-------------------------------------------------------------------------------- TITLE: Nasal Polyposis and Ethmoid Surgery SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: October 10, 1990 RESIDENT PHYSICIAN: Wayne Williams, M.D. FACULTY: Karen Calhoun, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. -------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. Nasal Polyposis A. Etiology B. Histology C. Diagnosis D. Treatment II. Non-Endoscopic Ethmoid Surgery A. Transantral B. External III. Endoscopic Ethmoid Surgery A. Indications B. Pediatric C. Post Operative Care D. Complications I. Nasal Polyposis A. Introduction -frequent problem for rhinologist -associated with many diseases: allergic rhinitis, cystic fibrosis, asthma, aspirin idiosyncracy, Kartagener's syndrome -difficult to treat and frequently recur B. Clinical Features -Characteristic Appearance: glistening, pale, gray, smooth, soft, semitranslucent, freely movable, attached by a pedicle, painless, non-bleeding. -Most commonly found in middle meatus -Can project posteriorly into nasopharynx. -Antral Choanal Polyp: Extends from maxillary antrum, usually lateral wall, through natural ostium, then choana. Usually cystic with antral portion filling maxillary sinus. Histologically, numerous plasma cells, unlike intranasal polyps which have abundant eosinophils. Externally are lined with normal respiratory epithelium. C. Etiology -not known -Long believed to be manifestation of allergy -Challenged in 1970's: many studies demonstrating cause and effect relationship between nasal polyposis and allergy does not exist. -Chronic inflammation and infection does not to be cause, but does predispose to polyp formation. -Frequently classified as "atopic" or "non-atopic" -Present Theory: Dysfunction of autonomic nervous system (increased norepinephrine, change in vascular permeability). -The disorder interferes with drainage of interstitial fluid causing mucosal edema. Capillary permeability increases. Collagen fibrils are pushed apart and structural stability is lost. Polypoid changes occur with thickening of the stroma. D. Histology -Usually typical respiratory airway epithelium: psuedostratified cylindric epithelium with numerous ciliated cells and goblet cells. -Anterior location: increased stratified squamous epithelium -Occasionally transitional form found similar to bladder mucosa -Goblet cell density actually less in polyps than normal mucosa. No difference comparing patients with and without allergies. Normal distribution is higher concentration in posterior nose than anterior with majority on inferior and middle turbinates. Maxillary sinus much higher concentration than other sinuses with ethmoid next in order. -Marked thickening of basement membrane -High stromal eosinophil count -Polyp free of nerve endings. E. Examination -Anterior rhinoscopy with decongestant usually reveals disease -Nasal Endoscopy: -assists in diagnosis -identify if surgical intervention necessary -determine mucosal response to medical therapy -Technique: -topical decongestant and anesthetic -3 passes: along floor, superiorly, middle meatus -note anatomy, mucosal condition, secretions -Radiography F. Differential Diagnosis -Benign: -encephalocele, meningocele: if stalk superior or not evident consider CT before biopsy. -inverting papilloma: 65% had surgery for nasal obstruction -juvenile nasopharyngeal angiofibroma: young males with nosebleeds; usually has extended into ptyerygomaxillary fossa -Malignant: -squamous cell carcinoma: most common malignant tumor of nose -adenocarcinoma: from minor salivary glands -esthesioneuroblastoma: from olfactory area; very rare -If not characteristic polyp appearance, is unilateral, bleeds easily, then get CT with contrast prior to biopsy. G. Medical Treatment -Treatment of Choice; no cure, only control -Treat infection: high incidence anaerobic infection -Systemic steroids: 60mg qd x 3-5 days, 7 day taper. -Topical steroids: taper to maintenance once response -Allergy testing: screening RAST, IgE levels and appropriate skin testing if indicated. -Desensitization frequently helps symptoms, but rarely alters polyp size. -Avoid aspirin -Treat asthma, if present. H. Surgery -Indications: failure of medical therapy nasal obstruction steroid contraindication persistent infection or sinus disease -Asthma not a contraindication to polypectomy; does not aggravate or precipitate asthma -Procedure: Polypectomy -for minimal disease can