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Surgical Approaches for Nasal Polyps Removal
Quynh-Chi Dang • Aug 4, 2021 • 130 hits
Sinus surgery may be necessary if all medical treatments for nasal polyps removal fail. Functional endoscopic sinus surgery is the most common procedure to debride and clear the sinuses, but Draf III and endoscopic maxillary mega antrostomy are alternate surgical options if revision surgery is needed. Dr. Patricia Loftus explains her approach to surgical nasal polyps removal on the BackTable ENT Podcast.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• The most common method of nasal polyps surgery is the functional endoscopic sinus surgery, or FESS procedure. In this minimally invasive procedure, an endoscope is inserted into the patient’s nostril in order to remove nasal polyps and widen nasal passages.
• Dr. Loftus prefers to perform a “full house FESS”, a procedure that thoroughly opens all the sinuses, on her nasal polyps patients. She notes that additional turbinate reduction may be unnecessary, as swelling may reduce naturally.
• Draf III and endoscopic maxillary mega antrostomy are two sinus revision surgeries. Although they are more invasive procedures, they may be necessary for patients who have undergone a failed functional endoscopic sinus surgery or patients with primary ciliary dyskinesia.
• Nasal stents are often placed after sinus surgery to keep the sinuses open and to reduce swelling and scarring. Dr. Loftus recommends placing the drug-eluting PROPEL stent in the sinus frontal recess area.
Table of Contents
(1) Functional Endoscopic Sinus Surgery
(2) Sinus Revision Surgeries: Endoscopic Maxillary Mega-Antrostomy & Draf III
(3) Grafts & Stents for Nasal Polyps Surgery
Functional Endoscopic Sinus Surgery
If a patient does not respond to medication, sinus surgery is the next best alternative for nasal polyps removal. The most common method of nasal polyps surgery is the functional endoscopic sinus surgery, or FESS procedure. In this minimally invasive procedure, the otolaryngologist inserts an endoscope through the patient’s nostril in order to remove nasal polyps and widen nasal passages. In her nasal polyps patient, Dr. Loftus prefers to perform a full house FESS (complete uncinectomy, middle meatal antrostomy, full ethmoidectomy, sphenoidotomy, and frontal pathway clearance) in order to open all the sinuses. She does not recommend using balloon dilation because it does not clean out mucus or remove nasal polyps.
Turbinate surgery is sometimes performed in conjunction with FESS. In this surgery, the otolaryngologist uses the endoscope to shave down the inferior turbinate, one of three body projections in the airway, to further open the patient’s airway. Dr. Loftus notes that turbinate reduction surgery may be unnecessary, as turbinate swelling is often a symptom of sinusitis; once sinus swelling ceases, the inferior turbinate usually reduces naturally as well.
[Dr. Ashley Agan]
If these patients end up needing surgery, are most patients with nasal polyps, are you doing a full house FESS? Do you think, are you a fan of big antrostomies, or is a balloon dilation enough to ventilate the sinuses? Tell us what you think about that.
[Dr. Patricia Loftus]
I don't do a ton of balloons. I do think that there is a place for balloons, and I know there is data out there showing that they work in the right type of situation. I don't think that polyps are one of those situations though. You need to get in there and remove the polyps. Just dilating the sinus is not going to help if there's still a lot of edema and polyp in the way. If there's a lot of mucus in the sinuses that needs to be cleaned out, obviously an AFS patient would not be a candidate for a balloon.
I don't do balloons commonly, but definitely not for polyp. My goal with them is to treat their current symptoms with medications and to surgically make a nice wide open cavity so that they could get topical treatment in there so that they don't have to be dependent on taking a course of prednisone every time they're having a really bad flare. Even if not all sinuses are fully involved--meaning that they might not all have mucosal thickening--we know the polyps mostly come from the ethmoid, so I do think to make a nice big open cavity, you do need to open all of the sinuses.
A polyp patient is someone that I would do a full house FESS, septum if needed. My residents ask me a lot about doing turbinate reductions. What's interesting is that, like we were saying, for most of these patients, it's actually not allergies. So, if their inferior turbinates are swollen, they are sort of just going along with the whole like chronic rhinosinusitis thing. As the inflammation in the sinuses go down, the inflammation in the inferior turbinates tends to go down too. I don't usually do inferior turbinate reduction at the same time, but I will just start the full house FESS.
