Nasal polyps and aspirin-exacerbated respiratory disease

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Nasal polyps are soft inflammatory mucosal swellings associated with chronic rhinosinusitis. They commonly produce persistent bilateral obstruction, reduced smell, discharge and disturbed sleep. Symptoms may be more disabling than the visible size suggests: loss of smell affects food enjoyment and awareness of smoke or spoiled food. A proper assessment combines the patient's functional burden with endoscopic disease and previous treatment response.

Aspirin-exacerbated respiratory disease, also called NSAID-exacerbated respiratory disease, is an important severe airway phenotype. Asthma, recurrent polyp disease and respiratory reactions to aspirin or other cyclo-oxygenase-1 inhibiting NSAIDs form the characteristic pattern. A patient may not recognise the connection until asked about wheeze or abrupt nasal symptoms after painkillers. The 2026 British Rhinological Society consensus places these patients within coordinated ENT, respiratory and allergy care, considering surgery, aspirin treatment after desensitisation and biologics according to individual disease and access criteria.

Key points

Typical inflammatory polyps cause persistent bilateral blockage, smell loss and rhinorrhoea rather than a short-lived cold.
Assess asthma, previous sinus operations, steroid exposure and reactions to aspirin or other NSAIDs.
Aspirin-exacerbated respiratory disease combines chronic polyp disease, asthma and respiratory reactions to aspirin or related NSAIDs.
Use regular topical corticosteroid treatment and saline, checking delivery and adherence before escalation.
Surgery can improve obstruction and access for topical treatment, but recurrence remains possible and postoperative medical treatment continues.
NICE TA1134 recommends dupilumab for a defined severe adult subgroup, including at least one previous sinus operation and SNOT-22 of at least fifty.
Aspirin desensitisation and maintenance treatment belong in an experienced specialist service, not an unsupervised home challenge.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Chronic mucosal inflammation

Polyps arise within chronically inflamed sinonasal mucosa. Type 2 inflammation is common in severe adult disease, but individual inflammatory profiles vary and should be interpreted alongside the clinical presentation.

NSAID-exacerbated airway disease

Asthma and polyp disease may coexist with respiratory reactions to aspirin and other relevant NSAIDs. This phenotype often carries greater recurrence and systemic steroid burden, warranting coordinated specialist assessment.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Oedematous mucosal growth
Inflammatory signalling promotes mucosal swelling and polyp formation, narrowing nasal airflow and sinus access. The resulting obstruction can further limit effective delivery of topical treatment.
2
Smell impairment
Obstruction of airflow towards the olfactory region and ongoing mucosal inflammation both contribute to smell loss. Improvement may not track polyp size perfectly because more than one mechanism is involved.
3
Shared inflammatory pathways
Upper and lower airway inflammation can reinforce a severe clinical phenotype. Dupilumab blocks interleukin-4 and interleukin-13 signalling through their shared receptor component, targeting a relevant pathway rather than mechanically removing polyps.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Persistent polyp symptoms

Ask about months of blockage, reduced smell, postnasal discharge, snoring and sleep disruption. Typical polyps appear pale and smooth on examination; marked unilateral disease, ulceration or bleeding needs further investigation rather than reassurance from appearance alone.

Respiratory medicine history

Ask specifically about aspirin, ibuprofen and other over-the-counter anti-inflammatory drugs, recording the agent, timing and respiratory symptoms. An intolerance label without reaction details is insufficient for decisions about challenges, analgesia or antiplatelet treatment.

Previous disease control

Document topical regimens, technique, oral steroid courses and prior operations. Repeated brief steroid improvement followed by relapse suggests uncontrolled disease, but the number of operations alone does not establish that previous surgery was comprehensive.

Unified airway assessment

Review asthma symptoms, exacerbations and current inhaled treatment, including any biologic already prescribed for another indication. The nasal and respiratory teams should agree priorities and avoid independent treatment changes that destabilise lower airway control.

