A review of nasal polyposis and surgical management

ENT 14 (1), 2008 71 Bangladesh J of Otorhinolaryngology 2008; 14(2) : 71-74 A review of nasal polyposis and surgical management Md. Monjurul Alam1, Md. Abu Yusuf Fakir2, M. Alamgir Chowdhury3 Abstract Nasal polyps are common, affecting up to four percent of the population. Their etiology remains unclear, but they are known to have associations with allergy, asthma, infection ,cystic fibrosis, and aspirin sensitivity. Computerized tomography allows evaluation of the extent of the disease and is essential when surgical treatment is to be considered. There is good evidence for the use of corticosteroids (systemic and topical) both as primary treatment and as postoperative prophylaxis against recurrence. Surgical treatment has been refined significantly over the past twenty years with the advent of endoscopic sinus surgery. Symptomatic improvement is more in Endoscopic sinus surgery (ESS) compared to conventional procedures (including polypectomy, Caldwel-luc and intranasal ethmoidectomy). Overall complications following ESS are relatively very few polyp reccurrence are also less (8%) for ESS compared with14% for coventional surgery. Keywords: Nasal polyposis, surgical procedures, FESS Introduction Nasal polyposis are benign lesions, round, soft, semitranslucent, pale or yellow glistening structures that originate from any part of the nasal mucosa or paranasal sinuses (although most commonly from the ethmoid or middle meatus regions)1. Objectives To provide a systematic review of the clinical effectiveness of endoscopic sinus surgery (ESS) for the removal of nalsal polyps. Methods A systematic review of the literature was undertaken. Searches of electronic databases, websites and reference lists were made to identify relevant studies. Comparative studies were included if they were primary research, focused on FESS for the removal of nasal polyps, reported patient relevant outcomes and were published in English. In addition, case series studies were included if they met the above criteria and enrolled more than 50 patient with polyps. Nasal Polyposis have uncertain eitiology and may be linked to chronic inflammation, allergy, autonomic nervous system dysfunction and genetic predisposition.2 Functional endoscopic sinus surgery (FESS) is a minimally invasive technique that uses an endoscope to improve ventilation and drainage in addition to polyp removal1,3. The extent of surgery varies according to the extent of disease and surgeon’s individual practice. This technique has been used for more than a decade in treating sino-nasal conditions. Advantages are claimed over conventional surgery: permitting a better view of the surgical field, a more precise and thorough clearance of the inflammatory change, fewer complications and lower recurrence rate14. Twenty-three studies were included in the review article. Etiology, prevalence, clinical features, investigations and treatment of Nasal Polyps are discussed in reference to different authers. Mostly surgical management were discussed in details and medical management also discussed in brief. 1. Associate Professor, Dept. of Otolaryngology-Head and neck Surgery, BSMMU, Dhaka 2. Registrar, Dept. of Otolaryngology and Head-Neck Surgery, Dhaka Medical College Hospital, Dhaka 3. Professor, Otolaryngology-Head and Neck Surgery, Medical College for Women & Hospital Uttara Sector1, Dhaka-1230, Bangladesh. Address of correspondence : Dr. Md. Monjurul Alam, Associate professor, Otolaryngology, Head & Neck Surgery, BSMMU, Dhaka. Etiology of nasal polyposis The etiology of NP is unknown. Some theories consider polyps a consequence of conditions which cause chronic inflammation in the nose and nasal sinuses characterized by stromal edema and variable cellular infiltrate.5 Studies provide little evidence to support the relationship of allergy with NP found in only 1%-2% of patients with positive skin prick tests.6 . ENT 14 (1), 2008 72 Bangladesh J of Otorhinolaryngology In addition, studies have shown that NP are no more common in atopic individuals.7 An association between polyposis and fungal cultures has been established for many years.8 There is some evidence for a genetic element to NP. A link has been demonstrated recently between HLAA74 and NP9 (Luxemburger et al 2000), but the current knowledge in this area remains very limited. Medical conditions commonly associated with polyps include asthma, bronchiectasis, and cystic fibrosis.10 Prevalence In the general population, the prevalence of NP is considered to be around 4%.11 They predominantly affect adults and usually present in patients older than 20. They are uncommon in children under 10 and may be the presenting feature of cystic fibrosis. There is a 2:1 male to female preponderance11. Up to a third of NP patients have asthma, whereas polyps are only found in 7% of asthmatics10. Clinical features The main presenting symptom of NP is nasal obstruction which is constant but can vary depending on the site and size of the polyps. Sufferers will also frequently complain of watery rhinorrhea and postnasal drip. Anosmia or hyposmia with an ensuing alteration in taste are also characteristic symptoms of NP.11 NP are almost invariably bilateral and when unilateral require histological examination to exclude malignancy or other pathology such as inverted papiloma11. Investigations Plain X-rays are insensitive and of no value in the diagnosis of NP but they may show opacification of the affected. Sinuses12. A CT scan will show the extent of NP and anatomical variations and is essential if surgical treatment is to be implemented13.In unilateral cases of NP, an magnetic resonance imaging scan may aid diagnosis, particularly for investigations of more serious conditions such as neoplasia14. Treatment of NP Therapy for NP involves a combination of observation,medical, and surgical treatments depending on individual case assessment. 72 Vol. 14, No. 2, October 2008 Medical treatment The advent of topically administered corticosteroids has improved the treatment of upper (NP and rhinitis) and lower (asthma, chronic obstructive airways disease) airway disease15. Both topical and systemic glucocorticoids may affect the eosinophil function by both directly reducing eosinophil viability and function or indirectly reducing the secretion of chemotactic cytokines by nasal mucosa and polyp epithelial cells16. Systemic steroids are reserved for advanced or refractory cases particularly when allergy is present. Leukotriene receptor antagonists have recently been shown to be effective17, but larger scale trials are required to prove their efficacy. Allergic fungal rhinosinusitis is treated by both topical and systemic antimycotics as an adjunct to sinus surgery. Surgery is considered the first-line therapy particularly for invasive fungal rhinosinusitis18. Surgical treatment No single surgical technique has proved to be entirely curative and patients often undergo repeated procedures despite rece (...truncated)