character of nasal
scan of nose and paranasal sinuses will show the extent of nasal polyp, polyps and is found in 80-90% of all cases.1 Most nasal polyps are
changes in the sinuses and anatomical variations, which are important characterized by significant eosinophil accumulation compared with
considerations if surgical treatment is planned. Coronal CT is the nasal mucosa from the same patients or from healthy individuals or
standard view, which provides the required information in most of patients with allergic rhinitis. However, antochoanal polyps seem to
the cases. Axial view may be required in some cases, especially those have different cellular content, with a predominance of neutrophils
with complications. The most important advantage of CT scanning and almost an absence of eosinophils. Polyps from both atopic and
is the precise view of the sinuses and ostiomeatal complex.2 Nasal nonatopic patients have similar cellular profiles, with activated
polyposis will be seen as homogenous soft tissue opacity in the nasal eosinophils, mast cells, and T cells, but they are different from polyps
cavity and involved paranasal sinuses (Figure 2). In case of allergic in patients with cystic fibrosis or antrochoanal polyposis.2
fungal sinusitis, there will be heterogenous soft tissue opacity within
the sinuses (Figure 3). Several staging methods have been described Treatment
for assessment of the degree of inflammatory changes in paranasal Nasal polyposis can be a frustrating disease for the patient and
sinuses on CT scan, the most commonly used is the Lund-Mackay for the treating physician. Management of nasal polyps comprises a
system. 6 combination of medical and surgical therapies. The recurrence of nasal
polyposis constitutes a serious clinical problem. Recurrence rates up
to 40-60% have been reported.8–10 These are used as either a primary
treatment or following surgery, to prevent recurrence. Steroids have
a multifactorial effect initiated by their binding to the cytoplasmic
glucocorticoid receptor cell. The number of glucocorticoid receptors
is reduced by glucocorticoid treatment.11
Myers reported cases with intranasal injection of corticosteroids
with complete regression of the polyp in few cases, and partial
regression in large number of patients. He advocated the use of
repeated injections of steroid into the polyp and concluded this
method is very useful in patients where surgery need to be avoided.12
Intranasal injections is not a routine practice now; instead steroid
preparations are used most commonly as nasal spray or drops, and
sometimes systemically. A short course of oral steroid followed by
intranasal steroid spray can significantly reduce the nasal polyp, at
times complete regression (Figure 4) & (Figure 5). Topical steroids
have been investigated extensively. In all patients the addition of
simple saline nasal douche for cleaning the nose prior to topical
Figure 2 CT scan Nose and Paranasal sinus, showing an Antrochoanal polyp
in right nasal cavity. medications is beneficial, as these irrigations have been shown to
improve nasal mucocilliary clearance.13

Figure 3 Heterogenous opacity seen in a case of allergic fungal sinusitis with

bilateral nasal polyposis.

Pathology of nasal polyps

Nasal polyps are lined by a pseudostratified ciliated columnar
epithelium, thickening of the epithelial basement membrane, scanty
blood vessels and nerve endings, few glands and goblet cells. The
stroma contains eosinophils, neutrophils, lymphocytes, monocytes, Figure 4 CT scan of a patient with bilateral nasal polyp (before treatment).
plasma cells, mast cells and macrophages. Mast cells occur about
twice as frequently in nasal polyps as in the normal nasal respiratory Van Camp C et al.,14 in their 25 patients treated with oral
mucosa and they were occasionally found within the surface Prednisolone, observed 72% of the patients showing subjective
epithelium and in the tunica media of larger veins. The mast cell improvement due to the involution of polyps in the nasal cavity.
granules of polyps are relatively small and they either lack the outer However, on CT of the paranasal sinuses only 52% showed a clear

Citation: Bhat VS. Steroid therapy for nasal polyp: compliance due to cost and phobia in developing countries. J Otolaryngol ENT Res. 2018;10(6):312‒316.
DOI: 10.15406/joentr.2018.10.00369
 Copyright:
Steroid therapy for nasal polyp: compliance due to cost and phobia in developing countries ©2018 Bhat 314

