Revision Sinus Surgery

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nebulized antibiotic therapy, and allergic fungal sinusitis (AFS).

The various methods and packing used to prevent lateralization of the middle turbinate are beyond the scope of this chapter and will be covered in detail elsewhere in this volume.

Postoperative Debridement

The role of postoperative debridement and the exact timing and frequency of debridement are not standardized. The management philosophies are based mainly on empiric data with a dearth of prospective, double-blinded, randomized, controlled studies addressing this topic. Most sinus surgeons feel that aggressive debridement of the postsurgical sinus cavity is critical for success. The rationale underlying debridement is that if debris composed of crusts, blood clots, bone chips, and fibrin are allowed to accumulate, there will be a tendency for increased adhesions and synechiae formation with resultant scar and recurrent rhinosinusitis. Ancillary arguments for debridement include more rapid relief of nasal congestion and fewer postoperative infections [3]. A minority of surgeons consider debridement unnecessary, opting instead to prevent postoperative adhesions by placing packing in the middle meatus.

■ A major disadvantage to regular and routine aggressive debridements is the increased bleeding and pain 16 associated with both injection of local anesthetic and the instrumentation of the sensitive postoperative na-

sal cavity.

Debridement also can be time-consuming in the edematous and inflamed surgical cavity and can potentially cause additional mucosal damage that delays wound healing.

The literature on this topic has been somewhat conflicted and controversial. A study by Nissen et al. [23] looked at 17 patients and compared symptom scores, healing, and adhesion rates between debrided and nondebrided sides in the same patient over a 3-month period of time. Although there was no statistical significance shown, the numbers of patients enrolled and the short follow-up period are more consistent with a pilot study and only limited conclusions can be drawn. Ryan et al. [30] analyzed 120 patients in a retrospective review. His group found that despite minimal postoperative follow up with an average of only 2.8 visits and 1 debridement, 78% of patients reported either significant improvement in symptoms or outright cure at 18 months follow up. Postoperative antibiotic therapy and topical nasal corticosteroids were both used routinely and the authors sug-

Dennis F. Chang, David B. Conley, and Robert C. Kern

gest that these are more critical in the absence of regular postoperative debridements. Probably the best study to date on the topic, however, included 60 patients in a randomized, partially blinded, controlled, prospective trial [3]. Debrided patients had significantly less crusting in the sinus cavities as well as significantly less postoperative adhesion formation compared to those who had saline irrigation alone. The procedure did induce more postoperative pain but there was no difference in bleeding. The study concluded that increased adhesions from increased crusts and debris may increase the need for revision sinus surgery, and that debridements should be undertaken to prevent this as much as possible.

■The current weight of evidence supports debridement to remove crusts, bone chips, and fibrin as a method to prevent adhesions and synechiae in adult patients following FESS.

An interesting perspective can be gained by looking at the pediatric FESS population and the role that debridement plays in postoperative management. Pediatric patients have a limited tolerance for office endoscopy and debridement, traditionally mandating a return to the operating room under general anesthesia for second-look and cleansing of the sinus cavities 2–4 weeks after the primary operation. Over time, this management has been challenged with several groups contending in prospective studies that postoperative improvement in nasal obstruction, drainage, and chronic cough was identical in pediatric patients with and without any postoperative debridement [21, 22]. Pediatric patients undergoing revision surgery and those suffering from cystic fibrosis were excluded from these trials. Since the extent of sinus surgery, and possibly the disease itself, may be different from the adult population, any conclusions based on data from the pediatric FESS literature cannot be readily extrapolated.

The timing and frequency of debridements is also a matter of contention. Kuhnel et al. [19] noted that avulsion of epithelium occurred in 23% of patients when debrided in the 1st week and advised the first postoperative manipulation be delayed until the 2nd week after surgery. Bugten et al. performed debridements at 6 and 12 days and found that crusts and adhesions were significantly reduced [3]. A third debridement was reserved for patients with infections or recalcitrant crusting. Some surgeons advocate aggressive debridements daily in the 1st week of surgery or weekly over 6–8 weeks until healing is complete, although patient comfort is significantly impacted and these regimens have fallen somewhat out of favor.

■A recent position statement by the American Rhinologic Society maintains that four postoperative

Postoperative Medical Management

debridements in a 6-week period for routine FESS patients is reasonable and six debridements in the complex patient is fair.

