Nasal Polypectomy

Background

Nasal polyps may present in patients who report perennial nasal congestion, obstruction, and anosmia or hyposmia. In contrast to many individuals who have chronic rhinosinusitis without nasal polyps who present with headache and facial pressure and pain, patients with nasal polyposis generally do not report those symptoms unless they have a concurrent infection. Nasal polyps typically are semitranslucent, pale, gray masses in the nasal cavity.

Nasal polypectomy is a surgical procedure to remove polyps located in the nasal passages. Nasal polyps affect 2-5% of the population ^[1] and may occur in association with chronic rhinosinusitis, cystic fibrosis, Kartagener syndrome, Samter triad (asthma, nasal polyposis, and aspirin sensitivity), or as an isolated phenomenon. Children with nasal polyps should be evaluated for cystic fibrosis. Studies suggest both allergies and a family history of nasal polyps are predisposing factors in the growth of nasal polyps. ^{[2, 3]} The role of environmental exposure to smoking, pollution, and other chemicals remains controversial. ^{[4, 5]}

Current research in nasal polyposis suggests multiple factors, including thymic stromal lymphopoietin/OX40 ligand axis up-regulation affecting eosinophilic inflammation, ^[6] interleukin (IL)–31 up-regulation of Th2 cytokines expressed by polyp cells promoting growth, ^[7] activity of forms of STAT3 affecting the development of nasal polyps, ^[8] and a multitude of other factors undergoing additional research endeavors.

Additionally, Staphylococcus aureus exotoxins acting as superantigens may be a risk factor for chronic rhinosinusitis with nasal polyposis, and the presence of this superantigen is related to the severity of chronic rhinosinusitis with nasal polyposis. ^[9]

Nasal polyps are correlated with appreciable morbidity, economic costs, and impairment in quality of life. ^{[2, 10, 11]} Although medical management is possible, often nasal polypectomy is required for patients in whom conservative therapies fail. ^{[12, 13]}

See the image below.

Rigid endoscopic view of the left nasal cavity, showing the septum on the left. Polyps with some blood and hemorrhage are on top of them in the center portion. The rim of white from 1 o'clock to 4 o'clock indicates the lateral nasal wall vestibule. The polyps cover the inferior turbinate, which is partially visible at 4 and 5 o'clock.

Indications

Nasal polypectomy is indicated for uncontrolled symptoms or symptoms that fail maximum medical therapy. ^{[3, 14]}

Contraindications

Nasal polypectomy is contraindicated for asymptomatic disease or with significant patient comorbidities including, but not limited to, cardiac and pulmonary disease, significant bleeding disorders, or poorly controlled diabetes or asthma.

Outcomes

Successful control of the disease is varied due to the continued presence of the underlying mechanism giving rise to the polypoid mucosa. Although polypectomy may reduce the number of polyps, subjective improvement in symptoms is widely varied. ^{[15, 16, 17, 18]}

Pre-procedure planning

Preoperative assessment with computed tomography imaging is the criterion standard. Some surgeons also use intraoperative computed tomography imaging or neuronavigational equipment to help identify landmarks and/or during revision cases to further augment patient safety.

Equipment

Sinus instrumentation generally includes the following:

• Cup forceps

• Through-cutting forceps

• Backbiting instruments

• Curettes

• Probes

• Suctions

• Powered instrumentation

• Sinus rigid endoscopes of varying degrees

Patient preparation

Anesthesia

Topical intranasal oxymetazoline or liquid cocaine may be applied to pledgets placed into the nose. Lidocaine with epinephrine may be injected into the septum, sinus anatomy, and polyps. General anesthesia is used during the procedure.

Positioning

The patient is positioned supine on the operating room table.

Monitoring and follow-up

Following surgery, a large portion of patients require continued medication use to avoid relapse and limit inflammation. ^{[19, 20, 21]} Nasal irrigation with isotonic nasal saline is performed beginning 1-3 days following surgery and should be performed multiple times each day. A multitude of medication regimens for management both preoperative and postoperative care have been described. ^{[22, 23, 24]} Postoperative visits with nasal endoscopy and debridement are performed until the nasal mucosa has healed and any crusting or synechia has resolved. Follow-up regimens vary from weekly to every 3 weeks. Long-term follow-up is recommended to assess and treat any polyp recurrences. ^[25]

Complications

Possible complications include the following:

• Cerebral spinal fluid leaks

• Ocular problems

• Bleeding

• Synechia

• Local infection

• Nasofrontal duct stenosis

• Mucocele

Prevention of surgical complications is possible with careful review of the computed tomography scans, knowledge of surgical anatomy, and possible addition of intraoperative computed tomography imaging or neuronavigational equipment. ^[26]

Approach considerations

Functional endoscopic sinus surgery is frequently required in the management of nasal polyposis. ^{[27, 28]} The goal of functional endoscopic sinus surgery is nasal polyp removal, enlargement of sinus ostia, removal of bony partitions and osteitic bone, and improved sinus drainage. ^{[29, 30]}

Careful attention is paid to the anatomy of the orbits, skull base, sphenoid region, anterior ethmoid artery, optic nerve, and carotid artery. Meticulous mucosal preservation techniques are strongly recommended.

Computed tomography images of the patient should be reviewed prior to the surgery and should be available during the surgery for further review if necessary.

Some surgeons may administer oral steroids prior to polypectomy in an attempt to decrease polyp size, anatomic obstructions, and related bleeding.

Polypectomy

The patient is induced with general anesthesia. The nose is topically decongested with oxymetazoline or cocaine. Local anesthesia with lidocaine and epinephrine is injected into the septum, sinus anatomy, and polyps.

If neuronavigation is to be used, the equipment is prepared. Using rigid endoscopes of various degrees attached to a camera, the anatomy is visualized on a video screen.

The polypoid tissue may be removed with polyp forceps, through-cutting instruments, or microdebrider. Careful attention must be paid to the surrounding anatomy so as not to injure the orbit, skull base, or vascular structures.

Polyps are typically removed from posterior to anterior to compensate for the obscuring effects of bleeding. Some surgeons also perform total ethmoidectomy, uncinectomy, middle meatal antrostomy, frontal sinusotomy or Draf procedure, and sphenoidotomy. If the sinus cavities also contain polyps, these may be removed at the time of surgery.

Absorbable packing may be placed lateral to the middle turbinate or in the middle meatus. Any bleeding encountered may be addressed with topical vasoconstrictants, commercial hemostatic matrix, or nasal packing.

Cautery is typically not applied; if required, it must be used with extreme caution, especially around the orbit and skull base, so as not to cause an unwanted complication. ^{[31, 32, 33, 34, 35]}

Postprocedural sinus care varies widely according to surgeon preference. Some surgeons perform weekly, biweekly or monthly endoscopic sinus debridement. ^[36] Others do not debride. Postoperative medication management may include saline rinses, nasal or oral steroids, nasal or oral antihistamines, oral or topical antibiotics, antileukotrienes, and immunotherapy. ^{[22, 23, 24]}