Candidates for Nasal Polypectomy
Multiple polyps can occur in children with chronic sinusitis, allergic rhinitis, cystic fibrosis (CF), or allergic fungal sinusitis (AFS). An individual polyp could be an antral-choanal polyp, a benign massive polyp, or any of a number of benign or malignant tumors (eg, encephaloceles, gliomas, hemangiomas, papillomas, juvenile nasopharyngeal angiofibromas, rhabdomyosarcoma, lymphoma, neuroblastoma, sarcoma, chordoma, nasopharyngeal carcinoma, inverting papilloma). Evaluate all children with benign multiple nasal polyposis for CF and asthma.
Pathophysiology: The pathogenesis of nasal polyposis is unknown. Polyp development has been linked to chronic inflammation, autonomic nervous system dysfunction, and genetic predisposition. Most theories consider polyps to be the ultimate manifestation of chronic inflammation; therefore, conditions leading to chronic inflammation in the nasal cavity can lead to nasal polyps.
- First notify a pediatric otolaryngologist, especially if medical therapy has failed or if the origin or diagnosis of the underlying pathology of the nasal polyp is unknown.
- Consider consultation with a pulmonary specialist when benign nasal polyps are identified because they could result from asthma, allergy, or CF. Patients with these diseases often have associated pulmonary problems.
The Nasal Polypectomy Procedure
- Nowadays, when polyps are isolated or limited in number, the polypectomy may take place in a specialist’s office. Or your doctor may combine this procedure with another sinus surgery. Polypectomies are usually performed using a small mechanical suction device or a microdebrider. After removal, polyp tissue is usually biopsied, or tested, to rule out malignancy.
- Oral and topical nasal steroid administration is the primary medical therapy for nasal polyposis. Antihistamines, decongestants, and cromolyn sodium provide little benefit. Immunotherapy may be useful to treat allergic rhinitis but, when used alone, does not usually resolve existing polyps. Administer antibiotics for bacterial superinfections.
- Corticosteroids are the treatment of choice, either topically or systemically. Direct injection into the polyp is not approved by the Food and Drug Administration because of reports of unilateral vision loss in 3 patients after intranasal steroid injection with Kenalog. Safety may depend on specific drug particle size; large molecular weight drugs such as Aristocort are safer and less likely to be transferred to the intracranial area. Avoid direct injection into blood vessels.
- Oral steroids are the most effective medical treatment for nasal polyposis. In adults, most authors use prednisone (30-60 mg) for 4-7 days and taper the medicine for 1-3 weeks. Dosage varies for children, but the maximum dose usually is 1 mg/kg/d for 5-7 days, then taper over 1-3 weeks. Responsiveness to corticosteroids appears to depend on the presence or absence of eosinophilia, so patients with polyps and allergic rhinitis or asthma should respond to this treatment.
- Patients with polyposis not dominated by eosinophilia (eg, patients with CF, primary ciliary dyskinesia syndrome, or Young syndrome) may not respond to steroids. Long-term use of oral steroids is not recommended because of the numerous potential adverse effects (eg, growth retardation, diabetes mellitus, hypertension, psychotropic effects, adverse GI effects, cataracts, glaucoma, osteoporosis, and aseptic necrosis of the femoral head).
- Many authors advocate topical nasal steroid administration for nasal polyps, either as the primary treatment or as a continual secondary treatment immediately following PO steroids or surgery. Most nasal steroids (eg, fluticasone, beclomethasone, budesonide) effectively relieve subjective symptoms and increase the nasal airflow when measured objectively (primarily in double-blind placebo-controlled studies). Some studies indicate fluticasone has a faster onset of action and possible mild superiority to beclomethasone.
- Topical corticosteroid administration generally causes fewer adverse effects than systemic corticosteroid use because of the former’s limited bioavailability. Long-term use, especially at high dosages or in combination with inhaled corticosteroids, presents a risk of hypothalamic-pituitary-adrenal axis suppression, cataract formation, growth retardation, nasal bleeding, and, in rare cases, nasal septal perforation.
- As with any long-term therapy, monitor use of topical corticosteroid sprays. However, long-term (>5 y) studies evaluating the use of beclomethasone have shown no degradation of the normal respiratory epithelium to squamous epithelium seen in chronic atrophic rhinitis. Additionally, the newer generation of systemic steroids (eg, fluticasone, Nasonex) appears to have less bioavailability than older nasal steroids, such as beclomethasone.
- Surgical intervention is required for children with multiple benign nasal polyposis or chronic rhinosinusitis who fail maximum medical therapy. Simple polypectomy is effective initially to relieve nasal symptoms, especially for isolated polyps or small numbers of polyps. In benign multiple nasal polyposis, polypectomy is fraught with a high recurrence rate.
- Endoscopic sinus surgery (ESS) is a better technique that not only removes the polyps but also opens the clefts in the middle meatus, where they most often form, which helps decrease the recurrence rate. The exact extent of the surgery needed, whether complete extirpation (ie, Nasalide procedure) or simple aeration of the sinuses, is not entirely known, simply because of the dearth of studies. Rare comparisons show that complete extirpation procedures are as effective or superior to aeration of the sinuses; complication rates are low with experienced surgeons. Use of a surgical microdebrider has made the procedure safer and faster, providing precise tissue cutting and decreased hemostasis with better visualization.
- Direct surgery at diseased tissue that is apparent on the CT scan at the time of surgery. Patients with diseases such as CF, primary ciliary dyskinesia syndrome, or Young syndrome may proceed to surgery without extensive medical treatment because these diseases usually do not respond well to corticosteroid treatment. Once diseased tissue has been removed from the nasal cavity and sinuses, the pulmonary systems usually improve. Consider use of an image-guided system to define the exact location of intranasal, sinus, orbital, and intracranial structures for massive polyposis or revision surgery because surgical landmarks may be absent or altered. For specific techniques in pediatric sinus surgery, with and without polyps.
- Nasal polyposis occurs in 6-48% of children with CF. Surgery is performed when children become symptomatic. Recurrence of polyps in CF is almost universal, requiring repeated surgeries every few years. In fact, recurrence is typical for many diseases that cause nasal polyps; patients should receive preoperative counseling about this possibility.
- For lesions other than benign nasal polyps that result in a nasal polyp, the polyp should be biopsied or removed, depending on the disease process.
No activity restrictions are necessary for a child with nasal polyps. The child’s activity level may decrease because of diminished ability to breath through the nose, decreasing sport or physical activity performance. After sinus surgery, activities are limited; these limitation recommendations vary from surgeon to surgeon. Most surgeons specifically restrict nose blowing because it may increase intranasal pressure and cause potential problems in areas of already thinned bony dividers in patients with nasal polyposis.
Following a polypectomy, your doctor will treat any underlying inflammation to minimize the risk that polyps will recur. Specific follow-up treatments depend on the extent of the surgery, but usually include steroid nose sprays and occasionally involve antibiotics and oral steroids. Long-term follow-up is recommended. At these check-ups, your doctor may use endoscopic instruments to monitor polyp recurrence in the nose and sinuses.