Surgical management of polyps in the treatment of nasal airway obstruction

Surgical management of chronic rhinosinusitis with nasal polyps under local anaesthesia: indications and results

Objective

Our objective was to specify the indications and duration of effectiveness of Awake Patient Polyp Surgery (APPS) in Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). Secondary objectives were to evaluate complications and Patient-Reported Experience (PREMs) and Outcome Measures (PROMs).

Methods

We collected information regarding sex, age, comorbidities and treatments. Duration of effectiveness was the duration of non-recurrence defined by the time between APPS and a new treatment. Nasal Polyp Score (NPS) and Visual Analogic Scales (VAS, from 0/10 to 10/10) for nasal obstruction and olfactory disorders were assessed preoperatively and one month after surgery. PREMs were evaluated using a new tool: the APPS score.

Results

Seventy-five patients were enrolled (SR = 3.1, mean age = 60.9 ± 12.3 years). 60% of patients had a previous history of sinus surgery, 90% had stage 4 NPS and more than 60% had overuse of systemic corticosteroids. Mean time of non-recurrence was 31.3 ± 2.3 months. We found a significant improvement (all p < 0.001) for NPS (3.8 ± 0.4 vs 1.5 ± 0.6), VAS obstruction (9.5 ± 1.6 vs 0.9 ± 1.7) and VAS olfactory disorders (4.9 ± 0.2 vs 3.8 ± 1.7). Mean APPS score was 46.3 ± 5.5/50.

Conclusions

APPS is a safe and efficient procedure in the management of CRSwNP.

Eosinophilic and Non-eosinophilic Chronic Rhinosinusitis with Nasal Polyps and Their Clinical Comparison in Indian Population

Eosinophilic chronic rhinosinusitis with nasal polyps (eCRSwNP) and non-eosinophilic chronic rhinosinusitis with nasal polyps (neCRSwNP) are two distinct endotypes of chronic rhinosinusitis with nasal polyps (CRSwNP). The aim of the study was to find the prevalence of eCRSwNP and neCRSwNP, their clinical comparison and to establish predictive values for clinical and diagnostic factors to differentiate between eCRSwNP and neCRSwNP in Indian population with CRSwNP. This study was a prospective cohort, multi- institutional study. A total of 162 patients who were diagnosed with nasal polyps at different military hospitals in India during the period from 2011 to 2020 were selected for study. They were diagnosed in accordance with EPOS guidelines. They were randomly divided into two groups as eCRSwNP and neCRSwNP based on the response to oral corticosteroids for 2 weeks duration and the prevalence of eCRSwNP was established. Blood samples were collected and endoscopic sinus surgery was performed in all patients after atleast 2 months of last steroid dose. Preop CT scan scores, preop nasal endoscopy scores, preop blood eosinophil counts, preop tissue eosinophil counts were compared between the groups. Postop followup was done at 6 months by comparing CT scan scores and nasal endoscopy scores. Predictive values for clinical and diagnostic factors were established to diagnose eCRSwNP in Indian population. Out of a total 162 patients, 121 (74.6%) patients were classified into eCRSwNP and 41 (23.6%) into neCRSwNP out of a total of 162 patients with CRSwNP. CRSwNP was seen in the 4th decade. eCRSwNP was seen in the later part and neCRSwNP was seen in the early part. eCRSwNP was more common in males and neCRSwNP was more common in females. Smoking, asthma and aspirin intolerance were more commonly seen in eCRSwNP than neCRSwNP, p < 0.001, p = 0.020 respectively. Preop total CT scan score, preop bood absolute eosinophil count,preop blood eosinophil percentage, tissue eosinophil percentage, postop nasal endoscopy score, postop CT scan score were stastically significant in eCRSwNP, p < 0.001 except preop total nasal endoscopic score. Tissue absolute eosinophil count had best predictive accuracy plotted with receiver operating characteristic (ROC) curve analysis, area under curve (AUC) 0.923(95% CI, 0.876-0.970). The cutoff points determined to diagnose eCRSwNP were ≥ 15 for preop total CT scan score,  ≥ 378 × 106/L for preop absolute blood eosinophil count,  ≥ 6.5% for preop blood eosinophil percentage,  ≥ 14% for tissue eosinophil percentage,  ≥ 16 for absolute tissue eosinophil count, ≥ 1 for 6 months postop total nasal endoscopy score,  ≥ 2 for 6 months postop total CT scan score. eCRSwNP and neCRSwNP are two distinct endotypes of nasal polyps present in Indian population with CRSwNP. Two thirds of the patients with nasal polyps were eCRSwNP and the prevalence in Indian population is more than the East Asian population but less than the Western population. There is a high chance of recurrence and treatment failures for eCRSwNP than neCRSwNP. The cutoff points for various non invasive diagnostic predictors are useful to diagnose the patients with eCRSwNP during the outpatient visits and hence plan for better treatment strategies.

