Nasal Polyp Surgery

Nasal Polyp Surgery

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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.

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.

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. [1]

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. [2]

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. [3] Polyps can undergo fibrosis and neovascularization. [4]

Patients present with nasal airway obstruction, chronic rhinosinusitis, exacerbation of asthma, and nasal and facial deformity (rarely). [5, 6, 7] 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.

Palmer JN, Messina JC, Biletch R, Grosel K, Mahmoud RA. A cross-sectional, population-based survey of U.S. adults with symptoms of chronic rhinosinusitis. Allergy Asthma Proc. 2019 Jan 14. 40 (1):48-56. [Medline].

De Corso E, Lucidi D, Battista M, et al. Prognostic value of nasal cytology and clinical factors in nasal polyps development in patients at risk: can the beginning predict the end?. Int Forum Allergy Rhinol. 2017 Jun 30. [Medline].

Cornet ME, Kostamo K, Rinia AB, et al. Novel roles for nasal epithelium in the pathogenesis of chronic rhinosinusitis with nasal polyps. Rhinology. 2018 Dec 1. [Medline].

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].

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

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

Novelli F, Bacci E, Latorre M, et al. Comorbidities are associated with different features of severe asthma. Clin Mol Allergy. 2018. 16:25. [Medline]. [Full Text].

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].

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.

Dadgarnia M, Rahmani A, Baradaranfar M, et al. The relationship between endoscopic and radiologic findings and olfactory status of patients with chronic rhinosinusitis with nasal polyps before and after the endoscopic sinus surgery. Eur Arch Otorhinolaryngol. 2018 Nov 27. [Medline].

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].

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

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].

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].

Kilty SJ, Lasso A, Mfuna-Endam L, Desrosiers MY. Case-control study of endoscopic polypectomy in clinic (EPIC) versus endoscopic sinus surgery for chronic rhinosinusitis with polyps. Rhinology. 2018 Jun 1. 56 (2):155-7. [Medline].

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].

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

Andrew T 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.

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 and Chairman, Department of Otolaryngology-Head and Neck Surgery, McGill University Faculty of Medicine; Chief Otolaryngologist, MUHC; Director, McGill Head and Neck Cancer Program, Royal Victoria Hospital, Canada

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

Disclosure: Nothing to disclose.

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;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.

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.

Nasal Polyp Surgery

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