Contents
Introduction . . . . 87 Nasal Polyps in the Primary Scenario . . . . 87 Nasal Polyposis in the Frontal Sinus –
Secondary or Revision Surgery . . . . 91 Postoperative Care After Frontal Sinus Polyp Surgery . 92 Conclusion . . . . 93 References . . . . 93
Introduction
Nasal polyposis is a genetic disorder where upon re- active nasal/sinus mucosa fueled by chronic inflam- mation/infection from immunologic stimulation cause marked mucosal edema with development of nasal polyps. Several studies have discussed the etiol- ogy and pathogenesis of nasal polyps [10–12]. This chapter discusses how to clinically approach nasal polyps affecting the frontal recess and sinus from the viewpoint of observation versus that of medical ther- apy versus that of surgery in primary and revision case scenarios.
Nasal Polyps in the Primary Scenario
Nasal polyps, in most cases, even in obstructive poly- posis, do not cause major symptoms ascribed to the frontal sinus. It is rare for these patients to complain of headache, pressure, or pain.
The Frontal Sinus and Nasal Polyps
James A. Stankiewicz, James M. Chow
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Core Messages
쐽 (Overview)All patients with significant nasal polyposis generally have frontal sinus disease
쐽 Most patients prior to medical therapy or sinus surgery have minimal or no symp- toms related to the frontal sinus
쐽 In most cases, surgical opening of the fron- tal ostia/sinuses is not necessary
쐽 Only patients with symptoms or signs referable to the frontal sinus refractory to medical therapy require frontal sinus sur- gery
– Patients with pain, headaches, pressure – Patients with purulent drainage from the
frontal sinus
쐽 Postoperatively, polyps will most likely return in the upper ethmoid/frontal recess and are not problematic in most cases 쐽 Medical therapy can control symptomatic
recurrent frontal recess/sinus polyps in most cases
쐽 The choice of surgical procedure to control frontal sinusitis/polyps is dependent upon extent and location of disease and anatomy
Most patients with nasal polyps complain of:
쐽 Nasal obstruction
쐽 Drainage
쐽 Loss of smell related to nasal obstruction and/or infection
Rarely, polyposis can be so severe as to cause bone thinning and dehiscence in the frontal recess or fron- tal sinuses. More commonly, the CT scans show opac- ification or mucosal thickening of the frontal sinuses in these patients. No author has done a study to show what comprises frontal sinus opacification – polyps, fluid, or mucosal thickening.
쐽 It is fair to say that diffuse polyposis, which exists in the lower sinuses, especially the eth- moid, does not occur to the same extent in the frontal.
The recent study by Larsen and Tos showed that most polyps originated from mucosa of the ostia, clefts or recesses which do not exist inside the frontal sinuses [10]. Of 69 autopsies reviewed, polyps existed in 32%
but were symptomatically “silent”. This would sug- gest that when considering surgical intervention in patients with medically refractory polyposis, conser- vatism in dealing with the frontal sinus should be the rule. In this chapter, we outline a protocol or care plan on how to deal with the frontal sinus in an oper- able nasal polyposis patient.
In patients in whom the symptoms are not related to the frontal sinus, the frontal sinus should be gener- ally left untouched at the initial surgery. Del Gaudio reported that of 207 patients with frontal recess or frontal disease, only 32% of polyp patients had head- aches [5]. Of patients with frontal sinus opacification, only 26% had pain or headache. Endoscopic removal of frontal recess polyps and agger nasi cells is all that is generally necessary. It is important in patients with asymptomatic frontal sinus disease that polyp dis- ease in the frontal recess be removed without ostio- plasty, taking care not to injure mucosa posteriorly, laterally, or medially. Irrigation of the frontal sinus can be performed to remove mucus or debris. An- other study by Del Gaudio et al. nicely showed how
nasal polyposis can expand sinus walls [4]. It is not uncommon to see frontal recess/ostia expansion due to polyposis, which allows the frontal sinus better drainage and less chance of postoperative stenosis. If on CT scan the frontal ostium is dilated or widened, a curved microdebrider can remove polyps obstruct- ing the recess/ostium up into the sinus without dan- ger of stenosis. A narrow ostium on CT scan should not be instrumented except for irrigation. Also given the reason that the frontal/upper ethmoid area is the first area to develop recurrent polyps, rarely is ag- gressive frontal ostioplasty or Lothrop (modified) primarily necessary. Three papers, two by Jacobs and the other by Kennedy (both Triologic theses) indicate that patients who had their polyps removed were markedly improved subjectively, but had visible na- sal polyps in the frontal recess postoperatively [6–8]
(Fig. 11.1). Guidelines for performance of frontal si- nus surgery are listed in Table 11.1. While some sur- geons recommend routine preservation of the mid- dle turbinates, best success is achieved with middle turbinate reduction or removal, allowing the frontal sinus better drainage. (Table 11.2) In most cases, pa- tients will do well.