The effects of oral steroid therapy on prolidase enzyme activity in patients with nasal polyps

Objective

To compare prolidase enzyme activity (PEA) in serum and polyp specimens of patients with nasal polyps obtained before and after the oral steroid therapy.

Materials and methods

Thirty three patients with nasal polyps (39 ± 13 years) received 1 mg/kg of oral steroids. Serum samples were collected from each patient, but nasal polyp specimens could be obtained only from 23 patients (38 ± 13 years) before and after the oral steroid therapy. PEA was measured by ELISA method.

Results

Serum PEA values were 210 (176–242) U/L and 184 (147–217) U/L before and after the oral steroid therapy, respectively (p = 0.015). Polyp tissue PEA was 1337 (738–2130) U/g and 871 (590–1663) U/g before and after the oral steroid therapy, respectively (p = 0.429).

Conclusion

In patients with nasal polyps, significantly lower serum PEA after the oral steroid therapy may be a consequence of the role of prolidase enzyme in inflammatory processes which are important for the development of nasal polyps. More comprehensive studies with larger sample sizes are needed to elucidate the role of PEA in the pathogenesis of nasal polyps.

NAVIGATE II: Randomized, double-blind trial of the exhalation delivery system with fluticasone for nasal polyposis

BACKGROUND

Chronic rhinosinusitis is common and sometimes complicated by nasal polyps (NPs). Corticosteroid nasal sprays are often unsatisfactory because they are ineffective at delivering medication to high/deep sites of inflammation.

OBJECTIVE

We sought to assess whether an exhalation delivery system with fluticasone (EDS-FLU) capable of high/deep drug deposition improves outcomes.

METHODS

Patients (n = 323) 18 years and older with moderate-to-severe congestion and NPs were randomized to twice-daily EDS-FLU (93, 186, or 372 μg) or exhalation delivery system (EDS)-placebo for 24 weeks (16 double-blind plus 8 open-label when all received 372 μg). Coprimary end points were change in nasal congestion/obstruction at 4 weeks and summed bilateral polyp grade at 16 weeks. Secondary end points included symptoms, polyp elimination, and functioning.

RESULTS

EDS-FLU was superior on both coprimary end points (P < .001 vs EDS-placebo, all doses). Mean polyp grade improved continuously through week 24 (P < .009, all comparisons), with polyps eliminated on at least 1 side in approximately 25% of patients at week 24 versus 8.7% with EDS-placebo (P ≤ .014, all comparisons). Sino-Nasal Outcomes Test scores also improved significantly versus those in patients receiving EDS-placebo (-21.1 to -21.4 vs -11.7 at week 16, P < .05 all doses). At the end of the double-blind period, EDS-FLU (all doses) significantly improved all 4 defining disease symptoms. In most patients (68%), those receiving EDS-FLU reported "much" or "very much" improvement. The number of patients eligible for surgery decreased by 62%-67%. The safety profile was similar to that reported in prior trials evaluating conventional corticosteroid nasal sprays in comparable populations.

CONCLUSION

EDS-FLU produces clinically and statistically significant improvement in all 4 diagnostically defining disease symptoms, polyp grade, and quality of life in patients with chronic rhinosinusitis with NPs.

The role of human papilloma virus and herpes viruses in the etiology of nasal polyposis

BACKGROUND/AIM

The aim of this study was to investigate the etiological role of human papilloma virus (HPV), herpes simplex virus (HSV), varicella-zoster virus (VZV), Epstein-Barr virus (EBV), cytomegalovirus (CMV), and human herpes virus-6 (HHV-6) and -7 (HHV-7) in the occurrence of nasal polyposis.

