Routine histopathology in uncomplicated sinus surgery: is it necessary?

A 10-Year Retrospective Review of the Histology of Symptomatic and Asymptomatic Unilateral Nasal Polyps

Background The aim of this study was to determine the histological diagnosis of unilateral nasal polyps and to determine the prevalence of neoplastic pathologies. This study also assessed difference in pathologies whether patients presented symptomatically or were asymptomatic (if they had a mass found incidentally for unrelated throat symptoms).  Method This was a 10-year retrospective study of patients undergoing unilateral nasal mass surgery between 2004 and 2014 at a UK district general hospital. We recorded patient demographics, laterality, histology, symptoms, clinical suspicion, and imaging findings. Results  123 patients were included who underwent unilateral surgery between 2004 and 2014 (male n=83, female n=40; mean age 56 years ± 19.5). The majority were of inflammatory origin (n=92; 74.8%). The most common benign neoplastic cause was inverted papilloma (n=19; 15.4%). A number of malignant neoplastic causes were also found, including: melanoma (n=3; 2.44%), olfactory neuroblastoma (n=2; 1.63%), and other non-inflammatory masses (n=7; 5.69%). 15 of these masses were found incidentally, with 14 being inflammatory, and one an olfactory neuroblastoma; therefore, 6.67% of our incidental unilateral nasal masses were found to be of neoplastic pathology. Conclusion This study's findings support the continued practice of routine biopsy of unilateral nasal masses for histological diagnosis, irrespective of whether they are symptomatic or found incidentally. The accuracy of both clinical suspicion and radiological suspicion on CT scans is not adequate to alter this practice.

The incidence of significant pathology in patients presenting with benign-appearing unilateral nasal polyps

Objective

The presentation of unilateral nasal polyps traditionally necessitates histological evaluation for a neoplasm. This study sought to determine the rates of significant pathology in patients presenting with benign-appearing unilateral nasal polyps, to inform practice.

Method

All patients who underwent nasal polypectomy for benign-appearing unilateral nasal polyps over a 13-year period were included.

Results

A total of 77 patients were included. On histology, 60 cases (77.9 per cent) were found to be inflammatory polyps. Thirteen cases were neoplastic, of which 11 (14.3 per cent) were benign and 2 (2.6 per cent) were malignant neoplasms. The following significant pathologies were found: Schneiderian papillomas, in 10 cases (13.0 per cent); neurofibroma, in 1 case (1.3 per cent); adenoid cystic carcinoma, in 1 case (1.3 per cent); and malignant melanoma, in 1 case (1.3 per cent).

Conclusion

Our data support routine histological assessment for all unilateral nasal polyps. Malignancy is rare (2.6 per cent) in patients presenting with benign-appearing unilateral nasal polyps. In elderly, unfit patients with minimal symptoms, initial conservative management may be reasonable.

The Efficiency of Routine Histopathological Examination for Bilateral Nasal Polyposis

The necessity to routinely carry out histopathologic examinations of surgically removed polyps in patients with chronic rhinosinusitis with bilateral nasal polyps (CRSwNP) is uncertain. The aim of this study was to describe the histopathology of polyps from a large series of patients who underwent endoscopic sinus surgery for CRSwNP and the rate of neoplasms. This is a retrospective study of the histopathological result of all patients with CRSwNP who underwent functional endoscopic nasal surgery and in whom histologic examination was performed, from 2006 to 2015, in a tertiary medical center. Data on demographics and whether a nasal lesion was suspected for neoplasm prior to surgery were analyzed. Two hundred thirty-five patients underwent bilateral nasal polypectomy and histopathologic examinations of the surgical specimens. The rate of neoplasms in nonsuspicious cases was 2.3% (5 cases) and all were inverted papilloma. To conclude, inverted papilloma and other neoplasms are considered rare incidental findings in patients presenting with bilateral nasal polyps. This study demonstrated a higher rate of the latter than that reported in the literature. Our study further emphasizes that despite the low incidence of these pathologies, a histopathologic examination of every nasal polypectomy is warranted so as not to miss potential serious pathologies. We stress that a routine histopathological examination should be practiced at least in the elderly population.

Sinonasal malignancy: What to do with an unexpected pathology result?