■However, treatment ultimately must be tailored to each individual patient and disease case.

Nasal Saline Irrigation and Lavage

The effectiveness of daily saline irrigation of the sinuses and nares in the treatment of chronic rhinosinusitis as well as allergic and nonallergic rhinitis is well established. Postoperatively, nasal saline remains a crucial component in maintaining clean, moist, well-aerated sinus cavities. Crusting is significantly reduced and nasal obstruction and edema are improved. The exact manner, technique, and volume of delivery will vary from institution to institution at the preference of both the surgeon and the patient, but there appears to be a consensus that saline lavage is both recommended and necessary in the postFESS patient.

Nasal saline irrigation protocol:

1.During postoperative days 1–7, patients are discouraged from irrigating the nose vigorously as the surgical site is still fresh and sore. They are encouraged to begin gently instilling commercially prepared normal saline spray in their nares twice daily.

2.After the first postoperative visit and debridement, they are given an instruction sheet that teaches them how to mix their own saline solution.

3.They are taught to adjust both the amount of salt and the temperature of the solution to optimize comfort.

4.Noniodized salt should be used as iodine may irritate the nose.

5.Patients are informed of the various devices for irrigation including bottles designed for irrigation or a simi- lar-sized bulb syringe.

6.They are taught to lean over, breathe through their mouth, and passively irrigate one naris and then another without snorting in the saline solution.

7.Saline lavage should be done at least twice a day and separately from any other concurrent nasal steroid spray.

8.This regimen is continued for at least 3–6 months while the sinus cavities complete healing.

The postoperative course, the presence of polyps, the incidence of perioperative infections, and other factors will then determine whether antibiotics and steroids are added to the saline solution. The only randomized singleblinded trial to look at saline lavage in the postoperative patient compared mechanical lavage with pressurized saline to chemical lavage with saline impregnated with an

137

antiseptic and a mucolytic [24]. Ultimately there was no difference in efficacy between the two groups, although there was a trend toward significance with the chemical lavage group causing less crusting.

A commercially available oily mixture made of nasal emollient derived from pine and eucalyptus has proven especially effective in relieving patients of excessive nasal crusting after sinus surgery. This problem is minimized by preserving the turbinates during surgery; however, some aspect of crusting is usually unavoidable. In some cases, the middle turbinates have completely degenerated into polypoid form and preservation is impractical.

Corticosteroids

Intranasal corticosteroids have long been a part of preoperative maximal medical therapy, having minimal systemic absorption and mild, local side effects. The continued use of intranasal corticosteroids postoperatively is justified primarily for two reasons. First, the continued anti-inflammatory effect of the steroid may be increased in efficacy since there should theoretically be greater delivery to the more open postoperative sinus cavity. The removal of the uncinate process, the medialization of the middle turbinate, and the exposed skull base mucosa from a complete ethmoidectomy are all anatomic factors that facilitate greater distribution of topical medications to the sinus mucosa. Second, in the case of nasal polyps, disease recurrence is common and the persistent daily use of intranasal corticosteroids is widely believed to reduce the rate of recurrence. Rowe-Jones et al. [29] studied 72 patients over a 5-year period in a prospective, randomized, placebo-controlled, and double-blinded manner. A statistically significant improvement was demonstrated not only in patient subjective symptoms, but also in endoscopic edema and polyp scores and total nasal volume. The placebo group also required more oral steroid tapers, and of the 12 patients who failed the study due to excessive requirements for oral steroid tapers, 10 were from the placebo group. Older studies using flunisolide and beclomethasone have also shown improvement in the prevention of nasal polyp recurrence at 1 year and 2.5 years [11, 18]. A more recent paper by Desrosiers’ group demonstrated an interesting effect of postoperative intranasal steroid use [8]. In a prospective observational study of 157 patients, intranasal corticosteroid use was associated with lower rates of bacterial recovery, especially for revision FESS patients. This phenomenon may be partially explained by the high rate of colonization of post-FESS patients with Staphylococcus aureus and the potentially anti-inflammatory and proinnate immune actions of intranasal corticosteroids, which could result in improved

isms have always been recognized as more significant contributors in chronic versus acute disease, their presence in the postoperative patient is increased. Bhattacharyya et al. [2] demonstrated that Strep. pneumoniae, H. influenzae, and M. catarrhalis combined, only made up 10.8% of over 290 cultures taken from post-FESS sinus cavities. Of special interest, S. aureus and coagulase-negative staphylococcus represented the number one and number two most cultured organism, and together represented nearly 30% of all organisms. Pseudomonas aeruginosa was third at 7.2%. Fungal organisms were cultured in only 1.7% of the specimens.