MATERIALS AND METHODS

Nasal polyp samples from 30 patients with nasal polyposis and normal nasal mucosa from 10 patients without nasal polyps were obtained. DNA was extracted from tissues. Real-time polymerase chain reaction was performed for all runs.

RESULTS

No HSV-1, HSV-2, or VZV was detected in the samples. Among the patient samples, EBV and HHV-7 DNA were detected in 18 (60%), HHV-6 was detected in 20 (66.7%), and HPV was detected in 4 (13.3%) samples. Among the controls, CMV DNA was positive in one (10%). EBV was positive in 5 (50%), HHV-6 and HHV-7 were positive in 7 (70%), and HPV was positive in 2 (20%) samples. No significant difference was found among the groups with any test in terms of positivity.

CONCLUSION

The association of Herpesviridae and HPV with the pathogenesis of nasal polyps was investigated in this study and no relationship was found. Thus, these viruses do not play a significant role in the formation of nasal polyps.

Adhesion molecules as predictors of nasal polyposis recurrence

BACKGROUND

Nasal polyposis is a chronic inflammation of nasal and paranasal sinuses in the pathogenesis of which adhesion molecules may have a significant role. This study investigates the possible role of certain adhesion molecules, mucins, and oncogenes in nasal polyposis recurrence.

METHODS

A sample study of 21 individuals (17 men and 4 women) aged 47.44 ± 15.10 years with nasal polyposis who had undergone nasal surgery twice was used. Twenty-one individuals aged 46.9 ± 12.8 years suffering from nasal polyposis who had undergone surgery only once in the same period were used as a control sample.

RESULTS

Statistically significant differences between the two groups were observed regarding epithelial membrane antigen (EMA/mucin 1) of stromal cells (p < 0.001) and CD86 stromal expression (p = 0.009). No patient of the control group exhibited high (++) CD86 stromal expression, whereas six patients of the resurgery group did so. When EMA and CD86 were included in a logistic regression model, stromal EMA was found to be positively related to recurrence.

CONCLUSION

Adhesion molecules may relate to nasal polyp prognosis and recurrence rates.

Importance of CT Scan of Paranasal Sinuses in the Evaluation of the Anatomical Findings in Patients Suffering from Sinonasal Polyposis

Sinonasal polyps are benign lesions arising from nose and/or sinuses mucosa. Paranasal sinuses computed tomogram (CT) scan are important for functional endoscopic sinus surgery (FESS) as their information assist the surgeon in pre-operative planning. This study aimed to show importance of CT scan in evaluation of anatomical variations to prove a correlation with disease process and extent of disease in sinonasal polyposis patients. A study was done from Sept, 2010 to Sept, 2011 with 33 patients presenting with nasal polyps. All recruited patients, after thorough history, general examination and thorough ENT examination, were examined by nasal endoscopy and sinus CT scans. All scans were carried out using a 3 mm thickness in axial and coronal planes with sagittal reconstruction. An analysis was then carried out to see anatomical variations and disease extent in CT scans. Maxillary sinus was the most commonly and most severely affected sinus, while the sphenoid sinus was the least involved sinus. Ostiomeatal complex (OMC) was found to be blocked in 84.85 % cases. There were few anatomic variations (57.58 %) found as hypertrophied uncinate process (30.30 %), septal deviation (21.21 %), skull base type-2, Concha bullosa, Haller's cell, Paradoxical middle turbinate, Onodi cell, pneumatized crista galli and dehiscent skull base. Hyperdense and heterogeneous opacification in paranasal sinuses was seen in 12.12 % patients. Importance of CT scans is to know anatomical variations as etiology, fungal etiology, to know extent of polyposis and anatomical variations to prevent complications during FESS and Navigation sinus surgery.

Availability of preoperative systemic steroids on endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis

PURPOSE

To analyze the outcome of endoscopic sinus surgery (ESS) after preoperative systemic steroid (PSS) treatment for chronic rhinosinusitis (CRS) with nasal polyposis (NP) and to investigate and compare clinicopathological factors associated with the outcome.

MATERIALS AND METHODS

We performed a retrospective chart review of 468 patients with CRS with NP who underwent primary ESS between January 2005 and October 2011. 124 patients who met the inclusion criteria were included. Beginning from 2008, our clinic administered steroid preoperatively in patients of CRS with NP, thus there were 84 patients with preoperative systemic steroid (PSS group) and another 40 patients without such regimen (no PSS group). To evaluate the outcome after ESS, poor outcome and complication were analyzed according to the following parameters: age, sex, follow-up duration, eosinophilic infiltration, atopy, asthma, Lund-Mackay score, and polyp grade.