BACKGROUND

Endoscopic sinus surgery has become the mainstay in surgical treatment of sinusitis and nasal polyps. While rare, diagnostic discrepancies or pathological contamination during routine specimen analysis has been described. Thus, an accurate diagnosis and indication for surgery are mandatory before proceeding with surgical intervention.

METHODS

We present the case of a 40-year-old female patient who underwent endoscopic sinus surgery (ESS) for chronic sinusitis without nasal polyposis and fragments of squamous cell carcinoma (SCC) were found in the pathology specimen.

RESULTS

We propose an algorithm to help guide physicians presented with a tissue diagnosis that does not match the clinical scenario. Moreover, we discuss strategies to help prevent medical errors and the importance of DNA genetic analysis in this situation.

CONCLUSION

When an unexpected diagnosis occurs, the pathology slides should be reviewed for a second opinion. If the unexpected diagnosis is confirmed, the tissue should undergo STR genetic analysis to ensure against tissue contamination.

Incidental finding of lymphoma after septoplasty

Introduction:

Septoplasty, or surgical correction of the deviated septum, is an elective, routinely performed rhinologic procedure to address nasal airway obstruction. In many cases, resected septal cartilage and bone fragments are sent for pathologic review, although there is no consensus on this practice. We reported two cases of incidentally diagnosed lymphoma after elective septoplasty and discussed clinical presentation, diagnosis, and management.

Methods:

Retrospective chart review of two patients who underwent septoplasty at a tertiary academic medical center and found to have incidental lymphoma based on histopathology.

Results:

Two patients who underwent septoplasty had an incidental diagnosis of lymphoma on pathologic analysis. One patient was noted to have an S-shaped septal deviation that produced bilateral nasal obstruction. She underwent a difficult septoplasty, in which the mucoperichondrial flap was firmly adherent to the underlying septum and bone. Final pathology demonstrated diffuse large B-cell lymphoma. She was treated with chemoradiation and remained free of disease at 59 months. The other patient had a history of nasal trauma, which produced left septal deviation. He underwent an uncomplicated septoplasty, with pathology that demonstrated low-grade B-cell lymphoma. Because there was no evidence of active disease, the decision was made to not treat and to observe the patient clinically.

Conclusions:

This is the first reported series of septal lymphoma incidentally diagnosed on routine septoplasty. Although histopathologic review of specimens from routine nasal and sinus surgery is not routinely performed, this report highlighted the importance of this process, on a case-by-case basis, in detecting unexpected malignancies that otherwise were clinically silent.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

The usefulness of routine histopathology of bilateral nasal polyps - a systematic review, meta-analysis, and cost evaluation

Background

Controversy regarding the usefulness of routine histopathological examination of bilateral nasal polyps removed during endoscopic sinus surgery to identify occult diagnoses still exists. There is a paucity of high-level evidence in the literature.

Methods

A systematic review and meta-analysis was conducted. Two independent reviewers were used. Pooled proportions and numbers needed to screen were calculated. A cost per life year model was generated based on varying survival benefits and compared to other Canadian screening programs to provide financial context.

Results

Six studies (n = 3772 patients) were included. Of the 3772 patients, 3751 had a pre-operative clinical and post-operative pathological diagnosis of inflammatory nasal polyps. Agreement proportion was 99.44 %. There were 18 unexpected benign and three unexpected malignant diagnoses identified. This translated to a proportion of 0.48 and 0.08 % respectively. Number needed to screen was 210 and 1258 respectively. Pooled proportion for expected findings using a random effect model was 0.99 (95 % CI = 0.99–1). Pooled proportion for unexpected benign findings using a random effect model was 0.00522 (95 % CI = 0.00133–0.01). Pooled proportion for unexpected malignant findings using a random effect model was 0.00107 (95 % CI = 0.000147–0.00283). The cost to pick up one unexpected benign diagnosis was $14557.2. The cost to pick up 1 unexpected malignant diagnosis was $87204.56. Cost per quality life year calculated ranged from 3211.83 to $64677.58 based on varying assumptions on the survival benefits of identifying an unexpected malignancy.

