A 42-year-old woman with a 3-month history of bilateral nasal polyps presents after 6 weeks of topical fluticasone nasal spray (200 µg twice daily). She reports minimal improvement in nasal obstruction and continues to have sleep disturbance. Nasal endoscopy confirms persistent large polyps bilaterally. She denies asthma, cough, or recurrent infections. Chest X-ray is normal. What is the most appropriate next step in management?

Explanation

## Management of Steroid-Resistant Nasal Polyps **Key Point:** After adequate trial of topical nasal corticosteroids (6–8 weeks at therapeutic dose) with persistent symptoms and polyp burden, endoscopic sinus surgery is the next appropriate step. This patient has documented medical failure and significant functional impairment (sleep disturbance). ### Criteria for Surgical Intervention **High-Yield:** ESS is indicated when: 1. Polyps persist despite 6–8 weeks of high-dose topical corticosteroid therapy 2. Significant functional symptoms (obstruction, sleep disruption, quality of life impact) 3. Objective endoscopic evidence of polyp burden 4. Exclusion of systemic disease (cystic fibrosis, ABPA, granulomatosis with polyangiitis) This patient meets ALL four criteria. ### Why This Patient Needs Surgery | Finding | Significance | |---------|-------------| | 6 weeks of topical fluticasone 200 µg BID | Adequate dose and duration for medical trial | | Persistent large polyps on endoscopy | Objective failure of medical therapy | | Sleep disturbance | Significant functional impairment | | Normal CXR, no asthma/cough | Systemic disease excluded | | No ABPA features | No contraindication to surgery | ### Why Other Options Are Incorrect **Increasing Topical Dose:** Further escalation of topical corticosteroids beyond 200 µg BID is not evidence-based and delays necessary surgical intervention in a patient with documented medical failure. **Adding Montelukast:** While leukotriene receptor antagonists (LTRAs) may have adjunctive benefit in asthma-associated polyps, they are not indicated as monotherapy or as a bridge in steroid-resistant polyps without asthma. No evidence supports delaying surgery with LTRA addition. **Pulmonology Referral for Sarcoidosis:** The clinical presentation (bilateral polyps, normal CXR, no systemic symptoms) does not suggest sarcoidosis. Extensive workup for rare systemic disease is not warranted when the diagnosis is clear and medical therapy has failed. ### Surgical Approach **Clinical Pearl:** Functional endoscopic sinus surgery (FESS) with complete removal of polyps and ethmoidectomy is the standard approach. Goals include: - Complete removal of polyp tissue - Wide middle meatal antrostomy to prevent recurrence - Preservation of normal mucosa and anatomy **Mnemonic:** **FESS** — Functional Endoscopic Sinus Surgery for Failed medical therapy, Endoscopic confirmation, Significant symptoms, Systemic disease excluded.