■S. aureus frequently colonizes chronic rhinosinusitis and postoperative patients and may play a role in the progression of mucosal inflammation.

S. aureus is widely believed to be a significant pathogen in the etiology of chronic rhinosinusitis and its presence in the operated sinus cavity is a cause for concern. Recent reviews illustrate a convincing argument for staphylococcal superantigens and their nonspecific activation of local T-cell receptors as a factor in the development of chronic rhinosinusitis with nasal polyposis [32, 36]. Another striking finding is the relatively high prevalence of Pseudomonas bacteria in the postoperative setting; these bacteria have a very strong propensity for developing multidrug resistance.

Antibiotic resistance is an emerging problem in all fields of medicine and post-FESS patients have often received multiple long-term courses before undergoing surgery. Consequently, it should come as no surprise that these patients often present with infections by multidrug resistance bacteria that are difficult to eradicate. The study by Bhattacharyya makes a strong argument for culture directed antibiotic therapy in the postoperative setting and points out that a good FESS should provide much improved access to at least the maxillary antrum and ethmoid cavity for representative specimens [2].

The issue of resistance coupled with possible systemic side effects from protracted use of oral antibiotics has led to an increased interest in the topical delivery of antibiotics. As nasal saline irrigation was already a well-es- tablished regimen used by patients, a natural extension was the addition of both corticosteroids and antibiotics to the wash. The philosophy was to increase delivery of antibiotic to the affected sinus cavities while decreasing systemic absorption. The prevalence of Staphylococcus and Pseudomonas in the postoperative patient made the addition of two types of antibiotics especially attractive. For staphylococcal coverage, mucopirocin is added to saline rinses; gentamycin and tobramycin represent the most popular antibiotics mixed into saline for pseudomonal coverage.

One criticism of using saline to deliver antibiotics centers on the concentration of the antibiotic in the solution. While it offers an improvement over oral ingestion alone, the presence of large amounts of saline significantly dilutes whatever antibiotic is mixed and ultimately decreases the concentration delivered to the sinus cavities. A more suitable alternative would appear to be the delivery of a small volume of solution by means of a nebulizer. Initial trials by Vaughan et al. [34] and Desrosiers et al. [7] demonstrated safety as well as improvement in infection clearance rates, nasal symptomatology, and quality of life surveys. Vaughan’s study was an uncontrolled pilot study, which not only showed a longer disease-free interval (17 weeks versus 7 weeks) for the nebulized antibiotic treatment group, but also decreased facial pain and postnasal drip [34].

■A randomized controlled study on intranasal antibiotic use by Desrosiers’ group showed that there was symptomatic improvement, but comparison between a nebulized saline control group and the nebulized tobramycin group revealed no significant differences [7].

The paper concluded that large-particle nebulized aerosol therapy in and of itself may offer a safe and effective management alternative, but was unable to show any additional benefit of tobramycin [7].

Recent research has placed new emphasis on biofilm formation and the role that it plays in recalcitrant chronic rhinosinusitis, especially in the operated patient. Previous work had demonstrated the increased prevalence of Staphylococcus and Pseudomonas species in the postFESS patient and various theories had been advanced as to why infections in this patient population were so difficult to clear [2]. Both Staphylococcus and Pseudomonas are known biofilm producers and it is now thought that bacterial biofilms help to explain the decreased efficacy of oral antibiotics, since the minimal inhibitory concentration (MIC) of antibiotics delivered in oral form is simply inadequate to affect bacteria in biofilms. An impractical solution would simply be to increase the MIC of various antibiotics, as studies have shown that high MICs are capable of overcoming biofilm resistance [15]. As high concentrations are difficult to attain in serum due to systemic toxicity, the focus is placed on topical antibiotics, which may achieve concentrations high enough to penetrate biofilms and eradicate bacteria but with negligible systemic absorption. Preliminary work by Desrosiers et al. [9] recently demonstrated the capacity of supra-MIC levels of moxifloxacin to kill bacteria in biofilms in vitro. An elegant animal model for both inducing chronic rhinosinusitis and then studying the effects of various topical medications on the maxillary sinus through a surgically