Conclusions

Routine pathological examination in screening for neoplasia may be low yield, however, no compelling evidence was found to cease such practice. Surgeons should exercise individual judgment in requesting routine examination.

Electronic supplementary material

The online version of this article (doi:10.1186/s40463-015-0100-8) contains supplementary material, which is available to authorized users.

Medicolegal Issues in Endoscopic Sinus Surgery and Complications

Complications occur during and after endoscopic sinus surgery. Complications leading to temporary or most commonly permanent injury often are involved in litigation for malpractice. This article concentrates on areas of importance that are considered during medicolegal deliberations.

Incidence of neoplasia in patients with clinically suspicious nasal lesions and the value of computed tomography imaging in diagnosis

BACKGROUND

There is no consensus as to whether all routine bilateral polypectomy specimens should be sent for formal histopathological diagnosis to exclude underlying neoplastic pathology. This study assessed the necessity for histopathological investigation as routine practice in cases of bilateral and unilateral nasal lesions by estimating the incidence of unexpected pathologies. It also evaluated the ability of computed tomography to predict histopathological diagnosis in patients with unilateral nasal lesions.

METHODS

A retrospective analysis was conducted of 98 patients undergoing nasal polypectomy over a 12-month period.

RESULTS

Five of 23 patients with a unilateral lesion on nasendoscopy had inverted papillomas on histopathological examination. None of the 75 patients with clinically bilateral lesions on nasendoscopy showed evidence of neoplasia on histopathological examination. Patients with inverted papillomas had significantly lower total Lund-Mackay scores than those with bilateral polyps. Asymmetry scores of inverted papilloma patients were significantly higher compared to both bilateral and unilateral polyps patients.

CONCLUSION

The results suggest that histopathological diagnosis is only necessary in unilateral lesion patients as no unexpected histopathological diagnoses were made in bilateral lesion patients. Computed tomography imaging may have a role in predicting histopathological diagnosis by demonstrating asymmetry and less overall sinus opacification in patients with neoplastic lesions.

The utility of routine polyp histopathology after endoscopic sinus surgery

BACKGROUND

Routine histopathological assessment is standard practice for nasal polyp specimens obtained during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Retrospective studies suggest that routine histopathology of nasal polyps shows few unexpected diagnoses that alter patient management. Our objective was to study the use of routine pathological analysis, and its cost to the healthcare system, in a prospective manner.

METHODS

A multicenter prospective assessment was performed from data collected between 2007 and 2013. Only cases of patients undergoing ESS for bilateral CRS were included. We excluded unilateral disease cases, and cases in which diagnoses other than polyps were suspected either preoperatively or intraoperatively. We then compared the preoperative diagnosis with the final histopathology and identified the rate of unexpected pathologies. A cost analysis was performed.

RESULTS

Only 4 of 866 pathological specimens were identified as having a clinically significant unexpected diagnosis. All unexpected pathologies in this series were benign. These 4 cases account for 0.46% of all specimens reviewed. This translates to a number needed to screen of 217 cases of bilateral CRS to discover 1 unexpected pathology. The associated cost for making an unexpected diagnosis was $19,192.73.

CONCLUSION

Routine histopathology of nasal polyps in ESS for bilateral CRS with polyps yields few unexpected and management-altering diagnoses. It carries a significant cost to the healthcare system. In cases of bilateral CRS with no other concerning clinical features, clinicians should exercise judgment in submitting polyp specimens for pathology rather than routinely sending polyps for histopathologic analysis.

Value-based analysis of routine pathologic septal and inferior turbinate specimens

OBJECTIVE

To determine the frequency and clinical relevance of unanticipated histopathologic results in routine sinonasal surgery and evaluate the necessity for histologic processing of nasal septal cartilage, bone, and inferior turbinate specimens.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care academic medical center.

SUBJECTS AND METHODS

A retrospective review of surgical pathology reports on adult patients undergoing sinonasal surgery during a 5-year period from 2005 to 2010 was performed. All cases with the preoperative diagnosis of sinonasal neoplasia, autoimmune disease, or directed septal biopsies were excluded from review.

RESULTS

A total of 1194 pathology reports were reviewed from 1172 individual patients. This included histopathologic evaluation of 1194 septal cartilage and bone specimens and 714 inferior turbinate specimens. None of the patients had unanticipated histopathologic findings that were clinically significant.