RESULTS

There was no significant difference in poor outcome rates between the PSS and no PSS group (35.0% vs. 47.6%, p=0.185). There was no significant difference in complication rates between the PSS and no PSS group (10% vs. 6%, p=0.468). As with the multivariate analysis of the clinicopathological factors to the poor outcome rate, presence of asthma and eosinophilic infiltration were significantly related (odds ratio as 6.555 and 4.505, respectively), whereas PSS was confirmed as less likely related (odds ratio 0.611).

CONCLUSION

Low dose PSS administration does not seem to have an effect on the outcome after ESS in patients who have CRS with NP. Eosinophilic infiltration and presence of asthma are important predictors of surgical outcome.

The efficacy and safety of an office-based polypectomy with a vacuum-powered microdebrider

BACKGROUND

The waiting time for functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) in the Canadian public healthcare system can be lengthy. Many such patients have significant nasal obstruction resulting in a poor quality of life. A simple and safe office-based polypectomy device to debulk nasal polyps allows immediate alleviation of nasal obstruction and better access for topical medications. The aim of this study is to assess the efficacy, safety, and patient tolerability of a vacuum-powered microdebrider in the outpatient clinic setting.

METHODS

The clinical charts of patients with CRSwNP who underwent office polypectomy with a vacuum-powered microdebrider between May 2012 and February 2013 were retrospectively reviewed. These patients were either awaiting surgery or had recurrent polyposis postsurgery that was amenable to office polypectomy. Previously completed procedural and clinical outcomes questionnaires by the patients and surgeon were analyzed.

RESULTS

Sixty-eight patients underwent office polypectomy in this case series. Fifty-nine procedures (87%) were successfully completed. Failed complete polyp resections were due to fibrous polyps (n = 7; 10%), device failure (n = 1; 1.5%), and obstruction from a deviated nasal septum (n = 1; 1.5%). There was a 43% improvement in nasal obstruction score and significant reduction in polyp grade postpolypectomy. Majority of patients (n = 66; 97%) reported a comfort level of "fair" to "excellent." Bleeding was "light" in 61 cases (90%). There were no complications encountered.

CONCLUSION

The vacuum-powered microdebrider is a safe, effective, and well-tolerated instrument to resect nonfibrous nasal polyps in the outpatient setting.

State of the art treatment of nasal polyposis

BACKGROUND

Nasal polyposis represents the end point of multiple inflammatory pathways and controversy continues as to the exact roles of medical and surgical approaches in the management of nasal polyposis.

METHODS

A combination of both is often required to manage polyps adequately with surgery and intranasal steroids remaining the mainstay of therapy.

RESULTS

Fortunately, new technological advances are making surgery safer and more efficient. In the postoperative period, debridement is effective in reducing the formation of adhesions, and topical medications may play a beneficial role in preventing polyp reformation.

CONCLUSION

Additional investigations into the optimal perioperative medical management is needed to ensure optimal surgical outcomes.

Nasal centripetal endoscopic sinus surgery

OBJECTIVES

My aim in this article is to report 26 years of experience in order to evaluate the applicability and efficiency of centripetal dissection in intranasal ethmoid sinus surgery.

METHODS

I performed a retrospective review of 2,500 patients treated in the Felippu Institute, São Paulo, over the 26-year period from 1984 to July 2010. All of the patients underwent intranasal ethmoid sinus surgery with the centripetal technique. Before surgery, an otolaryngological examination, nasal endoscopy, and computed tomographic scans with axial, coronal, and sagittal projections were performed. All surgeries were carried out under general anesthesia and with the help of a surgical microscope or (after 1997) a rigid 30 degrees endoscope. The surgical technique required a standard endoscopic sinus surgery set. The complications of intranasal ethmoid sinus surgery were recorded and classified as intraoperative, short-term, or long-term.

RESULTS

I observed an intraoperative complication (cerebrospinal fluid leak) in 4 patients. There were no cases of periorbital damage. I recorded no short-term or long-term complications. All of the intraoperative complications were resolved during surgery.

