What is
Nasal Polypectomy?
Nasal
polyps are localized swellings within
the nose or sinuses found most often near
the openings of the sinuses. Unlike polyps
in the bowel, these swellings are not
pre-cancerous lesions, but arise because of
chronic nasal and sinus inflammation. A
polypectomy is a surgical procedure that
removes polyps to relieve nasal obstruction.
Nasal polyps are another common condition seen in
the nose. There exact cause is not known but
they represent the end point of an
inflammatory process, which affects the
whole of the nose and sinuses. A polyp is a
protrusion of the lining of the sinuses into
the nose, treatment therefore requires the
underlying inflammatory condition be
identified and treated as well as possible
mechanical removal of a polyp if it is
causing obstruction either to the nose or to
the sinuses. Surgery therefore is not an
alternative to medical management but only
one part of the treatment. Sometimes small
polyps can be removed easily in out patients
under local anaesthetic, however often they
require removal under general anaesthetic.
There are various ways of removing these,
each of which has its advantages and
disadvantages and the preference of each
individual surgeon has some part to play. As
with all nasal operations I try and avoid
any form of packing although this is
occasionally necessary. Post operative nasal
douching is often very comforting and one
must never forget the long-term medical
management of the inflammatory process
underlying the condition.
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Effects
of Nasal Polypectomy
The surgeon's goal is always to remove polyps
completely, thus reducing the probability of
re-growth.
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Candidates
for Nasal Polypectomy
Multiple polyps can occur in children with chronic sinusitis,
allergic rhinitis, cystic fibrosis (CF), or
allergic fungal sinusitis (AFS). An
individual polyp could be an antral-choanal
polyp, a benign massive polyp, or any of a
number of benign or malignant tumors (eg,
encephaloceles, gliomas, hemangiomas,
papillomas, juvenile nasopharyngeal
angiofibromas, rhabdomyosarcoma, lymphoma,
neuroblastoma, sarcoma, chordoma,
nasopharyngeal carcinoma, inverting
papilloma). Evaluate all children with
benign multiple nasal polyposis for CF and
asthma.
Pathophysiology:
The pathogenesis of nasal polyposis is unknown.
Polyp development has been linked to chronic
inflammation, autonomic nervous system
dysfunction, and genetic predisposition.
Most theories consider polyps to be the
ultimate manifestation of chronic
inflammation; therefore, conditions leading
to chronic inflammation in the nasal cavity
can lead to nasal polyps.
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Your
Consultation
-
First notify a pediatric
otolaryngologist, especially if medical
therapy has failed or if the origin or
diagnosis of the underlying pathology of
the nasal polyp is unknown.
-
Consider consultation with a pulmonary
specialist when benign nasal polyps are
identified because they could result
from asthma, allergy, or CF. Patients
with these diseases often have
associated pulmonary problems.
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The Nasal Polypectomy
Procedure
Nowadays, when polyps are isolated or limited in number, the
polypectomy may take place in a specialist's
office. Or your doctor may combine this
procedure with another sinus surgery.
Polypectomies are usually performed using a
small mechanical suction device or a
microdebrider. After removal, polyp tissue
is usually biopsied, or tested, to rule out
malignancy.
Medical Care:
-
Oral and topical nasal steroid
administration is the primary medical
therapy for nasal polyposis.
Antihistamines, decongestants, and
cromolyn sodium provide little benefit.
Immunotherapy may be useful to treat
allergic rhinitis but, when used alone,
does not usually resolve existing
polyps. Administer antibiotics for
bacterial superinfections.
-
Corticosteroids are the treatment of choice, either topically or
systemically. Direct injection into the
polyp is not approved by the Food and
Drug Administration because of reports
of unilateral vision loss in 3 patients
after intranasal steroid injection with
Kenalog. Safety may depend on specific
drug particle size; large molecular
weight drugs such as Aristocort are
safer and less likely to be transferred
to the intracranial area. Avoid direct
injection into blood vessels.
-
Oral steroids are the most effective medical treatment for nasal
polyposis. In adults, most authors use
prednisone (30-60 mg) for 4-7 days and
taper the medicine for 1-3 weeks. Dosage
varies for children, but the maximum
dose usually is 1 mg/kg/d for 5-7 days,
then taper over 1-3 weeks.
Responsiveness to corticosteroids
appears to depend on the presence or
absence of eosinophilia, so patients
with polyps and allergic rhinitis or
asthma should respond to this treatment.