improvement. Therapeutic efficacy seemed to be better in the group of placebo in identical tablets for 2 weeks. Then, patients in both groups
ASA intolerant patients and worse in the allergic group.14 received Fluticasone propionate nasal drops, 400μg twice daily, for
8 weeks, and then Fluticasone nasal spray, 200μg twice daily, for 18
weeks. Patients taking oral Prednisolone demonstrated a significant
mean decrease in the polyp size in 2 weeks. The difference in polyp
size between those in the oral corticosteroid group and those receiving
placebo was maintained at 10 weeks. In the placebo group, sense of
smell improved after administration of intranasal drop (at 10 weeks)
but almost returned to baseline value after the completion of treatment
with nasal spray. They noticed suppression of basal and dynamic
adrenal function by oral Prednisolone at 2 weeks but returned to
normal values after 10 weeks. They concluded that short course of
oral corticosteroids could be recommended for most patients with
nasal polyps as an initial therapy if subsequent treatment with topical
steroids is planned.18
Cassano P19 evaluated the results of a medical treatment of
nasal polyp with a combination of oral Deflazacort with a topical
Beclomethasone dipropionate in the prevention of recurrence of nasal
polyposis after surgery. In the follow up at 6, 12 and 24 months, the
possible recurrence of polyposis, nasal blockage and the olfactory
functions were evaluated. After six months the disease recurrence
was observed in 33% of the cases, whereas after one year the
Figure 5 CT scan of patient in figure 4, after a short course of oral steroid
and follow up intranasal steroid spray. percentage rose to 50%. At 24 months recurrence was observed in
57% of the patients. However most cases did not show any sign of
Bonfils P15 in a prospective study in 181 patients, treated with further progression. Throughout the entire follow-up period under
a standard regimen, combining short term oral Prednisolone and observation only 6 patients (20%) had recurrence severe enough to
Beclomethasone nasal spray, observed that the treatment was necessitate revision surgery. The comparison with a control group
successful in 68% of the patients given medical treatment alone. without receiving steroid therapy highlighted the significance of the
Mean symptom intensity declined by 35 to 80% at 6 months, but results obtained. No important clinical side effects were observed
then remained unchanged for 2 years, during follow-up period. He during the study.19
concluded that medical treatment should be the first line therapy for
nasal polyposis. Surgery should not be proposed until corticosteroid Systemic steroid treatment is known to produce glucose
therapy has been found to be unsuccessful over a mean 6 months of a intolerance due to increased hepatic production and decreased
well-conducted treatment and good patient compliance.15 peripheral utilization of glucose. Deflazacort is proved to be
significantly less diabetogenic than prednisone. Studies have been
Rino K et al., 16 studied the effects of oral Prednisolone and conducted to compare the efficacy and safety of Deflazacort and
Fluticasone nasal spray in the management of nasal polyp. Fluticasone Prednisolone. It has been suggested that Deflazacort depresses the
propionate spray 200 mcg (two sprays twice daily) for 3 weeks along osteoblast less than Prednisolone, leading to a smaller decrease in
with oral Prednisolone 1 mg/kg in divided and tapering doses for 3 serum osteocalcin levels with Deflazacort. Also, Deflazacort appears
weeks was administered. They found 98.5% showing a reduction in to have less negative impact on growth rate in children. Different
nasal obstruction score after treatment, and 83.6% showing a reduction studies show that a long-term treatment with Deflazacort has a
in nasal discharge symptom score. Sixty patients (89.6%) showed smaller effect on glucose metabolism than other drugs of this class.
a reduction in hyposmia symptom score after treatment and 68.7% The overall incidence of adverse events in Deflazacort recipients
showed a reduction in facial pain symptom score after treatment. is lower than that recorded in patients treated with Prednisolone or
Nasal polyp size was found to be significantly reduced after treatment, Methylprednisolone.20 Deflazacort is safer than other glucocorticoids
and no patients developed any adverse effects during or following the because of its pharmacologic property of causing less calcium and
treatment initiation except mild burning sensation with Fluticasone hydroxyproline excretion, less metabolic effects on glucose balance
nasal spray in three patients, which subsided after a few days.16 and less neuronal degeneration compared with other glucocorticoids.
21
Deflazacort produces less interference with glucose metabolism
Tuncer U et al., 17 observed polyp-free nasal cavity in 12%, clear
than Prednisolone in healthy subjects, prediabetic and insulin-treated
involution of polyps in 76% , and no response to the therapy in 12%
diabetic patients. short-term glucocorticoid administration increased
after local Fluticasone spray and oral methyl Prednisolone therapy
fasting plasma glucose levels after Prednisolone and Betamethasone,
and concluded that steroid therapy plays a major part in the treatment
but not after Deflazacort.22
of the nasal polyposis, and steroids can delay the necessity for surgical
intervention.17 Tae Wook Kang et al.,23 studied the effectiveness of nasal
irrigation with Budesonide after endoscopic surgery for recurrent
Kowalski ML18 reported a randomized clinical trial by
nasal polyposis patients having asthma. They found that Budesonide
Vaidyanathan et al conducted in patients with bilateral moderate to
irrigation reduced the nasal symptoms, prevented recurrence of polyp
large sized nasal polyps to assess whether initial therapy with oral
and improved the quality of life of these patients. The requirement of
steroids would lead to greater and sustained reduction in polyp size
oral steroid was reduced in the study group. However, since the study
and greater improvement in symptoms, nasal airflow, and quality
sample was very small, the results of the study need to be supported
of life during the follow up treatment with topical steroids. Patients
by larger studies, before it is generalized.23
were randomly assigned to receive oral Prednisolone 25 mg/day or