CONCLUSION

Many surgeons obtain histopathologic diagnoses on all tissue removed from a patient. Based on our institutional case series, histopathology of the septum and inferior turbinates in routine sinonasal cases may not be necessary. A value-based approach to processing grossly unremarkable septal and turbinate tissue by waiving histologic processing and subsequent microscopic evaluation could provide significant cost savings.

Unexpected tumor incidence in surgically removed unilateral and bilateral nasal polyps

OBJECTIVE

The objective of the study was to investigate the postoperative tumor incidence on routine histopathologic examination of surgical specimens in patients who underwent endoscopic sinus surgery with the preoperative diagnosis of unilateral or bilateral nasal polyposis.

METHODS

Patients who underwent endoscopic sinus surgery with the preoperative diagnosis of unilateral or bilateral nasal polyposis between 2000 and 2009 were included in the study as the 2 separate groups. In both groups, tumor incidence that had been noticed on routine postoperative histopathologic examination was recorded retrospectively. Patients who had a preoperative diagnosis other than nasal polyposis, determined on biopsy, were excluded.

RESULTS

Of 251 patients included, 197 had the preoperative diagnosis of bilateral nasal polyposis, and 54 had unilateral nasal polyposis. No tumor was diagnosed on postoperative histopathologic examinations in patients with preoperative bilateral nasal polyposis. Seven patients (12.96%) with the preoperative diagnosis of unilateral nasal polyposis had tumors on postoperative histopathologic examinations. Two of these 7 patients had malignant tumors that were reported preoperatively by intranasal biopsy as inflammatory polyps.

CONCLUSIONS

Diagnosis of a neoplasia is an extremely rare situation, unless there are special findings of tumor in patients with preoperative diagnosis of bilateral nasal polyposis. On the other hand, histopathologic examinations should be carried out in every case operated with preoperative diagnosis of unilateral nasal polyposis, as the tumor incidence is higher.

Is routine histopathological analysis of nasal polyposis specimens necessary?

Our objective is to evaluate the incidence of unexpected pathologies in routine nasal polyposis specimens and necessity for histopathological evaluation of nasal polyps. A retrospective chart review of all patients who underwent nasal polyposis surgery between January 2004 and June 2010 were reviewed. The patients were divided into two groups. Group 1 consisted of patients with bilateral nasal polyposis. Group 2 consisted of patients with unilateral nasal polyposis. One hundred and seventeen patients (81 male, 36 female) were involved in this study. The mean age was 44.9 ± 17.7 years, ranging between 18 and 72 years. Group 1 consisted of bilateral nasal polyposis specimens. Eighty-five patients were identified with bilateral nasal polyposis. From these 85 patients, no specimens present any evidence of occult pathology on histopathological examination. Group 2 consisted of unilateral nasal polyposis specimens. There were two cases of allergic fungal sinusitis, two of inverting papilloma, one of mucocele, one of plasmacytoma, one of hemangioma, one of esthesioneuroblastoma, and one of schwannoma. Final histopathology of the remaining 23 patients was consistent with inflammation and/or nasal polyposis. We think that in cases of unilateral polyps histopathological examination of the entire material is mandatory. However, routine histological examination of bilateral nasal polyposis may possibly not be necessary in cases where the clinical assessment very clearly has not disclosed any unusual or suspicious signs.

Is routine histopathological examination of FESS material useful?