-
Patients with polyposis not dominated by eosinophilia (eg, patients
with CF, primary ciliary dyskinesia
syndrome, or Young syndrome) may not
respond to steroids. Long-term use of
oral steroids is not recommended because
of the numerous potential adverse
effects (eg, growth retardation,
diabetes mellitus, hypertension,
psychotropic effects, adverse GI
effects, cataracts, glaucoma,
osteoporosis, and aseptic necrosis of
the femoral head).
-
Many authors advocate topical nasal steroid administration for nasal
polyps, either as the primary treatment
or as a continual secondary treatment
immediately following PO steroids or
surgery. Most nasal steroids (eg,
fluticasone, beclomethasone, budesonide)
effectively relieve subjective symptoms
and increase the nasal airflow when
measured objectively (primarily in
double-blind placebo-controlled
studies). Some studies indicate
fluticasone has a faster onset of action
and possible mild superiority to
beclomethasone.
-
Topical corticosteroid administration generally causes fewer adverse
effects than systemic corticosteroid use
because of the former's limited
bioavailability. Long-term use,
especially at high dosages or in
combination with inhaled
corticosteroids, presents a risk of
hypothalamic-pituitary-adrenal axis
suppression, cataract formation, growth
retardation, nasal bleeding, and, in
rare cases, nasal septal perforation.
-
As with any long-term therapy, monitor use of topical corticosteroid
sprays. However, long-term (>5 y)
studies evaluating the use of
beclomethasone have shown no degradation
of the normal respiratory epithelium to
squamous epithelium seen in chronic
atrophic rhinitis. Additionally, the
newer generation of systemic steroids (eg,
fluticasone, Nasonex) appears to have
less bioavailability than older nasal
steroids, such as beclomethasone.
Surgical Care:
-
Surgical intervention is required for
children with multiple benign nasal
polyposis or chronic rhinosinusitis who
fail maximum medical therapy. Simple
polypectomy is effective initially to
relieve nasal symptoms, especially for
isolated polyps or small numbers of
polyps. In benign multiple nasal
polyposis, polypectomy is fraught with a
high recurrence rate.
-
Endoscopic sinus surgery (ESS) is a better technique that not only
removes the polyps but also opens the
clefts in the middle meatus, where they
most often form, which helps decrease
the recurrence rate. The exact extent of
the surgery needed, whether complete
extirpation (ie, Nasalide procedure) or
simple aeration of the sinuses, is not
entirely known, simply because of the
dearth of studies. Rare comparisons show
that complete extirpation procedures are
as effective or superior to aeration of
the sinuses; complication rates are low
with experienced surgeons. use of a
surgical microdebrider (see
Image 34) has made the procedure
safer and faster, providing precise
tissue cutting and decreased hemostasis
with better visualization.
-
Direct surgery at diseased tissue that
is apparent on the CT scan at the time
of surgery. Patients with diseases such
as CF, primary ciliary dyskinesia
syndrome, or Young syndrome may proceed
to surgery without extensive medical
treatment because these diseases usually
do not respond well to corticosteroid
treatment. Once diseased tissue has been
removed from the nasal cavity and
sinuses, the pulmonary systems usually
improve. Consider use of an image-guided
system to define the exact location of
intranasal, sinus, orbital, and
intracranial structures for massive
polyposis or revision surgery because
surgical landmarks may be absent or
altered. For specific techniques in
pediatric sinus surgery, with and
without polyps, see
Pediatric Sinusitis, Surgical Treatment.
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Nasal polyposis occurs in 6-48% of
children with CF. Surgery is performed
when children become symptomatic.
Recurrence of polyps in CF is almost
universal, requiring repeated surgeries
every few years. In fact, recurrence is
typical for many diseases that cause
nasal polyps; patients should receive
preoperative counseling about this
possibility.
-
For lesions other than benign nasal
polyps that result in a nasal polyp, the
polyp should be biopsied or removed,
depending on the disease process.
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Recovery
No activity restrictions are necessary for a
child with nasal polyps. The child's
activity level may decrease because of
diminished ability to breath through the
nose, decreasing sport or physical activity
performance. After sinus surgery, activities
are limited; these limitation
recommendations vary from surgeon to
surgeon. Most surgeons specifically restrict
nose blowing because it may increase
intranasal pressure and cause potential
problems in areas of already thinned bony
dividers in patients with nasal polyposis.
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Risks
Following a polypectomy, your doctor will
treat any underlying inflammation to
minimize the risk that polyps will recur.
Specific follow-up treatments depend on the
extent of the surgery, but usually include
steroid nose sprays and occasionally involve
antibiotics and oral steroids. Long-term
follow-up is recommended. At these
check-ups, your doctor may use endoscopic
instruments to monitor polyp recurrence in
the nose and sinuses.
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Frequently Asked
Questions
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