A 42-year-old woman from Bangalore with a 10-year history of asthma and chronic rhinosinusitis presents with worsening nasal obstruction and anosmia over the past 6 months. Nasal endoscopy reveals multiple bilateral nasal polyps. She is allergic to aspirin and NSAIDs, developing urticaria and bronchospasm with exposure. CT paranasal sinuses shows extensive polypoid disease with opacification of all paranasal sinuses. Biopsy of a polyp shows eosinophil-rich infiltration with eosinophil count >10 per high-power field. Which of the following is the most appropriate next step in management?

Explanation

## Management of Severe Eosinophilic Nasal Polyposis with AERD ### Clinical Context: Samter's Triad **Key Point:** This patient has the classic triad of: 1. Chronic rhinosinusitis with nasal polyposis (CRSwNP) 2. Asthma 3. NSAID/aspirin sensitivity (Aspirin-Exacerbated Respiratory Disease, AERD) This constellation is known as **Samter's Triad** and represents a severe, recurrent phenotype of nasal polyposis. ### Standard Treatment Algorithm for CRSwNP **High-Yield:** Per established ENT and rhinology guidelines (EPOS 2020, Scott-Brown's Otorhinolaryngology), the **first-line management** for CRSwNP — even in severe or eosinophilic disease — is a **trial of high-dose intranasal corticosteroids (INCS) combined with a short course of systemic (oral) corticosteroids** for 8–12 weeks. This is the mandatory medical step before escalating to surgery or biologic therapy. ### Why Option B is Correct | Step | Intervention | Rationale | |------|-------------|-----------| | **1st line** | High-dose INCS + oral corticosteroids (8–12 weeks) | Reduces polyp burden, improves symptoms; required before escalation | | **2nd line** | FESS if medical therapy fails | For anatomical obstruction or inadequate medical response | | **3rd line** | Biologic therapy (dupilumab, mepolizumab) | Reserved for recurrent/refractory disease after surgery or failed medical therapy | **Clinical Pearl:** Even in biopsy-proven eosinophilic CRSwNP, biologics are NOT the first-line step. Guidelines require documentation of **inadequate response to corticosteroids** before initiating biologic therapy. The question asks for the "most appropriate **next step**" — the patient has not yet received a formal corticosteroid trial, making Option B the correct answer. ### Why the Other Options Are Incorrect - **Option A (Mepolizumab):** Biologic therapy is indicated only after failure of adequate medical therapy (corticosteroids) and/or surgery. Jumping directly to biologics without a corticosteroid trial is not guideline-concordant as a "next step." Additionally, mepolizumab's approval for CRSwNP is limited in many jurisdictions; dupilumab has broader approval for this indication. - **Option C (Aspirin desensitization):** This is a specialized, high-risk procedure requiring monitored settings. It is NOT a first-line or routine management step for nasal polyposis; it is reserved for select AERD patients who require NSAID use (e.g., for cardiovascular indications). - **Option D (Immediate FESS):** Surgery is not the immediate next step when medical therapy has not yet been optimized. FESS is reserved for failure of adequate medical management. ### AERD-Specific Note **Warning:** In AERD, corticosteroids remain the cornerstone of initial medical management. The eosinophilic phenotype predicts higher recurrence but does NOT bypass the requirement for a corticosteroid trial before escalation. [cite: EPOS 2020 Guidelines; Scott-Brown's Otorhinolaryngology 8th Ed; Cummings Otolaryngology 7th Ed Ch 43]