In patients with symptoms related to the frontal sinus, the frontal sinus will often also do well once surgery has been determined to be necessary, with removal of disease from the lower sinuses and judi- cious irrigations. Medical therapy should obviously be initiated prior to surgical therapy in most patients (Fig. 11.2). First-line therapy in these patients who of- ten complain of headache or severe pressure is anti- inflammatory medication. If polyps aren’t medically reduced to allow for drainage, then patients will not
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Table 11.1. Guidelines for frontal endoscopic sinus surgery (ESS) in the polyposis patient
1. Patient with acute or chronic complicated frontal sinusitis invading into orbit or skull base
2. Patients with chronic pain, marked pressure, or frontal headache with or without purulence refractory to med- ical therapy
3. Failed endoscopic sinus surgery in symptomatic chronic frontal sinusitis/polyposis
4. Mucocele and polyposis
improve. Antibiotics alone are not sufficient. Oral and topical corticosteroids are the best medications to reduce the size of polyps. Usually a short 7–10-day burst is sufficient to improve symptoms, although prolonged steroids for up to 1 month may be neces- sary [9]. In patients who have fungal polyposis, corti- costeroids may be necessary for 1 month or more.
This treatment along with antifungals or antibiotics as necessary will control most symptomatic patients.
Aggressive medical therapy can frequently reverse symptomatic frontal disease due to polyposis.
Indications for surgical intervention include:
쐽 Persistence of frontal symptoms
쐽 Abnormal physical examination with puru- lence from the frontal sinus despite aggressive medial therapy
Often, endoscopic total ethmoidectomy and opening the frontal recess or ostia will allow for drainage of the frontal sinuses. Where polypoid and fungal de-
Fig. 11.1. APostoperative persistent/recurrent nasal polyps in the frontal recess in an asymptomatic patient.B Modified Lothrop with polypoid changes in an asymptomatic patient
bris are anticipated in the frontal sinuses, endoscopic irrigation will often remove fungal debris unblock- ing the frontal ostia. Since, as earlier mentioned, polyposis will often expand the frontal ostia, endo- scopic irrigation and judicious removal via a micro- debrider of obstructive polyps is possible. It is im- portant to remember that frontal ostioplasty, in pa- tients without frontal sinus expansion, is difficult to perform due to osteitic changes. Great care must be taken to avoid causing frontal ostial stenosis. Conser- vative treatment around frontal recess/ostia works best in these patients. Only those patients with symp-
tomatic refractory or complicated polypoid disease require consideration for a modified Lothrop or an osteoplastic flap. Since in these patients the floor of the frontal sinus is often attenuated by disease caus- ing expansion, a modified Lothrop is a good proce- dure to consider. Certainly, extensive polypoid tissue with or without fungus, mucocele, or infection un- able to be cleared with a modified Lothrop should be considered for an osteoplastic flap and, in some cas- es, a craniofacial procedure (Fig. 11.3). It is rare that acute complicated sinusitis will occur in a patient with nasal polyposis in the frontal sinus. The goal of surgery in these patients is to drain all involved si- nuses. Trephination, endoscopic frontal ostioplasty, modified Lothrop, or osteoplastic flap should be con- sidered.