CONCLUSIONS

With the use of this technique, the surgeon can precisely identify the position of the surgical instrument without losing his or her orientation, and thereby significantly reduce the risk of complications.

The role of local steroid injection for nasal polyposis

Sinonasal polyps affect a small but significant percentage of patients with chronic sinusitis. Treatments vary and range from oral and topical medical treatments to surgical removal. Corticosteroids typically have been regarded as the gold standard medical treatment for sinonasal polyps. Delivery of steroids is traditionally via oral or topical means. Over the years, otolaryngologists have also found that intrapolyp injection of corticosteroids is an effective means to treat some patients with sinonasal polyps. This article reviews the prevalence, pathophysiology, and medical treatment options for sinonasal polyps. Focused attention is paid to treatment with steroid injections, including a review of its associated risks and benefits.

Clinico-pathological profile of sinonasal masses: an experience in national ear care center Kaduna, Nigeria

BACKGROUND

The presence of a mass in the nose and paranasal sinuses may seem to be a simple problem; however it raises many questions about the differential diagnosis. The aim of this study is to evaluate the clinico-pathological profile of sinonasal masses in our environmentThis is a retrospective analytical review of all the patients with sinonasal masses that presented to the national ear care center, Kaduna over a six year (2003-2008) period. Their biodata, clinical profile and histological diagnoses were analyzed.

FINDINGS

A total of 76 patients were analyzed, age range 5 to 64 yrs with a mean age of 33.3 yr median and modal age of 35.00 (SD = 13.1 +/- 1.5). Majority of the patients were in the age groups 21-50 yrs. There were 34 male and 42 female with M: F ratio of 1:1.2. The main presenting symptoms are nasal blockage 97.4% and rhinorrhea 94.7%. It was bilateral in 34 (44.7%), left side in 24(31.6%) and right side in 18(23.7%) patients. The commonest clinical diagnoses were simple nasal polyp 47(61.8%) and antrochoanal polyp 10(13.2%). About 59 (77.6%) were benign, 2 (2.6%) were malignant and 15 (19.7%) were lost to follow up. The commonest histological diagnosis is simple inflammatory nasal polyp in 28 (36.8%) patients and the least was nasal capillary hemangioma 2 (2.6%). About 55(72.4%) patients had surgical treatment.

CONCLUSIONS

Nasal obstruction and rhinorrhea are the commonest symptoms of presentation, simple inflammatory nasal polyp is still the commonest histological pattern seen in our environment, and surgery is still the best modality of treatment for benign tumor thus the need for advocacy for early recognition and referral to the ENT surgeon.

Endoscopic diode laser polypectomy and high-dose intranasal steroids in recurrent nasal polyposis

BACKGROUND

The aim of this clinical investigation was to determine the outcomes of an outpatient videoendoscopic diode laser polypectomy (DLPE) and subsequent topical high-dose corticosteroid application in chronic rhinosinusitis with recurrent nasal polyposis (NP).

METHODS

After ineffective revision sinus surgery and prolonged mometasone furoate application, 19 consecutive mild and moderate NP patients suffering from nasal obstruction (NO) and olfactory dysfunction (OD) were prospectively entered into the study to undergo DLPE under topical anesthesia. Beginning 1 week postoperatively, 250 microg of beclomethasone dipropionate aerosol spray (BDPAS) was self-administered into each nostril twice a day. Treatment efficacy was assessed after 1, 6, and 12 weeks and at quarterly long-term follow-ups based on objective parameters (videoendoscopic photodocumentation and rhinomanometry) and subjective evaluation of NO, OD, and satisfaction (visual analog scales [VASs]).

RESULTS

VASs indicated very low values for intraoperative pain and discomfort and high postoperative satisfaction. After 6 weeks, subjective and objective data revealed a significant improvement of NO and OD (p < 0.0005). Topical BDPAS application was well tolerated. At a median follow-up of 32 months (range, 1-4 years), 21% of the patients developed NP disappearance, 53% had a stable disease, and 26% had a progressive disease.

CONCLUSION

In therapy-refractory NP, endonasal DLPE represents a minimally invasive, symptom-oriented, safe and easily reapplicable outpatient treatment option that provides effective improvement of NO and OD. Compared with the pre-DLPE period, the proposed long-term quarterly follow-up combined with high-dose topical BDPAS application might reduce or delay the need for major surgery and appears to be suitable for disease control.