be done in office with wire snare -should use endoscope to guide excision and locate additional polyps -smaller polyps removed with ring forceps as atraumatically as possible after adequate injection. -Antral Choanal Polyp: Intranasal portion removed followed be Caldwel-Luc to remove antral portion. Some advocate endoscopic removal through enlarged ostium. II. Non-Endoscopic Ethmoid Surgery -Endoscopic ethmoid surgery has not replaced standard "external"approaches, but has provided a refinement of the older procedure for intranasal ethmoidectomy. A. Transantral Ethmoidectomy -access to ethmoid labyrinth provided through maxillary antrum. -Advantages: -provides good view of middle and posterior ethmoid cell and sphenoid sinus; defines orbit medially. -provides access to maxillary disease. -Indications: -same as for intranasal approach (ethmoiditis) -orbital decompression -disease in retrorbital cells (posterior) -maxillary sinus disease -Procedure -Caldwell-Luc -entry through medial roof of maxillary sinus -ethmoid exenteration -augmented with intranasal removal of anterior cells or turbinate reduction B. External Ethmoidectomy -Advantages: -medial orbital wall and base of skull more clearly defined; orbital contents protected -more exposure to sinus -Indications: -drainage orbital abscess -excision of orbital/ethmoid neoplasms -repair of CSF leak -extensive sinonasal polyposis -Procedure: -Modified Lynch incision -lacrimal sac and medial periorbita elevated -anterior ethmoid artery divided -ethmoid entered through lamina papyracea -note: important to reattach medial canthal ligament if detached. Avoid injury to trochlea. Frontoethmoid suture line marks level of skull base. III. Endoscopic Ethmoid Surgery A. Indications -procedure of choice for chronic sinusitis -functional endonasal endoscopic ethmoid surgery for chronic or recurrent sinusitis based on hypothesis that osteomeatal complex is the source of pathologic changes in adjacent paranasal sinuses. -abnormal anatomy in complex produces poor mucociliary clearance and inadequate ventilation. -abnormal anatomy can be from altered bony structures (concha bullosa, severe septal deviation, polyps, paradoxically curved middle turbinate, large bulla ethmoidalis, medially bent uncinate) or chronic mucosal inflammation (allergic rhinitis, chemical irritation, non-resolving infection. -hypothesis supported by fact that adjacent sinuses clear with enlargement of ostia and removal of inflamed mucosa at complex. B. Advantages -physiologic by re-establishing conditions that enhance mucociliary clearance and ventilation of the paranasal sinuses. -disease can be thoroughly removed under direct vision -not necessary to remove all disease -minimal trauma C. Disadvantages -requires special instrumentation and training -CT scan required D. Pediatrics -not infrequent to have abnormal sinus Xray in child without sinusitis being present. -Base diagnosis on clinical history and exam in conjunction with Xray -Most common symptoms: rhinorrhea, otitis media and persistent cough -Headaches, facial pain and fever less common than in adult -Frequently overlooked sign is mild periorbital edema present upon rising in the morning -Frequently associated with systemic disorder (65%): asthma, cystic fibrosis, immune disorder -Need pediatric evaluation -Preoperative detailed endoscopic endonasal exam usually omitted, however, CT remains important for evaluation on sinuses -Indications -Same as in adult -Useful only after exhaustive medical management has failed. -Direct and indirect drainage methods should be considered prior to FESS. -adenoidectomy/tonsillectomy -septoplasty -antrostomy -Adenoidectomy with inferior meatal antrostomy frequently initial procedure. -Very successful in younger patient. -Technique -More conservative limited anterior approach (Messerklinger) used almost exclusively -Compute maximal safe doses of vasoconstrictive agents prior to use -Use adult scopes (4mm) because better illumination and field of vision -Smaller instruments very helpful -Consider biopsy of nasal mucosa for electron microscopy. Should be done atraumatically from posterior nose. Traumatized tissue frequently read by pathologist as "squamous metaplasia" because cilia have been destroyed. E. Post-Operative Care -Pediatrics: -Post-op period cover with antibiotics, topical steroids (aqueous), saline irrigation (frequent), topical decongestants -2 week post-op scheduled return to OR for cleaning and