Topical corticosteroids in nasal polyposis

Nasal polyps are the common end-point of a number of conditions characteris ed by inflammation and are rarely 'curable' in its true sense. After consid eration of the underlying aetiology and confirmation of the diagnosis, they are normally managed by a combination of medical and surgical intervention s. Of these, topical corticosteroids have proved to be the medical treatmen t of choice. The objectives of the medical management are to eliminate or reduce the siz e of polyps, re-establish nasal airway and nasal breathing, improve or rest ore the sense of smell, and prevent recurrence of nasal polyps. The mechani sm of action of corticosteroids may be by a multifactorial effect on variou s aspects of the inflammatory reaction, the effect being initiated by their binding to a specific cytoplasmic glucocorticoid receptor. At a cellular l evel, there is a reduction in the number of antigen-presenting cells, in th e number and activation of T cells. in the number of mast cells, and in the number and activation of eosinophils. When polyps are large (grade 3) topical medication is difficult to instil i n a very blocked nose and surgery or short term systemic corticosteroids ma y be required. Topical corticosteroids are of use in the primary treatment of nasal polyps when they are of a small or medium size (grades 1 and 2) an d in the maintenance of any therapeutic improvement. The efficacy of topical corticosteroids such as betamethasone sodium phosph ate nose drops, beclomethasone dipropionate, fluticasone propionate and bud esonide nasal sprays in reducing polyp size and rhinitis symptoms has been demonstrated in several randomised, placebo-controlled trials. Beclomethaso ne dipropionate, flunisolide and budesonide sprays have also been shown to delay the recurrence of polyps after surgery. Placebo-controlled studies of agents that have shown a significant clinical effect in the management of nasal polyposis are reviewed.