A 38-year-old woman from Delhi presents with a 4-month history of nasal obstruction, chronic purulent nasal discharge, and recurrent headaches. Nasal endoscopy reveals bilateral nasal polyps, and CT paranasal sinuses shows opacification of maxillary and ethmoid sinuses with polypoidal masses. Regarding the management of chronic rhinosinusitis with nasal polyposis (CRSwNP), all of the following are appropriate EXCEPT:

Question

Accepted Answer

D. Functional endoscopic sinus surgery (FESS) with complete polyp removal is indicated when medical therapy fails and provides definitive cure without recurrence. ## Management of Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP)

**Key Point:** CRSwNP requires a stepwise approach combining medical therapy (intranasal corticosteroids as first-line) and surgical intervention when medical management fails. However, surgery is **not** curative — recurrence is common without continued medical therapy.

### Correct Statements (Options 0, 2, 3)

| Management Strategy | Evidence & Role |
|---|---|
| **Intranasal corticosteroid spray** | First-line; reduces polyp size, prevents recurrence; must be continued long-term [cite:Park 26e Ch 8] |
| **Leukotriene receptor antagonists** | Adjunctive therapy; especially useful in aspirin-exacerbated respiratory disease (AERD) and NSAID sensitivity |
| **Oral corticosteroids (short course)** | Perioperative use reduces polyp edema and improves surgical access; also used in acute exacerbations |

### Why Option 1 (FESS Provides Definitive Cure) is INCORRECT

**High-Yield:** FESS is **NOT** curative in CRSwNP. Polyp recurrence occurs in 10–30% of patients even after complete surgical removal if medical therapy is not continued.

**Clinical Pearl:** The role of FESS in CRSwNP is to:
- Remove obstructing polyps and improve access for topical therapy
- Restore sinus ventilation and mucociliary clearance
- Provide tissue for biopsy (to rule out malignancy or granulomatous disease)
- **NOT** to provide definitive cure

**Warning:** Patients who undergo FESS without continuation of intranasal corticosteroids have high recurrence rates. This is a critical counselling point and a common exam trap.

### Management Algorithm for CRSwNP

```mermaid
flowchart TD
  A[CRSwNP diagnosed]:::outcome --> B[Start intranasal corticosteroid spray]:::action
  B --> C[Assess response at 3-4 months]:::decision
  C -->|Good response| D[Continue long-term intranasal corticosteroids]:::action
  C -->|Poor response| E[Add oral corticosteroid course + consider FESS]:::action
  E --> F[FESS + complete polyp removal]:::action
  F --> G[Resume intranasal corticosteroids postoperatively]:::action
  G --> H[Monitor for recurrence]:::decision
  H -->|Recurrence| I[Repeat FESS or escalate to biologic therapy]:::action
  H -->|No recurrence| J[Continue maintenance therapy]:::action
```

**Mnemonic:** **CRSwNP** management = **C**orticosteroids **R**emain **S**taple **w**ith **N**asal **P**olyps (even after surgery).

Answer

A. Intranasal corticosteroid spray is the first-line medical therapy and should be continued long-term to prevent polyp recurrence

Answer

B. Oral corticosteroids (short course) can be used perioperatively or in acute exacerbations to reduce polyp size and improve surgical access

Answer

C. Leukotriene receptor antagonists (montelukast) may be considered as adjunctive therapy, particularly if aspirin sensitivity is suspected

Explanation

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