removal of any splints. -Many inject depo steroid into turbinates at conclusion of procedure -Synechia formation most common problem. Decreased by stenting middle meatus with non- absorbable material. -Adult: -Goal: prevent adhesions and assist in return of normal mucociliary clearance -Begin on 1st or 2nd post-op days with endoscopic removal of blood and fibrin clots -Medication as with children; If steroids required pre-op continue at dose with taper after majority of healing complete -Second cleaning 3-4 days later, with 3rd one week later. -Then monthly until completely healed -All adhesions should be lysed and polyps removed as identified. F. Complications: Operative -Prevention: -CT scan in OR -adequate time for vasoconstriction -marking distance on scope -frequent palpation of eye -Hemorrhage -mucosal bleeding can be heavy, especially when inflamed -control with vasoconstriction soaked packing -most common heavy bleeding from anterior ethmoid and sphenopalatine arteries. -control anterior ethmoid bleed with avitene/surgicel; and sphenopalatine with cautery or packing. -blood loss with general anesthesia averages 100cc more than with local. -CSF Leak -Usually at point above sphenoid ostium, fovea ethmoidalis or cribriform plate -should cover with fascia or rotate mucosal flap (from middle turbinate) and support with light packing for 6-7 days. -treat post-op leak conservatively -All require hospitalization with bed rest, head elevation and antibiotics. -get neurosurgical consultation -may need lumbar drain -almost all resolve -Carotid Artery Injury -rare -avoid by carefully noting position on CT -if occurs pack sinus immediately and get neurosurgical consultation -Orbital Entry -Exposed orbital fat not problem, if recognized early. -Sometimes see periorbital ecchymosis post-op. -Patient should never blow nose post-op. -Blindness: temporary or permanent direct injury to optic nerve prolonged elevated intraocular pressure -retrobulbar hemorrhage from orbital bleeding can produce increased pressure. -if suspected begin treatment immediately: -lateral canthotomy or external ethmoidectomy for decompression -mannitol 1gm/kg IV -orbital massage -any patient developing lid edema, proptosis or change in vision post-op should be admitted and immediate ophthalmologic consultation obtained. -Nasolacrimal Duct Injury -do not back-bite into hard bone during ostial enlargement -can develop temporary epiphora from edema at duct or in inferior meatus -direct injury may require dacrocystostomy -------------------------------------------------------------------------------- BIBLIOGRAPHY Berg, O., et al. Origin of the Choanal Polyp, Arch Oto Head Neck Surg, Nov 1988, 114, pp.1270-1271. Friedman, W.H.,et al. The Role of Standard Technique in Modern Sinus Surgery, Oto Clinics of N Am, Aug 1989, 22:4, pp.759- 776. Gross, C.W., et al. Functional Endonasal Sinus Surgery in the Pediatric Age Group, Laryngoscope, Mar 1989, 99, pp.272-275. Gross, C.W.,et al. Functional Endonasal Sinus Surgery in Children: Practical Considerations and Technical Aspects, Op Tech Oto-Head Neck Surg, June 1990, 1(2), pp.108-111. Gross, C.W.,et al. Pediatric Functional Endonasal Sinus Surgery, Oto Clinics of N Am, Aug 1989, 22:4, pp.733-738. Josephson, J.S., et al. The Importance of Postoperative Care in the Adult and Pediatric Patient Treated with Functional Endoscopic Sinus Surgery, Op Tech Oto-Head Neck Surg, June 1990, 1(2),pp.112-116. Josephson, J.S., The Role of Endoscopic Sinus Surgery for the Treatment of Nasal Polyposis, Oto Clinics of N Am, Aug 1989, 22:4, pp.831-840. Kamel, R., Endoscopic Transantral Surgery in Antrochoanal Polyp, Arch Oto Head Neck Surg, July 1990, 116, pp.841-843. Kennedy, D.W., et al. Functional Endoscopic Sinus Surgery: Theory and Diagnostic Evaluation, Arch Oto Head Neck Surg, 1985, 111, pp.576-582. Kimmelman, C.P., et al. The Efficacy and Safety of Transantral Ethmoidectomy, Laryngoscope, Nov 1988, 98, pp.1178-1182. Perkins, J.A., et al. Nasal Polyps: A Manifestation of Allergy?, Oto-Head and Neck Surg, Dec 1989, 101(6), pp. 641-644. Sogg, A., Longterm Results of Ethmoid Surgery, Ann Oto Rhino Laryng, 1989, 98, pp.699-701. Tos, M., et al. Goblet Cell Density in Nasal Polyps, Ann Oto Rhino Laryng, 1990, 99, pp.310-315. Weymuller, E.A., Complications of Endoscopic Sinus Surgery, Op Tech Oto-Head Neck Surg, June 1990, 1(2), pp. 149-151. -----------------------------------END------------------------------------------