implanted irrigating catheter has recently been published [4]. Irrigation with saline alone demonstrates no significant difference from untreated animals with regard to the degree of inflammation of sinus mucosa and underlying bone, and no changes in the amount of purulence could be found. Further work will concentrate on the effects of topical antibiotics and steroids in the rabbit model and future clinical trials to establish safety profiles, dosages, and regimens will also be needed.

cin B therapy in 60 patients in a prospective, controlled, double-blinded trial. found no difference in any of the parameters studied. Furthermore, a larger, more recent, randomized multi-institutional trial failed to show any efficacy with the use of amphotericin nasal rinses [12].

■The efficacy of topical antifungal medications for any form of chronic rhinosinusitis is currently unproven.

Allergic Fungal Sinusitis

AFS represents a special subgroup of chronic rhinosinusitis whose treatment is especially challenging [1]. Even with intranasal corticosteroids and multiple courses of systemic steroids, disease recidivism requiring revision FESS is common. Part of the difficulty in elucidating optimal medical therapy for AFS is the fact that the etiology of this disease remains unclear. Complete eradication of fungus from the sinus cavities with both surgical and medical therapy would appear to be a reasonable goal. Unfortunately, the extreme toxicity of systemic antifungal therapy has limited its use in patients with AFS.

The usefulness of postoperative immunotherapy in AFS was highlighted by Folker et al. [14]. Results demonstrated improved mucosal staging, improved sinusitisspecific quality of life, and decreased reliance on both systemic and topical nasal corticosteroids. The study was not blinded and the decision was made not to withhold

16 fungal immunotherapy from any patients with AFS who desired it. As such, the control group was selected retrospectively. Future work would focus on a true parallel prospective, controlled study with blinding. This work suggests the importance that atopy to fungal antigens plays in the etiology of AFS.

Practical management of AFS consists of surgical removal of polyps and reestablishment of sinus aeration with complete removal of fungal mucin. Medical management is then aggressively employed to prevent reobstruction of the ostia via polyps or edema. If the polypoid disease progresses to the point of obstruction, then the cycle of fungal mucin reaccumulation and polyp formation typically requires revision surgery. Aggressive medical and topical therapy is usually required to maintain postoperative AFS patients.

Ponikau et al. [25] suggested that a fungal-mediated process may be the primary etiologic agent not just in AFS, but in all forms of chronic rhinosinusitis. Initially, treatment with topical antifungal medications such as amphotericin B was advocated with some studies showing positive results [26, 28]. These were nonblinded and uncontrolled observational studies. A recent paper by Weschta et al. [35], which examined topical amphoteri-

Conclusion

The management of chronic rhinosinusitis can be challenging. While surgical therapy is often required, the postoperative medical management of the disease is believed to be critical for optimal outcome. Postoperative debridement, steroids, saline lavages, antibiotics, topical and nebulized therapy, and the special challenges presented by AFS have been discussed in detail. Many of these issues remain controversial and further research is needed to clarify their role in the treatment of chronic rhinosinusitis.

References

1.Bent JP, Kuhn FA (1994) Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg 111:580–587

2.Bhattacharyya N, Kepnes LJ (1999) The microbiology of recurrent rhinosinusitis after endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg 125:1117–1120

3.Bugten V, Nordgard S, Steinsvag S (2006) The effects of debridement after endoscopic sinus surgery. Laryngoscope 116:2037–2043

4.Chiu AG, Antunes MB, Feldman M, Cohen NA (2007) An animal model for the study of topical medications in sinusitis. Am J Rhinol 21:5–9

5.Citardi MJ, Kuhn FA (1998) Endoscopically guided frontal sinus beclomethasone instillation for refractory frontal sinus/recess mucosal edema and polyposis. Am J Rhinol 12:179–182

6.DelGaudio JM, Wise SK (2006) Topical steroid drops for the treatment of sinus ostia stenosis in the postoperative period. Am J Rhinol 20:563–567

