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Nasal Polyp Surgery

  • Author: Andrew Cheng, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Jul 31, 2015
 

Background

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.

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History of the Procedure

Knowledge 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.

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Problem

Patients usually have chronic nasal symptoms prior to detection of nasal polyps.

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Epidemiology

Frequency

The 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%).

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Etiology

Polyp 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.

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Pathophysiology

The polyp surface consists of pseudostratified respiratory epithelium and is subject to metaplasia due to local pressure and trauma. Polyps can undergo fibrosis and neovascularization.[1]

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Presentation

Patients present with nasal airway obstruction, chronic rhinosinusitis, exacerbation of asthma, and nasal and facial deformity (rarely).[2, 3] Patients may also present with bleeding and anosmia. Not insignificantly, these patients may have undergone recurrent surgery and costly medical therapy.

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Indications

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.

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Relevant Anatomy

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.

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Contraindications

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.

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Contributor Information and Disclosures
Author

Andrew Cheng, MD Clinical Assistant Professor, Department of Otolaryngology-Head & Neck Surgery, New York Medical College

Andrew Cheng, MD 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, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Nader Sadeghi, MD, FRCSC Professor, Otolaryngology-Head and Neck Surgery, Director of Head and Neck Surgery, George Washington University School of Medicine and Health Sciences

Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Head and Neck Society, American Thyroid Association, American Academy of Otolaryngology-Head and Neck Surgery, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA 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 Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Eric J Moore, MD, FACS Residency Director, Associate Professor, Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Graduate School of Medicine

Eric J Moore, MD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate-Craniofacial Association

Disclosure: Nothing to disclose.

References
  1. Tang J, Liu S, Zhang L, Chen W, Shi S, Yu Q, et al. Correlation analysis of prognostic and pathological features of patients with chronic sinusitis and nasal polyps following endoscopic surgery. Exp Ther Med. 2013 Jul. 6(1):167-171. [Medline]. [Full Text].

  2. Deal RT, Kountakis SE. Significance of nasal polyps in chronic rhinosinusitis: symptoms and surgical outcomes. Laryngoscope. 2004 Nov. 114(11):1932-5. [Medline].

  3. Fokkens W, Lund V, Mullol J. European position paper on rhinosinusitis and nasal polyps 2007. Rhinol Suppl. 2007. (20):1-136. [Medline].

  4. Kingdom TT, Orlandi RR. Image-guided surgery of the sinuses: current technology and applications. Otolaryngol Clin North Am. 2004 Apr. 37(2):381-400. [Medline].

  5. Mendelsohn D, Jeremic G, Wright E, Rotenberg E. Revision Rates After Endoscopic Sinus Surgery: A Recurrence Analysis. Ann Otol Rhinol Laryngol. March 2011. 120(3):162-166.

  6. Kumar N, Sindwani R. Bipolar microdebrider may reduce intraoperative blood loss and operating time during nasal polyp surgery. Ear Nose Throat J. 2012 Aug. 91(8):336-44. [Medline].

  7. Bassiouni A, Wormald PJ. Role of frontal sinus surgery in nasal polyp recurrence. Laryngoscope. 2013 Jan. 123(1):36-41. [Medline].

  8. Vento SI, Blomgren K, Hytönen M, Simola M, Malmberg H. Prevention of relapses of nasal polyposis with intranasal triamcinolone acetonide after polyp surgery: a prospective double-blind, placebo-controlled, randomised study with a 9-month follow-up. Clin Otolaryngol. 2012 Apr. 37(2):117-23. [Medline].

  9. Nguyen DT, Felix-Ravelo M, Arous F, Nguyen-Thi PL, Jankowski R. Facial pain/headache before and after surgery in patients with nasal polyposis. Acta Otolaryngol. 2015 Jun 25. 1-6. [Medline].

  10. Brescia G, Marioni G, Franchella S, et al. A prospective investigation of predictive parameters for post-surgical recurrences in sinonasal polyposis. Eur Arch Otorhinolaryngol. 2015 Mar 13. [Medline].

  11. Bhattacharyya N. Progress in surgical management of chronic rhinosinusitis and nasal polyposis. Curr Allergy Asthma Rep. June 2007. 3:216-20. [Medline].

  12. Garrel R, Gardiner Q, Khudjadze M, Demoly P, Vergnes C, Makeieff M. Endoscopic surgical treatment of sinonasal polyposis-medium term outcomes (mean follow-up of 5 years). Rhinology. 2003 Jun. 41(2):91-6. [Medline].

  13. Gosepath J, Mann WJ. Current concepts in therapy of chronic rhinosinusitis and nasal polyposis. ORL J Otorhinolaryngol Relat Spec. 2005. 67(3):125-36. [Medline].

  14. Mostafa BE, Abdel Hay H, Mohammed HE, Yamani M. Role of leukotriene inhibitors in the postoperative management of nasal polyps. ORL J Otorhinolaryngol Relat Spec. 2005. 67(3):148-53. [Medline].

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