Nasal Polyp Surgery Treatment & Management

The following medical treatments are available (see Nasal Polyps, Nonsurgical Treatment):

• Topical steroid inhaler
• Topical antihistamine inhaler
• Systemic steroids
• Intranasal cromolyn treatment
• Treatment and control of allergic rhinitis
• Treatment of underlying sinusitis

Endoscopic 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. Results following nasal polypectomy are no better than nasal polypectomy with endoscopic sinus surgery and are worse for patients with Samter's triad.^[4] 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.

Careful 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.

Proper 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.

Stress 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.

Guidelines for follow-up care are as follows:

• Day 1-2 - Removal of nasal packing and debridement of sinuses and instruction for patient's self-care at home with topical antibiotic ointment
• Day 4-5 - Inspection and debridement of sinuses to ensure proper healing
• Day 10 - Inspection and debridement of sinuses and resumption of medical treatment with nasal steroid inhaler
• 2-3 weeks - Inspection and debridement of sinuses to ensure complete healing of nasal and sinus mucosa
• 5-6 weeks - Inspection and routine follow-up and medical care
• 3 months - Inspection and routine follow-up and medical care

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.

Major complications include the following:

• Central nervous system - Surgery-related cerebrospinal fluid leak, meningitis, intracranial hemorrhage, brain abscess, brain herniation
• Orbit - Blindness, optic nerve injury, orbital hematoma, eye muscle injury leading to diplopia, nasolacrimal duct injury leading to epiphora
• Vascular - Vascular injury leading to severe hemorrhage
• Death

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.

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.