7.Desrosiers M, Salas-Prato M (2001) Treatment of chronic rhinosinusitis refractory to other treatments with topical antibiotic therapy delivered by means of a large-particle nebulizer: results of a controlled trial. Otolaryngol Head Neck Surg 125:265–269

8.Desrosiers M, Abdolmohsen H, Frenkiel S, Kilty S, Marsan J, Witterick I, Wright E (2007) Intranasal corticosteroid use is associated with lower rates of bacterial recovery in chronic rhinosinusitis. Otolaryngol Head Neck Surg 136:605–609

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9.Desrosiers M, Bendouah Z, Barbeau J (2007) Effectiveness of topical antibiotics on Staphylococcus aureus biofilm in vitro. Am J Rhinol 21:149–153

10.Dijkstra MD, Ebbens FA, Poublon ML, Fokkens WJ (2004) Fluticasone propionate aqueous nasal spray does not influence the recurrence rate of chronic rhinosinusitis and nasal polyps 1 year after functional endoscopic sinus surgery. Clin Exp Allergy 34:1395–1400

11.Dingsor G, Kramer J, Olsholt R, Soderstrom T (1985) Flunisolide nasal spray 0.025% in the prophylactic treatment of nasal polyposis after polypectomy. A randomized, double-blind, parallel, placebo controlled study. Rhinology 23:49–58

12.Ebbens FA, Scadding GK, Badia L, Hellings PW, Jorissen M, Mullol J, Cardesin A, Bachert C, van Zele TP, Dijkgraaf MG, Lund V, Fokkens WJ (2006) Amphotericin B nasal lavages: not a solution for patients with chronic rhinosinusitis. J Allergy Clin Immunol 118:1149–1156

13.El Naggar M, Kale S, Aldren C, Martin F (1995) Effect of Beconase nasal spray on olfactory function in post-nasal polypectomy patients: a prospective controlled trial. J Laryngol Otol 109:941–944

14.Folker RJ, Marple BF, Mabry RL, Mabry CS (1998) Treatment of allergic fungal sinusitis: a comparison trial of postoperative immunotherapy with specific fungal antigens. Laryngoscope 108:1623–1627

15.Ghannoum M, O’Toole GA (2004) Biofilm antimicrobial resistance. In: Ghannoum M, O’Toole GA (eds) Microbial Biofilms. ASM, Washington DC, pp 250–268

16.Gross CW, Gross WE (1994) Post-operative care for functional endoscopic sinus surgery. Ear Nose Throat J 73:476–479

17.Hardy JG, Lee SW, Wilson CG (1985) Intranasal drug delivery by sprays and drops. J Pharm Pharmacol 37:294–297

18.Karlsson G, Rundcrantz H (1982) A randomized trial of intranasal beclomethasone dipropionate after polypectomy. Rhinology 20:144–148

19.Kuhnel T, Houseman W, Wagner W, Fayed K (1996) How traumatizing is mechanical mucuous membrane care after interventions in paranasal sinuses? A histological immunohistochemical study. Laryngorhinootologie 75:575–579

20.Mabry R (1987) Corticosteroids in rhinology. In: Goldman JL, Blaugrund SM, Shugar JMA (eds) The Principles and Practice of Rhinology. John Wiley, New York, pp 847–853

21.Mierzwinski J, Krzysztof D, Piotr L, Olijewski J, Piziewicz A, Burduk K (2006) Functional endoscopic sinus surgery in children – our experience. Otolaryngol Pol 60:517–520

22.Mitchell RB, Pereira KD, Younis RT, Lazar H (1997) Pediatric functional endoscopic sinus surgery: is a second look necessary? Laryngoscope 107:1267–1269

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23.Nilssen EL, Wardrop P, El-Hakim H, White PS, Gardiner Q, Ogston S (2002) A randomized control trial of post-opera- tive care following endoscopic sinus surgery: debridement versus no debridement. J Laryngol Otol 116:108–111

24.Pigret D, Jankowski R (1996) Management of post-eth- moidectomy crust formation: randomized single-blind clinical trial comparing pressurized seawater versus antiseptic/mucolytic saline. Rhinology 34:38–40

25.Ponikau JU, Sherris DA, Kern EB, Homburger HA, Frigas E, Gaffey TA, Roberts GD (1999) The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc 74:877–884

