Polypectomy (polyp removal) is a surgical therapeutic procedure in otolaryngology that can be used to treat polyposis nasi to improve nasal breathing. Polyposis nasi is a clinical picture characterized by an adaptive reaction in the form of hyperplasia (proliferation of cells in the tissue) in the area of the nose and sinuses. In addition to this characteristic cell proliferation, an edematous (storage of fluid in the tissue) change of the affected area in the nasal mucosa can also be observed. If the affected areas are examined with the aid of an endoscope, grayish and glassy-looking bulges are found. As a rule, the pathogenic (pathological) changes can be found first in the area of the ethmoidal sinus. The first pathological processes can also be seen from the maxillary sinus to the middle nasal meatus. Despite various scientific studies, it has not yet been possible to clarify why the area of the inferior turbinate is not prone to any polyp formation. Furthermore, despite numerous studies, the pathogenesis of nasal polyps has also not been adequately clarified. Of decisive importance for the pathogenesis seems to be the association with other diseases, which initially have no connection with the formation of polyps in the nasal area. Surgical intervention in the form of polypectomy is aimed at regenerating the physiologic function of the nose so that adequate ventilation (aeration) of the nose and drainage (outflow) of the paranasal sinuses subsequently become possible.
Indications (areas of application)
- Polyposis nasi – the presence of nasal polyps significantly impairs the function of the nose as an olfactory and respiratory organ. Fewer than one in ten patients complaining of polyposis nasi have physiologic olfaction. In addition, polyps can promote the occurrence of snoring at night and affect ventilation. The need for performing surgery depends on the condition of the affected patient. However, delaying therapy can dramatically worsen symptoms and potentially increase susceptibility to recurrence.
- Chronic ethmoidal sinusitis (inflammation of the ethmoidal cells)/sphenoidal sinusitis (inflammation of the sphenoid sinus) (rare).
Contraindications
- General health condition – depending on the symptoms, polypectomy is performed under local or general anesthesia. In case of reduced general health, refrain from performing under general anesthesia.
- Bleeding tendency – a congenital bleeding tendency, which may be due to hemophilia (hereditary blood clotting disorder), for example, requires special precautions to avoid serious peri- or postoperative complications. If there is still a risk, the operation must be canceled.
Before surgery
- Preoperative therapy – conservative treatment is usually given until surgical intervention. For the reduction of recurrences, it is beneficial to continue steroid therapy until shortly before surgery. Usually, nasal emulsions and budesonide (steroid hormone) are used for therapy.
- Anticoagulation – discontinuation of blood-thinning medications such as acetylsalicylic acid (ASA) or Marcumar should be done in consultation with the attending physician. Discontinuing medication for a short period of time significantly minimizes the risk of secondary bleeding without a significant increase in risk to the patient. If diseases are present that can influence the blood coagulation system and these are known to the patient, this must be communicated to the attending physician. If necessary, the presence of such a disease leads to the suspension of the therapeutic measure.
The surgical procedure
Pathological basis of polyp formation
- As described earlier, the probability of infestation of different nasal areas differs dramatically. It has not been possible to clarify either why histologically similar tissues (comparable under the microscope) are affected by polyp development and other areas are not. Furthermore, there are various theories for the pathogenesis of polyposis nasi.On the one hand, it is postulated that a local circulatory disorder may be the basis for the development of polyposis nasi.
- As a result of this reduced perfusion (supply) of the tissue, there is an accumulation of substances such as histamine and prostaglandins, which can be directly released by tissue-resistant mast cells. This approach is justifiable, among other reasons, because decreased blood flow can lead to the accumulation of histamine. Furthermore, both prostaglandins and histamine lead to the development of edema. An example of a disease whose pathogenesis is associated with histamine-associated edema is bronchial asthma. In previously conducted studies, this thesis could be supported, as a reduced blood flow in the polyp tissue compared to the non-infested tissue could be demonstrated.
- In contrast to this theory, there is also the approach of the “epithelial rupture theory”, in which the pathogenesis is based on a significantly increased tissue pressure in combination with a local aeration disorder. This combination inevitably leads to rupture of the epithelium (superficial tissue layer). After the tissue layer is torn, the existing opening protrudes into the connective tissue. After a short time, the opening is lined with an epithelial layer, resulting in a polyp. However, until now it has not been possible to detect a polyp precursor. Due to this, the number of researchers who support this theory is relatively small.