Red flags requiring action

Do not label a unilateral bleeding nasal mass as benign inflammatory polyps; arrange urgent ENT examination.
Acute breathing difficulty after aspirin or another NSAID requires immediate assessment and treatment according to the respiratory or anaphylaxis findings.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
ENT nasal endoscopyFirst step
Why
Confirm polyps and assess objective mucosal disease burden.
Interpretation and limitations
Endoscopy documents distribution and polyp extent and helps identify an atypical lesion. A validated nasal polyp score can track change, but should be combined with symptoms rather than used as the sole treatment target.
02
SNOT-22 and smell assessment
Why
Measure functional impact and provide a baseline for response.
Interpretation and limitations
SNOT-22 captures sinonasal quality of life; a score of at least fifty is one NICE dupilumab eligibility condition. Smell testing and the patient's practical experience provide additional information about treatment benefit.
03
CT sinuses and previous operative records
Why
Assess disease extent and whether further surgery could help.
Interpretation and limitations
Specialists review objective anatomy and previous surgical access before calling disease refractory. A new CT is not automatically necessary if comprehensive previous surgery and current anatomy are already adequately documented.
04
Phenotype and specialist NSAID assessment
Why
Clarify inflammatory pattern and clinically important drug reactions.
Interpretation and limitations
Blood eosinophils, IgE and other assessments support an overall phenotype but do not individually prove eligibility or predict response. A diagnostic aspirin challenge, if required, must be supervised in an appropriate specialist setting.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Enlarged inferior turbinates

Normal vascular turbinates can become prominent with rhinitis and be mistaken for a polyp. Their location and appearance should be assessed carefully rather than inferring a diagnosis from obstruction alone.

Unilateral sinonasal tumour

An irregular unilateral mass, recurrent bleeding or progressive facial symptoms raises concern for neoplasia. Urgent specialist assessment determines the appropriate imaging and tissue diagnosis.

Other chronic nasal disease

Chronic rhinosinusitis without polyps, fixed septal narrowing and other mucosal disorders can cause similar symptoms. Endoscopy clarifies the phenotype before treatment is escalated.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Initial treatmentOptimise local disease controlFirst stepTypical bilateral inflammatory polyps cause persistent obstruction or smell impairment.

1Start or optimise a suitable intranasal corticosteroid and demonstrate how the preparation should reach the nasal cavity.
2Offer an appropriate saline regimen and check adherence before concluding that topical therapy has failed.
3Review associated asthma and avoid a suspected triggering NSAID pending specialist advice.
4Arrange ENT assessment for persistent symptoms, diagnostic uncertainty or discussion of surgery after an adequate treatment trial.

02Recurrent severe diseaseChoose the next specialist interventionSymptoms recur despite topical therapy or after previous sinus surgery.

1Review endoscopy, symptom burden, steroid exposure and the adequacy of previous surgery.
2Discuss further surgery where it could improve disease clearance and topical access, rather than treating every postoperative recurrence as an automatic biologic indication.
3Consider a short individualised oral corticosteroid rescue course when benefits justify risks, while planning a strategy that reduces repeated systemic exposure.
4For aspirin-exacerbated disease, discuss specialist aspirin treatment after desensitisation alongside other options; absence of a local service should not delay an otherwise eligible biologic pathway.

03Biologic eligibilityApply the current NICE subgroupAn adult has severe disease uncontrolled by systemic corticosteroids or sinus surgery.

1Confirm at least one previous sinus surgery and a baseline SNOT-22 score of fifty or more, as required by NICE TA1134.
2Use specialist multidisciplinary assessment to consider conventional treatment optimisation, surgical adequacy, asthma and patient preferences.
3When the NICE and supply conditions are met, offer dupilumab as add-on treatment to intranasal corticosteroids.
4Agree safety review and multidomain response assessment; reassess non-response rather than continuing indefinitely without benefit.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

Licensed topical anti-inflammatory treatment for adult nasal polyps and ongoing symptom control.

Nasonex mometasone furoate 50 micrograms per actuation

For adult nasal polyposis, begin with two sprays into each nostril once daily, totalling 200 micrograms daily. If control remains inadequate after five to six weeks, increase to two sprays per nostril twice daily, totalling 400 micrograms daily. Re-evaluate if a further five to six weeks produces no improvement.