26.Ponikau JU, Sherris DA, Kita H, Kern EB (2002) Intranasal antifungal treatment in 51 patients with CRS. J Allergy Clin Immunol 110:862–866

27.Ramadan HH (1995) What is the bacteriology of chronic sinusitis in adults? Am J Otolaryngol 16:303–306

28.Ricchetti A, Landis BN, Maffioli A, Giger R, Zeng C, Lacroix J (2002) Effect of anti-fungal nasal lavage with amphotericin B on nasal polyposis. J Laryngol Otol 116:261–263

29.Rowe-Jones JM, Medcalf M, Durham SR, Richards DH, MacKay I (2005) Functional endoscopic sinus surgery: 5 year follow up and results of a prospective, randomized, stratified, double-blind, placebo controlled study of postoperative fluticasone propionate aqueous nasal spray. Rhinology 43:2–10

30.Ryan RM, Whittet HB, Norval C, Marks NJ (1996) Minimal follow-up after functional endoscopic sinus surgery. Does it affect outcome? Rhinology 34:44–45

31.Schleimer RP (2004) Glucocorticoids suppress inflammation but spare innate immune responses. Proc Am Thorac Soc 1:222–230

32.Seiberling KA, Grammer LC, Kern RC (2005) Chronic rhinosinusitis and superantigens. Otolaryngol Clin North Am 38:1215–1236

33.Senior BA, Kennedy DW, Tanabodee J, Kroger H, Hassab M, Lanza D (1998) Long-term results of functional endoscopic sinus surgery. Laryngoscope 108:151–157

34.Vaughan WC, Carvalho G (2002) Use of nebulized antibiotics for acute infections in chronic sinusitis. Otolaryngol Head Neck Surg 127:558–568

35.Weschta M, Rimek D, Formanek M, Polzehl D, Podbielski A, Riechelmann H (2004) Topical antifungal treatment of chronic rhinosinusitis with nasal polyps: a randomized, double-blind clinical trial. J Allergy Clin Immunol 113:1122–1128

36.Zhang N, Gevaert P, van Zele T, Perez-Novo C, Patou J, Holtappels G, van Cauwenberge P, Bachert C (2005) An update on the impact of Staphylococcus aureus enterotoxins in chronic rhinosinusitis with nasal polyposis. Rhinology 43:162–168

 Core Messages

■Nasal polyposis is the defining feature of a more severe subset of chronic rhinosinusitis.

■Patients with primary or recurrent disease should be evaluated for associated disorders such as asthma, allergic fungal rhinosinusitis, aspirin sensitivity, cystic fibrosis, immunoglobulin subclass deficiency, and primary ciliary dyskinesia.

■Oral and intranasal corticosteroids are the cornerstone of medical therapy for patients with chronic rhinosinusitis with nasal polyposis.

■Patients with medically refractory chronic rhinosinusitis with nasal polyposis or allergic fungal rhinosinusitis are surgical candidates.

■Intensive perioperative medical management and selective use of powered instrumentation facilitate safe and effective surgery.

■Close surveillance, early detection of recurrent polyposis, and tailored medical therapy are required to decrease the need for revision surgery and increase the interval between surgeries in refractory cases.

Introduction

Nasal polyposis (NP) is a clinical and pathological manifestation of chronic inflammation in the paranasal sinuses. Population-based surveys have shown a prevalence of 2–4% in the general population, while autopsy studies suggest a much higher rate of preclinical lesions [25, 35, 42].

In the past, the literature referred to NP as a clinical entity distinct from chronic rhinosinusitis (CRS). Today, NP is recognized as the defining feature of a more severe and treatment-refractory subset of rhinosinusitis, CRS with nasal polyposis (CRSwNP) [40]. Patients with CRSwNP demonstrate decreased disease-specific quality of life (QOL) and greater extent of disease on computed

tomography (CT) scans than their nonpolypoid counterparts [14]. CRSwNP patients also commonly have symptoms that persist despite maximal medical therapy, and improve less after surgery than patients with CRS without nasal polyposis (CRSsNP) [14, 29]. Despite ongoing research, the pathogenesis of NP remains elusive.

■The majority (>80%) of polyps appear to be the product of eosinophilic inflammation, characterized by subepithelial caps of eosinophils, pseudocyst formation with deposition of albumin, and elevated levels of the inflammatory mediators interleukin-5 and eotaxin [6].

