I am 46. Why did my nasal polyps recur despite surgery?

Question

Hello doctor,

I am a 46-year-old male diagnosed with nasal polyps two years ago, with persistent nasal blockage, reduced sense of smell, and occasional facial pressure. I also have moderate persistent asthma, diagnosed 10 years ago, managed with a Budesonide–formoterol inhaler twice daily and salbutamol as needed.

Over the past month, my nasal congestion has worsened, and I have been breathing mostly through my mouth at night. My recent peak flow readings have dropped from my usual 420 L/min to around 350 L/min. I have also had two asthma flare-ups in the past three weeks, requiring extra doses of my rescue inhaler.

My ENT noted a recurrence of nasal polyps despite undergoing endoscopic sinus surgery a year ago. Recent blood tests showed eosinophils at 8 percent (above normal) and vitamin D at 19 ng/mL. I experience postnasal drip and occasional thick yellow nasal discharge, especially in the mornings. My sleep is disturbed due to blocked nasal passages, leaving me fatigued during the day.

I am concerned that the nasal polyps may be worsening my asthma symptoms, and I would like to know whether I should consider another surgery or explore newer treatments such as biologics to manage both conditions effectively.

Please help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

From what you have described, you have chronic rhinosinusitis with nasal polyps (CRSwNP) and moderate persistent asthma, and both conditions are clearly influencing each other. This “upper airway lower airway” link is sometimes called united airway disease, inflammation in the sinuses can worsen asthma control, and poorly controlled asthma can make sinus issues harder to manage.

Your case also has features of type 2 (eosinophilic) inflammation.

Why your symptoms may be worsening:

Recurrent nasal polyps: ongoing obstruction, inflammation, and postnasal drip.
Type 2 inflammation tends to be steroid-responsive, but relapses are common if not addressed systemically.
Asthma link: Nasal inflammation can act as a trigger for asthma flares, explaining your recent drop in peak flow and extra inhaler use.
Vitamin D deficiency can impair immune regulation and worsen inflammation.

Current treatment options:

Optimize medical therapy before considering repeat surgery:

Intranasal corticosteroid sprays or rinses (Mometasone, Fluticasone), preferably via high-volume saline rinse steroid to reach the polyp tissue.
Short courses of oral corticosteroids (Prednisone) are sometimes used for acute worsening, but repeated courses have side effects.
Vitamin D supplementation aims for less than 30 nanograms/milliters; it may improve immune regulation.
Asthma control review is a possible step-up in inhaled therapy or adding a leukotriene receptor antagonist (Montelukast), which also helps some polyp patients.

Consider biologic therapy: Biologics are newer injectable medications that target the type 2 inflammatory pathway. They can treat both nasal polyps and asthma at the same time and reduce the need for repeated surgeries. Common options:

Biologic targets benefits:

Dupilumab IL-4 (interleukin) or IL-13 reduces polyp size, improves smell, and improves asthma control. Approved for CRSwNP asthma.
Mepolizumab IL-5 reduces eosinophils, helps with asthma, and may reduce polyps. Often used in eosinophilic asthma.
Omalizumab IgE (immunoglobulin E) works in allergic asthma and polyps. It requires IgE testing.
Benralizumab IL-5 rapid eosinophil depletion, asthma-focused, and some polyp benefit.

For someone with recurrent polyps, moderate asthma eosinophilia, biologics (particularly dupilumab) can be a strong alternative to another surgery or can be combined with surgery for better long-term control.

Surgery considerations: Repeat endoscopic sinus surgery (ESS) can help restore sinus ventilation and improve delivery of topical steroids, but in type 2 inflammation, polyps often recur without systemic control. Surgery treats the blockage but not the underlying immune driver.

Best results come when surgery is paired with ongoing medical or biologic therapy.

Lifestyle and adjunct measures: Daily saline irrigation (high-volume, lukewarm) to reduce mucus and allergens. Allergen avoidance if triggers are known.

I hope this has helped you.

Please feel free to reach out to me again if you have further queries.

Thank you.