Citation: Bhat VS. Steroid therapy for nasal polyp: compliance due to cost and phobia in developing countries. J Otolaryngol ENT Res. 2018;10(6):312‒316.
DOI: 10.15406/joentr.2018.10.00369
 Copyright:
Steroid therapy for nasal polyp: compliance due to cost and phobia in developing countries ©2018 Bhat 315

Non compliance for steroid therapy corticosteroids. The newer intranasal steroids are thought to
have a minimal effect on IOP because of their low bioavailability.
In spite of having researches which have proved the efficacy and The first report about IOP and inhaled steroids was published in
safety of steroid usage in nasal polyp, a large proportion of patients 1993 by Dreyer.31 Glaucoma was reported in three patients during
will discontinue the treatment after a small duration of usage. Patient treatment with inhaled Beclomethasone dipropionate. Simsek A
perceptions, beliefs and preferences, formulation characteristics and et al investigated intraocular pressure (IOP) alterations in patients
cost are the common barriers to the initiation of and adherence to using Mometasone furoate and Fluticasone furoate nasal spray for
steroid therapy.24 The common fears with steroids were habituation, six months. IOP was measured at the 3rd, 6th, 12th, and 24th weeks
damage to mucous membranes, and adverse effects on other of treat­ment for each patient. They did not observe increase in IOP
systems.25 Safety concerns and the fear of loss of effectiveness if used with this spray during 6-month follow-up period, and concluded that
for long period, was the other concerns which prevented people from new generation intranasal steroids can be used safely used in normal
using steroids.26 Mahadevia PJ et al.,27 studied the Patient preferences healthy individuals.32
for sensory attributes of intranasal corticosteroids by measuring
the strength of preferences for 6 sensory attributes; smell, taste, Conclusion
aftertaste, throat rundown, nose runout, and feel of spray in nose
or throat. Preferences were measured for 3 intensity levels of each Nasal polyp present as soft, painless, non neoplastic swelling due
sensory attribute; no taste, weak taste, and strong taste. They noted to hypertrophy and oedema of mucosa and submucosal tissue in the
that aftertaste was the most important attribute in 28% of patients, nasal cavity and paranasal sinuses. The goal of treatment of nasal
taste in 19%, throat rundown in 18%, nose runout in 12%, smell polyposis is symptomatic relief with elimination of polyps from the
in 11%, and feel of spray in 7%. They noticed 77% of the patients nose and paranasal sinuses and minimizing recurrence. Surgery often
accepting to adhere to a daily regimen for 3 months if the spray had alone fails to achieve the desired goals in nasal polyposis. Oral and
the lowest level of each sensory attribute; only 4% of patients, if given topical corticosteroids are quiet effective in this regard, when used
a spray with moderate levels of the sensory attributes. 27 With large alone or as an adjuvant to surgical treatment. Deflazacort, a relatively
number of steroid preparations in market, and many of them being new molecule of corticosteroid has bone sparing with less metabolic
over the counter products, there is variable preference to a particular sequelae, less diabetogenic and appears to be a safer option than other
compound and its preparation among patients. Many patients preferred systemic corticosteroids in patients with nasal polyposis. Counselling
Fluticasone furoate over Mometasone furoate after treatment for 2 about the safety of the steroid is essential to alleviate misconceptions
weeks, and Triamcinolone acetonide was preferred over Mometasone about steroid among the patients for achieving better compliance.
in several single dose studies.28 Fluticasone furoate was preferred over Pharmacists, with updated knowledge, can play a key role in
Fluticasone propionate in terms of having fewer odours, causing less maintaining adherence to steroid therapy. Corticosteroids should be
nose runout/throat rundown, and having fewer aftertastes.29 used with caution in ‘at-risk’ patients, particularly those with diabetes,
uncontrolled hypertension, and peptic ulcer
Counselling regarding proper self-administration may improve
adherence and facilitate better symptom control. Pharmacist has a Acknowledgments
major role in clarifying any potential misperceptions about intranasal
steroids, which could be a barrier to their appropriate use when None.
indicated. The benefit in intranasal steroids may not be immediate,
some benefit may be achieved within 3–4 hours, but these medications
Conflict of interest
provide optimal symptom control only when used continually for long The author declares there is no conflict of interest.
periods. Moreover, patients should be instructed to continue using the
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DOI: 10.15406/joentr.2018.10.00369
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Citation: Bhat VS. Steroid therapy for nasal polyp: compliance due to cost and phobia in developing countries. J Otolaryngol ENT Res. 2018;10(6):312‒316.
DOI: 10.15406/joentr.2018.10.00369