Others, such as those associated with ciliary dysmotility, are neutrophil-rich, yet may appear identical on clinical

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examination [58]. The reason for these findings is still unknown. Theories explaining polyp formation, regardless of the inciting event, are numerous and include loss of autonomic innervation, dysregulation of water and ion transporters, and chronic vascular changes leading to congestion and exudation [6, 42].

Since NP may be the presenting manifestation of several conditions, such as allergic fungal rhinosinusitis (AFRS) and cystic fibrosis (CF), specialized testing and referrals should be arranged if an underlying disorder is suspected. Those patients with disease refractory to maximal medical therapy are considered for surgical intervention. Well-designed and sometimes intensive medical regimens are essential in both the immediate perioperative period and the long-term for successful management.

Evaluation

Besides querying symptoms of CRS [10], a treatment history should be carefully elicited. Prior medical regimens should be assessed for adequacy of dose, duration, patient adherence, and medication interactions. A history of complications of oral steroid use, such as worsening hypertension, poor diabetic control, psychological disturbances, or osteoporosis, is worrisome, since systemic corticosteroids play a central role in the treatment of recurrent disease. Early identification of non-steroid-re- sponsive NP can minimize risks in patients who may not derive a benefit from corticosteroids.

Past surgical history, including complications and 17 perioperative medical care, is explored to gauge the severity, extent, and laterality of the disease. Prior operative reports should be scrutinized, noting that although sinus surgery has evolved from simple polypectomy under local anesthesia in the pre-endoscopic era to formal FESS

today, a wide range of prior procedures are possible.

■Reports of visual disturbance, watery nasal discharge (particularly unilateral), meningitis, excessive bleeding, epiphora, and facial numbness may indicate involvement of critical structures related to previous surgery or complications of severe polyposis.

A comprehensive head and neck examination, including an assessment of the cranial nerves with attention to trigeminal nerve function and extraocular movements, should be performed. Further ophthalmic evaluation may identify unilateral visual acuity loss, proptosis, or epiphora. The nose is examined externally for weakened cartilaginous support or widening from bony expansion from nasal polyps or neoplasm. Anterior rhinoscopy preand postapplication of a topical decongestant is then used

Frederick C. Roediger and Andrew N. Goldberg

to assess nasal cavity patency, mucosal health, septal position, and inferior turbinate size and response to vasoconstriction.

Nasal endoscopy is an essential component of the rhinologic exam in patients with recurrent polyposis. The procedure can define the extent and character of NP, detect subtle mucosal changes in the sinus cavities, and examination of the fovea ethmoidalis, cribriform region, and sphenoid may reveal pulsation related to dehiscence of the skull base or carotid. In addition, movement of nasal contents during ballottement of the eye during office endoscopy can signify dehiscence of the orbital wall. Treatment planning, postoperative care, and surveillance all depend heavily on the findings during nasal endoscopy.

A contemporary CT scan of the paranasal sinuses with fine cuts should be carefully analyzed for the extent of disease, skull-base and orbital integrity, nasolacrimal ducts, middle turbinates, and remaining surgical landmarks. Hallmarks of specific diagnoses, such as an expansile lesion with central serpiginous calcifications in AFRS or the dense bone associated with chronic infection, should be noted. MRI of the paranasal sinuses with gadolinium enhancement may also be indicated, for example to identify encephalocele or meningocele when skull-base dehiscence is detected on CT.

Serum total immunoglobulin E (IgE) levels are helpful in patients with concurrent asthma, since IgE levels correlate with airway hyperresponsiveness [56, 62]. However, the exact role of IgE in predicting the severity of CRS continues to be debated, with a correlation between serum total IgE level and mucosal disease on CT scan demonstrated in some studies [7] but not others [52]. No significant change in IgE is seen 1 year after sinus surgery in patients reporting improvement in symptoms, indicating that IgE levels are not a sensitive barometer for changes in CRS [34]. In contrast, peripheral eosinophilia has been shown to correlate with the degree of nasal polyposis [32] as well as disease severity on CT scan [7, 32, 52]. For those patients progressing to sinus surgery, an elevated mucosal eosinophil level (>5 cells per high-power field) indicates more severe disease [32].