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Table 11.2.Guidelines for extent of sinus surgery with nasal polyposis
1. Total ethmoidectomy 2. Wide maxillary antrostomy 3. Wide/large sphenoidotomy
4. If patient not asthmatic and without fungal disease – Consider saving middle turbinates.
5. Asthmatic patients with fungus, ASA Triad – – Remove middle turbinates
6. Primarily and revision surgery – asymptomatic frontal sinus
– Conservative removal polyp frontal recess/ostium 7. Symptomatic frontal sinus patients – primary & revision
A. Start out with ostioplasty if frontal recess/ostia dilat- ed or widened by disease
B. If ostia narrow remove lower polyps and irrigate sinuses
C. Modified Lothrop or create wide ostium if frontal markedly stenotic or closed
D. External sinus surgery – Osteoplastic flap
Fig. 11.2.Patient with nasal polyps and purulent frontal recess with headache/pressure
Nasal Polyposis in the Frontal Sinus – Secondary or Revision Surgery
After endoscopic sinus surgery for nasal polyposis and chronic rhinosinusitis, very few patients are cured despite a significant improvement in their symptoms. Indeed, in most patients, endoscopic si-
nus surgery is a beginning treatment and not the end. Most patients with polyps, especially asthmatics with or without aspirin sensitivity, will require long- term medical care to control polyposis.
In our own experience, the need for revision surgery is as follows:
쐽 Patients with nasal polyps without asthma – 30%
쐽 Patients with polyps and asthma – 50%
쐽 Samter’s triad (aspirin triad) – about 70%–80%
Therefore, medical therapy is important for control of disease. All patients are maintained on a topical steroid spray. Oral and topical steroids are used as necessary along with antibiotics or antifungals. Each patient is individualized to a therapeutic regimen to best control their polyps. Given as noted that polypo- sis is a genetic disorder almost all patients will, to a certain degree, regrow polyps. Indeed, as mentioned, the frontal ethmoid area is the first area for polyps to reappear after sinus surgery. In most cases, polyps block the frontal sinus postoperatively, but patients remain asymptomatic.
Patients who become symptomatic may require revision surgery.
Fig. 11.3. AMarkedly expanded frontal polyposis into the skull base (MRI, sagittal and coronal view) BMarkedly expanded ethmoid polyposis with proptosis (CT scan, coronal)
Symptom recurrence in these patients is most fre- quently due to:
쐽 Frontal sinus blockage by polyps and infection or
쐽 Frontal sinus ostial stenosis after frontal ostio- plasty
Prior to surgical intervention, a trial of topical ster- oid drops (not sprays) along with oral prednisone or injection of triamcinolone (40 mg/ml) into the polyps may reduce polyp size and symptoms [3].
Topical steroid drops, which can be ophthalmic or nasal drops, placed in ether a head-back (Mygind) or head-down (Moffitt) position can be effective.
Oral prednisone can be continued for up to 1 month or used in 3–4 months bursts to control dis- ease [2, 3, 9]. Patients with fungal disease and polypo- sis may benefit from antifungal irrigations, nebuliza- tion, or steroid nebulization.
Patients with persistent symptomatic frontal sinus polyposis refractory to medical therapy require revi- sion surgery. If endoscopic sinus surgery is chosen, then the frontal ostia should be opened as widely as possible but not circumferentially. Debris is cau- tiously irrigated, removing all secretions and fungi. A curved microdebrider can actually remove or debulk frontal sinus polypoid disease. A modified Lothrop provides not only a wider entrance into the frontal si- nus but also removal of the upper septum, causing less chance of polypoid growth below the frontal si- nus. Since chronic frontal sinus polyposis can often cause thinning of the sinus floor, a modified Lothrop is made less difficult in these cases. Severe expanded sinus polypoid disease with or without a mucocele can undergo treatment with an osteoplastic flap if it is not manageable using endoscopic techniques. The frontal sinus can either be obliterated or the floor opened from above (Lothrop) into the nose. Stenting should be considered for the endoscopic modified Lothrop if the anterior-posterior width is narrow and there is marked osteitic bone thickness present.
Stents should be left for at least 3 months. In a trou-
blesome revision case, stents should be left in place for perhaps a year or more.
Postoperative Care After Frontal Sinus Polyp Surgery
Surgery for nasal polyposis in general requires an in- dividualized regimen of short- and long-term care.