Analysis of the clinical value of histopathological examination of material collected during functional endoscopic sinus surgery. Retrospective analysis of collected data of patients undergoing functional endoscopic sinus surgery over a 7-year period. Data were collected from a pathology database of the Sint Lucas Andreas Hospital, Amsterdam, The Netherlands. All material collected from 1,944 functional endoscopic sinus surgery cases in 1,695 patients (some patients underwent revision surgery) operated between 2000 and 2007 was examined histologically. Patients with a histological outcome different from chronic inflammation or polyposis nasi, were checked on indication of surgery, type of surgery and preoperative clinical suspicion for (pre)malignancy. The impact of the histological diagnosis on the clinical course was evaluated. Thirty-seven unusual diagnoses were reported: 18 cases of inverted papilloma, one squamous cell carcinoma, two malignant lymphomas, one leiomyosarcoma, eight squamous cell papillomas, one Churg Strauss syndrome, one Schneiderian papilloma, two cases of Wegener’s granulomatosis and three cases of sarcoidosis. All other specimens were identified as chronic inflammation and/or nasal polyposis. Only two clinically significant, unexpected diagnoses, both inverted papilloma, have resulted from the histological investigation. We conclude that the close correlation between histopathology outcome and examination on clinical grounds or gross inspection indicates that routine histopathological examination of functional endoscopic sinus surgery material has little clinical value and it is questionable if this should be performed. In patients in whom there is a high degree of suspicion for (pre)malignancy, histopathological examination of functional endoscopic sinsus surgery material remains indicated.

Technical innovations and the evolution of endoscopic sinus surgery

Since the introduction of endoscopic sinus surgery, a number of significant technological advances, as well as an improved understanding of disease pathogenesis and management, have enabled major evolutions in surgical techniques. Modifications to surgical instruments, imaging, the development of the microdebrider, and other newer instrumentation have all contributed to the current level of patient success associated with endoscopic intranasal techniques. At the same time, it has become evident that anatomic variations are less important in the pathogenesis of chronic rhinosinusitis than was previously thought, and that ventilation alone is insufficient to resolve well-established disease. This paper reviews the changes that have occurred in endoscopic sinus surgery over the past 20 years since the techniques were first introduced into the United States, and the technologies that have enabled these changes and the development of extended endoscopic techniques. Continuing developments of interactive computer-guided surgery, endoscopic 3-dimensional imagery, robotics, and improved adjunctive therapies will further extend the role of endoscopic transnasal approaches to an expanded number of skull base and intracranial lesions.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.

Incidence of Inverted Papilloma in Recurrent Nasal Polyposis

OBJECTIVES

A diagnosis of inverted papilloma in apparently normal bilateral polyps is a possible albeit rare event. The frequency of this diagnosis varies between 0.00% and 0.92%. There are no studies evaluating whether this possibility is significantly different in patients operated for recurrence when compared with those undergoing first surgery. The aim of this study is to evaluate the frequency of inverted papilloma in a series of histologic specimens obtained from patients undergoing surgery for recurrent nasal polyposis.

METHODS

The authors conducted a retrospective chart and pathologic review of data from 1887 surgical interventions for removal of unremarkable bilateral nasal polyps. Frequency of inverted papilloma was assessed.

RESULTS

Five cases of inverted papilloma were identified. The incidence of this diagnosis was thus 0.26% (95% confidence interval, 0.08-0.62%). Age, gender, and number of recurrences did not influence the frequency of this diagnosis.

CONCLUSIONS

The occurrence of inverted papilloma in unremarkable recurrent cases of nasal polyps is rare. This rate is similar to the one observed in patients undergoing first surgery.

Histopathology of routine nasal polypectomy specimens: a review of 2,147 cases

OBJECTIVES

There is controversy about whether all nasal polyps removed at operation should be sent for histopathologic examination. The primary aim of this study was to assess the incidence of unsuspected clinically relevant diagnoses in a large series of patients undergoing nasal polypectomy. A review of the literature on the frequency of this event was also performed.

STUDY DESIGN

Retrospective study and review.

METHODS

Data from patients undergoing nasal polypectomy over a 14 year period were reviewed. All adult patients undergoing first surgical removal of bilateral nasal polyps were included. Monolaterality and presence of suspicious looking lesions were exclusion criteria.

RESULTS

A total of 2,147 patients were recruited. Eight cases of clinically relevant unexpected diagnoses were identified, corresponding to a frequency of 0.37% (95% confidence interval 0.16-0.73%). Inverted papilloma occurred in seven cases, neoplasia in one case. Affected patients tended to be older. Four previous smaller studies on this topic were identified. The reported incidence of unsuspected clinically relevant diagnoses varied between 0.00% and 0.92%.

CONCLUSIONS

Although rare, unexpected clinically relevant findings may be identified during routine histologic examination of nasal polyps specimens. Future cost effectiveness analyses are required to clarify whether routine histology is a cost effective strategy.