Use the lowest effective maintenance dose. This polyp indication is not established below eighteen years. Avoid untreated nasal mucosal infection and unhealed nasal trauma or surgery; assess persistent bleeding, septal perforation, visual symptoms, strong CYP3A inhibitors and total corticosteroid exposure. Nasonex is not recommended in patients with a nasal septal perforation.

Specialist add-on biologic for severe adult polyp disease, with NHS eligibility defined separately by NICE TA1134.

Dupilumab, Dupixent 300 mg pre-filled syringe

For adult chronic rhinosinusitis with nasal polyps, give an initial 300 mg subcutaneous dose, then 300 mg every other week. Continue intranasal corticosteroids. The UK SmPC advises considering discontinuation if there is no response after twenty-four weeks; partial responders may improve with longer treatment.

Do not import the 600 mg loading regimen used for other indications. Avoid with hypersensitivity; treat existing helminth infection and review vaccination before starting, avoiding concurrent live vaccines. Report new eye symptoms, eosinophilic systemic features or allergic reactions. Do not abruptly stop asthma or steroid treatment. Pregnancy and breastfeeding require an individual benefit-risk decision.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Recurrent obstruction

Polyps may recur after surgery because the underlying inflammatory tendency persists. Continued local treatment and follow-up help maintain benefit and identify when further intervention is necessary.

Cumulative corticosteroid harm

Repeated oral steroid rescue can contribute to metabolic, bone, ocular and adrenal complications. Reducing systemic exposure is a meaningful goal when judging long-term disease control.

Respiratory drug reactions

An unrecognised aspirin or NSAID sensitivity may lead to acute nasal and lower airway symptoms after analgesic exposure. Accurate documentation and specialist advice reduce avoidable re-exposure.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Track blockage, smell, endoscopic findings, SNOT-22 and the frequency of systemic steroid rescue, because meaningful response spans more than polyp size.
Review local steroid technique and adverse effects regularly, especially when treatment is combined with inhaled or oral corticosteroids.
The BRS recommends early biologic safety review and assessment of treatment response at approximately four to six months, followed by individualised review.
New persistent eye irritation on dupilumab requires assessment; significant eye pain or sudden visual change needs urgent ophthalmic review.
Monitor asthma when modifying or stopping a biologic and agree any steroid reduction with the supervising clinicians.
Document the specific NSAID reaction and the agreed analgesic plan in records visible across primary and specialist care.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Oral steroids are rescue treatment

The BRS describes short prednisolone courses, often around 0.5 mg/kg daily with an individualised local schedule, as temporary rescue treatment. Repeated courses should trigger reassessment of disease control, not be prescribed merely to satisfy biologic eligibility.

Aspirin treatment after desensitisation

Selected patients may undergo supervised escalating aspirin exposure followed by maintenance aspirin. This can help recurrent polyp and airway disease, often after surgical optimisation, but requires specialist selection, counselling and a plan for treatment interruptions.

Funded access and licence differ

The dupilumab licence describes severe adult disease inadequately controlled by systemic steroids or surgery. NICE TA1134 adds previous surgery and SNOT-22 criteria for its recommended NHS subgroup; a broader licence should not be presented as identical funded eligibility.

Children need another assessment

Polyps are uncommon in children. A child with suspected polyps needs specialist evaluation for underlying conditions and alternative lesions rather than automatic application of the adult medicine or biologic pathway.

11Common pitfallsFrequent interpretation and management errors.

01
Reassuring a patient about a unilateral ulcerated lesion because inflammatory polyps are usually benign.
02
Assuming that a positive eosinophil count alone establishes either aspirin sensitivity or biologic eligibility.
03
Stopping topical corticosteroid treatment after surgery or biologic initiation without an agreed clinical reason.
04
Using an unsupervised aspirin trial to test a history of painkiller-associated wheeze.
05
Copying a dupilumab loading dose from another licensed indication into the nasal polyp regimen.