Specialized testing for associated disorders, as outlined in Table 17.1, should be considered on a case by case basis.

Although recurrent nasal polyposis most likely indicates a diagnosis of CRSwNP alone, several associated disorders must be considered during history-taking (Table 17.1).

Inhalant Allergy

Allergic rhinitis (AR) is present in 15–20% of the general population [42]. However, although both atopy and NP

•Surgical excision and pathological examination to exclude inverted papilloma and AFRS

occur in subsets of patients with CRS, a direct or causal relationship between inhalant allergies and NP has yet to be proven.

■Positive skin tests occur in a similar percentage of patients with and without nasal polyps [6].

Less than 5% of patients with inhalant allergies have NP, similar to the general population [42], and the prevalence of NP is actually higher in nonallergic rhinitis than the corresponding allergic form [58].

Asthma

The frequencies of NP in allergic and intrinsic asthma are approximately 5% and 13%, respectively [58]. NP occurs most frequently in nonatopic asthma patients over age 40 years with severe, steroid-dependent disease [58]. Treating sinus disease in asthmatics is an important component of their care; a reduction of total annual oral prednisone and antibiotic use in patients with concurrent asthma has been well documented after FESS [47, 57, 64].

Allergic Fungal Rhinosinusitis

AFRS is thought to represent a type I hypersensitivity reaction to noninvasive fungus. Nearly all AFRS patients have NP [55]. Most AFRS patients present with a history of progressive nasal obstruction, anosmia, and dark nasal

17 discharge predominantly affecting one side. The characteristic CT scan findings include opacification of multiple ipsilateral sinuses containing areas of hyperattenuation from calcification and products of fungal metabolism (iron, magnesium, manganese) and expanding borders caused by mass effect of debris and dense polyposis [5, 11]. Bony erosion with skull-base or orbital involvement leading to proptosis occurs in roughly half of patients [23]. Recent work suggests that AFRS is a subset of eosinophilic mucin chronic rhinosinusitis [21, 48]. Despite thorough surgical debridement and intensive medical therapy, AFRS frequently recurs and requires reoperation [33].

Aspirin Sensitivity

disease than non-AS asthmatics [20]. The triad of aspirin sensitivity, asthma, and NP is termed Samter’s triad, or aspirin-exacerbated respiratory disease.

Cystic Fibrosis

■CF should be considered in the workup of any child with NP.

Most patients with CF present with either recurrent respiratory infections or manifestations of pancreatic insufficiency, such as failure to thrive or steatorrhea [54]. Most develop CRS, with approximately 20% of affected patients demonstrating NP on nasal endoscopy and >90% having pan-opacification of the sinuses on CT [58, 70].

Immunoglobulin Subclass Deficiency

Deficiency of one or more of the immunoglobulin G (IgG) subclasses occurs in up to 20% of the general population, yet most individuals are asymptomatic [46]. Some present in adolescence and early adulthood with CRSwNP and recurrent pulmonary infections. Testing reveals normal or near-normal total serum IgG with one or more subclass levels greater than two standard deviations below the age-adjusted mean [26]. Early diagnosis and immunoglobulin replacement can reduce the frequency and severity of infections and increase life expectancy.

Primary Ciliary Dyskinesia

This autosomal recessive disease is characterized by recurrent childhood respiratory infections and CRSwNP secondary to ciliary immotility [1]. Fifty percent of cases are associated with situs inversus [44]. The triad of bronchiectasis (after repeated pulmonary infections), CRS, and situs inversus is termed Kartagener’s syndrome [2]. Patients with PCD generally have a normal lifespan and have a lower rate of decline of lung function than patients with CF, so they are more likely to present undiagnosed as a young adult with NP [44].

Young’s Syndrome

Aspirin sensitivity (AS) is a clinical syndrome in which patients typically develop refractory CRS and asthma in the third to fourth decade of life, with acute respiratory exacerbations precipitated by aspirin or nonsteroidal antiinflammatory drugs, and is associated with NP 36% of the time [58]. These patients generally have worse respiratory

This disorder is characterized by azoospermia, NP, and recurrent sinopulmonary infections [24]. Patients have normal sweat chloride values and pancreatic function, unlike those with CF, and motile cilia, distinguishing them from patients with PCD.