You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > NASAL AND SINUS DISEASES Nasal Polyps, Surgical TreatmentArticle Last Updated: Mar 6, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Andrew Cheng, MD, Clinical Assistant Professor, Department of Otolaryngology-Head & Neck Surgery, New York Medical College Andrew Cheng is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Medical Society of the State of New York Editors: Eric Moore, MD, Residency Director, Assistant Professor, Department of Otorhinolaryngology/Head and Neck Surgery, Mayo Graduate School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Nader Sadeghi, MD, FRCS(C), Associate Professor of Surgery, Director of Head and Neck Surgery, Department of Surgery, Division of Otolaryngology, George Washington University; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: surgical treatment of nasal polyps, nasal polyps, polyposis, chronic allergic rhinitis, chronic sinusitis, cystic fibrosis, nasal obstruction, persistent nasal discharge, rhinorrhea, sinus infection, anosmia, nasal polyposis, chronic rhinosinusitis INTRODUCTIONSection 2 of 11
  Polyp formation in the nasal cavity is due to chronic allergic rhinitis, chronic sinusitis, and, less commonly, underlying disease such as cystic fibrosis. Patients usually present with nasal obstruction, persistent nasal discharge (rhinorrhea), sinus infection, and loss of the sense of smell (anosmia) of prolonged duration. History of the ProcedureKnowledge of nasal polyposis extends to medical antiquity. The disease process was mentioned in Egyptian and Indian medical treatises 2500-3000 years ago. Through the ages, several treatments have been advocated, including cautery with hot irons, application of caustic chemical substances, abrasion by drawing rags through the choanae and out the nose, and snaring. Today, the standard surgical therapy is endoscopically guided removal of diseased tissues with preservation of maximal amount of normal nasal mucosa. ProblemPatients usually have chronic nasal symptoms prior to detection of nasal polyps. FrequencyThe frequency of nasal polyps is uncertain. Only 0.5% of individuals with atopic symptoms manifest nasal polyposis, and most patients with diffuse nasal polyposis do not demonstrate an immunoglobulin E (IgE)–mediated type 1 hypersensitivity reaction. Patients with cystic fibrosis have a higher prevalence of nasal polyposis (up to 40%). EtiologyPolyp development within nasal and sinus regions implicates an IgE-type hypersensitivity and an immunologic or possibly inflammatory basis for such formation. The exact etiology of polyp formation is unknown. Research is demonstrating an eosinophil-mediated mechanism with damage to the mucosa by major basic protein, but the complicated interplay of secondary messengers and chemical mediators is not clear. Nasal polyposis in association with cystic fibrosis, sinobronchial syndrome, aspirin sensitivity, and Samter triad (asthma, aspirin allergy, nasal polyposis) indicates manifestation of nasal mucosal damage by many different possible disease processes. PathophysiologyThe polyp surface consists of pseudostratified respiratory epithelium and is subject to metaplasia due to local pressure and trauma. Polyps can undergo fibrosis and neovascularization. ClinicalPatients present with nasal airway obstruction, chronic rhinosinusitis, exacerbation of asthma, and nasal and facial deformity (rarely).1, 2 Patients may also present with bleeding and anosmia. Not insignificantly, these patients may have undergone recurrent surgery and costly medical therapy. INDICATIONSSection 3 of 11
The patient may require surgical intervention if severe symptoms of obstruction and infection prove refractory to medical treatment. Medical therapies include treatment for underlying chronic allergic rhinitis using antihistamines and topical nasal steroid sprays. For severe nasal polyposis causing severe nasal obstruction, treatment with short-term steroids may be beneficial. Topical use of cromolyn spray has also been found to be helpful to some patients in reducing the severity and size of the nasal polyps. Within the nasal and sinus region, polyps originate from the middle meatus/ostiomeatal complex. With surgical removal of diseased tissues (polyps), future recurrence of polyp formation is still possible. In endoscopic sinus surgery, the goal is to remove diseased tissue and provide adequate sinus aeration in order to prevent recurrence. RELEVANT ANATOMYSection 4 of 11
Nasal polyps can develop in all the paranasal sinuses, but the region of middle meatus/osteomeatal complex lateral to the middle turbinate is of great importance. CONTRAINDICATIONSSection 5 of 11
Severe pulmonary or cardiac problems may be contraindications to surgical treatment. Relative contraindications to surgical treatment include bleeding diathesis (which can be medically treated before surgery), acute asthma exacerbation, and the patient's inability or unwillingness to obtain appropriate postoperative follow-up care and treatment. WORKUPSection 6 of 11
Lab Studies
Imaging Studies
Other Tests
Diagnostic Procedures