- To better understand the pathogenesis (disease development), additional attempts have been made to determine or exclude other causes of polyposis nasi. Research focused in particular on the detection of granulation tissue (inflammatory altered tissue), an immunological disturbance of the T-cell response (T-cells are defense cells) and various allergens. In addition, of great interest is the epidemiological (disease theory at the population level) relevance of the disease.
- Although a precise elucidation of the pathogenesis is still pending, a link of polyp formation in the nose with various hereditary diseases, bronchial asthma, aspirin intolerance and chronic sinusitis (sinusitis) can already be identified, suggesting a genetic influence on the disease process. Thus, it is not surprising that a familial clustering of polyp formation in the nasal area has been demonstrated. It is possible that there is a genetic predisposition of the nasal mucosa in these patients, which leads to polyp formation given certain local influences and environmental factors.
Treatment options for polyps in the nasal mucosa.
- Before polypectomy as a surgical intervention, the full range of conventional effective treatment methods should be exhausted. The overall goal of therapeutic measures is to restore normal function of the nose and prevent recurrence. However, if no improvement in symptoms can be expected from purely conventional therapy, the combination of polypectomy and drug treatment is a reasonable intervention.
- However, a problem with anti-inflammatory (anti-inflammatory) treatment is that primarily topically applied steroids (hormonal preparations applied to the skin) are used, since nonsteroidal anti-inflammatory drugs (example: ibuprofen) and anti-allergic drugs such as antihistamines (example: cetericine) have no significant therapeutic effect in the treatment of nasal polyps. Despite this fact, the use of steroids is crowned with success in more than half of the cases. However, this therapeutic measure is sometimes associated with side effects such as adverse skin reactions. Nevertheless, side effects are comparatively more severe with systemic administration, so topical application via the nose is performed first. When polypectomy is combined with conventional therapy, it has been shown that the concentration of steroid can be reduced while maintaining the same effect. In addition, preoperative steroid treatment may facilitate the surgical procedure.
- If conservative treatment is not accompanied by an improvement in symptoms or if there is also an uncontrollable mycosis (fungal infection) or chronic sinusitis (sinusitis), polypectomy is the gold standard (first-line procedure).The main goal of the therapy is the removal of the polypy mucosa, so that a regeneration of the physiological nasal function is possible. Depending on the size of the individual polyps of the nasal cavity, a polypectomy with removal of the polyps by means of a snare under local anesthesia is optimal, if necessary. The use of polypectomy has the advantage of providing immediate improvement in nasal breathing. However, in the absence of combination therapy, the disadvantage is that recurrences occur relatively frequently due to regrowth of the polyps from the sinuses. Especially asthmatics suffer from frequent recurrences, which make a new polypectomy essential.
- If we look at the development of polypectomy, we can see that the surgical procedure as a functionally oriented endoscopic procedure is a focus of surgical therapy. The main goal of this endoscopic procedure is to remove the polyps to allow self-regeneration of the downstream areas. However, it should be noted that this minimally invasive method, with the preservation of the integrity of unaffected areas, is primarily successful in early stages of the disease. If there is already a tendency to recurrence or clear clinical symptoms, this gentle therapeutic option is no longer indicated. In order to achieve a significant symptom improvement in frequent recurrences in addition to polypectomy, it is necessary to improve the anatomical conditions with the help of septoplasty (nasal septum surgery) and conchotomy (nasal concha surgery) in parallel with polypectomy. In order to be able to accurately determine during the surgical procedure whether the mucosal area under consideration is healthy or pathologically altered tissue, the use of a special microscope is indicated.
After surgery
To avoid swelling, the surgical area should be cooled immediately after the procedure. Taking medication to prevent recurrence must be discussed with the attending physician. A follow-up examination should be performed in any case, as unnoticed complications may occur.
Possible complications
- Mucosal perforation – although polypectomy is a relatively gentle procedure, unplanned damage to the nasal mucosa may occur during the surgical procedure. The damage to the mucosa is one of the most important intraoperative complications of the procedure. The risk for the occurrence of perforation depends, among other things, on the way the procedure is performed.
- Nerve lesions – due to the proximity to the olfactory nerve (nervus olfactorius), intraoperative damage is possible. Consequence of the lesion would be olfactory dysfunction, but this can also be temporary (intermittent).
- Hematoma (bruise) – after surgery, for example, it may come to the formation of a hematoma in the treated mucosal area.