Anti-inflammatory medications, primarily steroids, are the drugs of choice. Together with oral steroid bursts or taper, topical steroids used as a drop can help control recurrent frontal recess/ostial polyps [2]. Injection of steroids into the polyps can also con- trol recurrent frontal recess/ostial polyps. Leuko- triene inhibitors should also be considered. Antifun- gal irrigation, nebulizations, or oral medications are costly and help temporarily in fungal-sensitive indi- viduals. Their use should be individualized. Not stay- ing on a regimen of selected medications will result in recurrence of the disease. In the most sensitive ASA Triad patients, aspirin desensitization should be considered (Fig. 11.4) [1].
Table 11.3 lists short- and long-term care consider- ations in frontal/frontal recess polyposis.
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Fig. 11.4.ASA Triad (Samter’s) patient controlled on topical steroids after aspirin desensitization
Conclusion
Frontal sinus anatomy relative to the lower and an- terior paranasal sinuses will often shield the frontal sinuses from symptomatic disease, especially with nasal polyposis. Conservative treatment with anti- inflammatory medications controls disease in most cases. Symptomatic frontal recess/sinus polyposis refractory to medical therapy requires wide osteo- plasty, modified Lothrop, or external open proce- dures to best control disease and relieve symptoms.
References
1. Berges-Gimeno MP, Simon RA, Stevenson DD (2003) Long term treatment with aspirin desensitization in asthmatic patients. J Allergy Clin Immunol 111 : 180–186
2. Bonfils P, Nores JM, Halimi P et al (2003) Corticosteroid treatment of nasal polyposis with a three year follow-up.
Laryngoscope 113 : 683–688
3. Citardi MJ, Kuhn FA (1998) Endoscopically guided frontal sinus beclomethasone instillation for refractory frontal sinus/recess edema and polyposis. Am J Rhinol 12(3) : 179–182
4. Del Gaudio JM (2003) Race and gender differences in fre- quency of skull base erosion in allergic fungal sinusitis.
Am J Rhinology, publication pending. Presented at Fall 2003 ARS meeting. Orlando, Florida
5. Del Gaudio JM, Wise SK (2004) Consideration of degree of frontal sinus disease to the presence of frontal headache.
Am J Rhinology, publication pending – Department of Otolaryngology-Head and Neck Surgery, Presented Spring ARS/COSM 2004 meeting, Phoenix, Arizona
6. Jacobs J (1997) One hundred years of frontal sinus surgery.
Laryngoscope 100 : Supp. 83 : 1–36
7. Jacobs J (1998) Conservative approach to inflammatory nasofrontal duct disease. Ann Otol 107 : 658–661
8. Kennedy DW (1992) Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope 102 (Suppl) 1–18
9. Kuhn FA, Javer AR (2002) Allergic fungal sinusitis: A four year follow-up. Am. J. Rhinology 14 : 149–156
10. Larsen PL, Tos, M (2004) Origin of nasal polyps: An endo- scopic autopsy study. Laryngoscope 114 : 710–719 11. Norlander T Fukami, M Westin KM (1993) Formation of
mucosal polyps in the nasal and maxillary/sinus cavities by infection. Otolaryngol-Head and Neck Surgery 109 : 522–529
12. Settipane GA (1987) Nasal polyps: Pathology, immunolo- gy, and treatment. Am J Rhinol 1 : 119–126
Table 11.3.Short- and long-term postoperative treatment for best control of nasal polyposis
Short-term
1. Oral prednisone burst, which can be repeated every 4 months.
2. Topical nasal steroid drops e.g., Dexamethasone – One month postoperative
3. Antibiotics which are culture directed for persistent bilateral infection
4. Saline irrigations 5. Leukotriene inhibitor
6. Antifungal (oral, topical, or irrigation) medications as needed
7. Triamcinolone injection Long-term
1. Oral prednisone every 3–4 months 2. Topical steroid drops or nebulization 3. Leukotriene (if helpful)
4. Prednisone 5 mg qd or qod for more difficult cases, increasing to 10 mg qd with URI
5. Antifungal irrigations, nebulizations, or oral medica- tions (as needed)
6. Select long-term regime individually 7. Triamcinolone injection
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