Histologic FindingsPseudostratified epithelium is usually found. Pay special attention to unilateral polyps that may be neoplastic, and examine them for malignancy or possible malignant transformation of benign neoplasia(20% in inverting papilloma). StagingStaging is relevant in inverted papilloma with malignant transformation. TREATMENTSection 7 of 11
Medical therapyThe following medical treatments are available (see Nasal Polyps, Nonsurgical Treatment):
Surgical therapyEndoscopic sinus surgery is the procedure of choice. With the advent of endoscopic sinus surgery, surgical treatment for sinus diseases has become safer, and the outcome has improved. With appropriate preoperative evaluation and planning, endoscopic sinus surgery is usually carried out in an ambulatory setting with minimal discomfort to patients. Sinus surgery can be carried out under local anesthesia with sedation or general anesthesia. Intraoperatively, extreme care must be exercised to avoid orbital and neurologic complications. The preoperative CT scan serves a vital role in proper evaluation of potential anatomic anomalies and changes due to disease process or anatomic variance. Patients undergoing preoperative consultation must be informed of potential orbital complications, the possibility of postsurgical cerebrospinal fluid leakage, possible bleeding from related sinus arteries, and the possibility of polyp recurrence despite surgical removal. Patients should also be counseled regarding the need for close follow-up care and postoperative medical treatment for allergy, asthma, and other related medical conditions. Preoperative detailsCareful review of the CT scan results preoperatively and the availability of CT scans during the procedure are important for a successful outcome. Inform the patient that the recovery of the sense of smell is unpredictable and is not guaranteed, even with proper surgical and medical treatment. Stress the importance of continual postoperative treatment of allergic rhinitis and chronic nasal conditions to ensure long-term success and prevent polyp re-formation. Intraoperative detailsProper instrumentation and methodical sinus surgery lead to decreased complications and a positive outcome of the surgical treatment. Surgical specimens are sent for pathological examination. Nasal packing material is recommended to minimize postoperative bleeding from the sinuses and nose. Recent advent of a computerized CT tracking system to better define important surgical anatomical sites during surgery in real time has been useful to avoid potential complications in selected potential complex cases. Complex surgical cases include history of prior/repeat sinus surgery, potential orbital and/or brain involvement of disease process, and other pre-existing anatomical variants. However, CT guidance surgery is not recommended for all sinus surgery cases. Medical judgment and careful patient selection will enhance the benefit for new technology in sinus surgery. Proper training and surgical techniques are paramount to ensure patient safety in all sinus surgeries. New technology should always be adjunct to careful surgical planning and implementation of treatment decision making. Postoperative detailsStress the importance of close follow-up care and debridement of the sinuses and nasal cavity. Resume medical treatment and control of allergic rhinitis to prevent polyp recurrence. It is not uncommon that patients may have good immediate postsurgery results in relief of nasal obstruction; however, loss to medical follow-up and lack of medical treatment postsurgery may mean not detecting the recurrence of polyposis. Patient education regarding the long term treatment plan and goal should be stressed. The need for long term treatment to prevent the recurrence of polyposis should be conveyed to all patients. Follow-upGuidelines for follow-up care are as follows:
After the above protocol, follow-up care in 4- to 6-month intervals should be sufficient. These guidelines may be individualized according to the clinical progress of the patient and severity of disease prior to surgery. COMPLICATIONSSection 8 of 11
Major complications include the following:
OUTCOME AND PROGNOSISSection 9 of 11
With proper patient selection for surgical treatment, sinus surgery offers a good outcome and long-term relief for patients. Proper preoperative counseling and education for patients regarding the importance of long-term follow-up and medical treatment will minimize the chance of polyp recurrence. FUTURE AND CONTROVERSIESSection 10 of 11
Improvement is needed in the treatment of chronic allergic rhinitis and associated nasal conditions. Good initial results have been noted with medical treatment combined with nasal steroid plus nasal cromolyn treatment to decrease the size and formation of nasal polyps. Chemical mediators, antifungal substances, leukotriene, and interleukin inhibitors are being investigated and may have a role in future treatment for nasal polyposis. Continual advances in medical and surgical technology with support from a computerized guidance imaging system during sinus surgery will continue to improve the outcome and safety of surgical sinus treatment. However, technological advancement should never replace good and sound judgment for surgical treatment recommendation by experienced and qualified ENT specialists. REFERENCESSection 11 of 11
Nasal Polyps, Surgical Treatment excerpt Article Last Updated: Mar 6, 2008 |
