Nasal Polyp Surgery

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.

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

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%).

In a study of 10,336 US adults, Palmer et al found that 11.5% of these individuals reported symptoms of chronic rhinosinusitis, with about 10% of this subgroup indicating that they had received a previous diagnosis of nasal polyps.[6]

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.

A retrospective case-control study by De Corso et al found that in a comparison of three sets of patients—those with persistent eosinophilic nonallergic sinonasal inflammation (n = 84), patients with neutrophilic inflammation (n = 106), and, as controls, patients with nonallergic noninfectious vasomotor rhinitis in whom nasal cytology revealed no evidence of inflammation (n = 105)—those in the eosinophilic group were most likely to develop nasal polyps. Specifically, 34.5% of the eosinophilic group developed nasal polyps, compared with 16.0% and 4.8% in the neutrophilic and control groups, respectively.[7]

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.

The polyp surface consists of pseudostratified respiratory epithelium and is subject to metaplasia due to local pressure and trauma.[8] Polyps can undergo fibrosis and neovascularization.[9]

Patients present with nasal airway obstruction, chronic rhinosinusitis, exacerbation of asthma, and nasal and facial deformity (rarely).[2, 3, 4] Patients may also present with bleeding and anosmia. Not insignificantly, these patients may have undergone recurrent surgery and costly medical therapy.

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.

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.

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.

See the list below:

• Relevant allergy or asthma studies (if indicated)

• Nasal smears or cultures for fungus and bacteria (if indicated)

See the list below:

• CT scan of sinuses without contrast: Specify coronal CT with 3-4 mm cuts and appropriate soft tissue and bone windows.

  • Evaluate the CT scan results with attention to anterior ethmoid artery, orbital and skull base anomalies, optic nerve and carotid in posterior ethmoidal (Onodi) cells, and sphenoid sinus.

  • Focus especially on previous surgical changes. Consider role and use of image-guidance system in revision or difficult cases.[10]

See the list below:

• Olfactory testing (if indicated)

• Medical workup for cystic fibrosis (if indicated)

See the list below:

• A nasal and sinus endoscopy with evaluation of anatomy, site of origin, past surgical changes, and evidence of other disease-causing polyps (tumor, infection, systemic diseases such as sarcoidosis, Wegener granulomatosis) may be appropriate (see Nasal Polyps, Nonsurgical Treatment).

Pseudostratified 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).

Staging is relevant in inverted papilloma with malignant transformation.

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

• Topical steroid inhaler

• Topical antihistamine inhaler

• Systemic steroids

• Intranasal cromolyn treatment

• Treatment and control of allergic rhinitis

• Treatment of underlying sinusitis

In 2019, the US Food and Drug Administration (FDA) approved the biologic agent dupilumab (Dupixent) as the first medical treatment for chronic rhinosinusitis with nasal polyps (CRSwNP) that has not been adequately controlled with intranasal steroids.[5]

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.[11] 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. A study by Mimari et al indicated that in patients with chronic rhinosinusitis with nasal polyps (CRSwNP), awake patient polyp surgery (APPS) is a safe and effective treatment. The procedure’s mean duration of effectiveness (the mean period between the operation and a new treatment) was about 2.5 years.  The rate of major complications, at 2.67%, was an improvement on the 12.5-20.0% rate reported for polyp surgery under general anesthesia.[12]

Intraoperatively in sinus surgery, 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.[13] 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.

Debridement may reduce intraoperative blood loss.[14] 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.[15, 16]

A study by Arancibia et al found long-term improvement in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) who underwent endoscopic sinus surgery. At median 12-year follow-up, the investigators found that the nasal symptoms score, nasal polyp score (NPS), Barcelona Smell Test 24 (BAST-24) score, and Lund-Mackay score (LMS) demonstrated strong improvement over baseline, including with regard to nasal symptoms, polyp size, computed tomography (CT) scan results, and olfaction. However, the Medical Outcomes Study Short Form-36 (SF-36) questionnaire did not show long-term improvement.[17]

A study by Nguyen et al found that endoscopic surgery for nasal polyposis improved moderate to severe facial pain/headache in approximately 60% of patients reporting these symptoms. The study included 107 patients with nasal polyposis, 52.33% of whom were suffering moderate to severe facial pain/headache prior to surgery. Six weeks postoperatively, 20.56% of the 107 patients were still experiencing this level of pain, necessitating neurologic counseling to determine whether it had a non-sinonasal cause.[18]

A case-control study by Kilty et al indicated that in appropriate patients with CRSwNP, disease-specific improvement in quality of life from endoscopic polypectomy in clinic (EPIC) is similar to that associated with traditional endoscopic sinus surgery. The investigators found no statistical difference between the two groups with regard to posttreatment sinonasal outcome test (SNOT-22) scores and the proportion of individuals in whom a minimal clinically important difference was attained.[19]

A prospective study by Brescia et al indicated that in patients who undergo endoscopic surgery for CRSwNP, the polyps are more likely to recur in cases of eosinophilic-type CRSwNP. The study, which included 143 patients, also found that nasal polyps recurred more quickly in eosinophilic-type CRSwNP than in the non-eosinophilic type.[20]

A study by Hopkins and Lund of patients with CRSwNP indicated that the need for additional surgery after a procedure is greater in those patients who have had prior sinus surgery than in those in whom the index procedure is the first operation. The investigators found that the 5-year rate of additional surgery in patients who had undergone a previous procedure and had symptom recurrence, compared with those in whom no prior surgery had been performed, was 20.2% versus 9.8%, respectively. Among the former group, the highest rates of additional surgery were in patients in whom the initial operation was carried out no more than 3 years before the index procedure.[21]

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.