I do like big antrostomies. The data out there shows that you don't have to make these huge antrostomies, but I just like them because they look nice. I do think that medication gets in there well. And you have to think about when you're doing the surgery, how can I make this easier for me in the office when I'm debriding them or when I'm monitoring? So, I kind of just think big holes make it easier for me, but I don't necessarily go straight to Draf III. Like I was mentioning, in an AERD patient, I might actually consider that, but in a straightforward polyp patient, I will just do a normal frontal sinusotomy. If they were to recur quickly and topical medication wasn't helping, then in a revision surgery, I would consider doing a Draf III.
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Sinus Revision Surgeries: Endoscopic Maxillary Mega-Antrostomy & Draf III
In patients who have undergone a failed FESS, there are two options for revision surgery: a mega antrostomy or a Draf III. A mega antrostomy involves removing the posterior two-thirds of the inferior turbinate and drilling the medial wall all the way down to the nasal floor. A Draf III consists of a superior septectomy and drilling out the intersinus septum and the floor of the frontal sinuses over to the orbit.
Dr. Loftus notes that with patients who have ciliary disorders, such as cystic fibrosis or primary ciliary dyskinesia, she may perform a mega antrostomy instead of FESS in order to increase the efficacy of their nasal rinses.
[Dr. Patricia Loftus]
People also asked me about mega antrostomies, which I think is interesting. I really don't do mega antrostomies for eosinophilic CR nasal polyp patients. Where I would do mega antrostomies would be for the patients that we were recently talking about with the ciliary disorders. Maybe a CF patient or a primary ciliary dyskinesia patient, because they actually have issues with their cilia moving the mucus out of the sinuses correctly. If you can make that cavity kind of flush with the nasal floor, the rinses could get in there better. With patients who don't have those issues, their cilia should start working well again once you open everything up and you ventilate the sinuses.
They shouldn't really have issues doing that once everything is healed and no longer inflamed. I don't necessarily do mega antrostomies just for your normal nasal polyp patient, but would consider that in like a cystic fibrosis polyp patient or primary ciliary dyskinesia patient with polyps.
[Dr. Gopi Shah]
Patricia, just for our listeners, can you define mega antrostomy and define Draf III?
[Dr. Patricia Loftus]
Yeah. For a mega antrostomy, really, all you're doing is you're removing the posterior two-thirds of the inferior turbinate, and you are drilling that medial wall all the way down flush to the nasal floor. I always leave the anterior one-third of the turbinate there for empty nose purposes, and I do leave kind of like a little nub of the posterior inferior turbinate. One, to cauterize, because we know what vessel comes in through there that can bleed and cause problems, but also kind of to leave it as a landmark as well. And then you just drill the floor down. So, you're not taking the whole turbinate. You're not cutting coming through the nasolacrimal duct. You're really just bringing that wall all the way down, flush with the floor.
In medial maxillectomy, that's a little different because you are coming all the way anteriorly, sort of flush with the anterior wall of the sinus. In that case, the nasolacrimal duct is removed.
Then for Draf III, what's included in that is a superior septectomy, and basically drilling out the intersinus septum and the floor of the frontal sinuses over to the orbit. So, you want to go laterally enough that actually when you sort of push on the nasal bone or kind of the medial portion of the eye, your two periosteum. So, you'll see movement on the sides laterally, and that's when I know that I'm lateral enough. Bringing it back to the skull base where your landmark is, you want to find the first olfactory neuron. So, you see that, and that's as far back as you go. Then, anteriorly, you want to drill the frontal beak out. You're basically making this nice wide open cavity that rinse can really get in there very nicely.
Grafts & Stents for Nasal Polyps Surgery
Nasal stents are often placed in the sinuses after nasal polyps surgery in order to keep the sinuses open, prevent scar tissue development, and prevent inflammation. After opening and clearing the sinuses, Dr. Loftus sutures the middle turbinate to keep it close to the septum and in the medial position. Then, she usually places a PROPEL stent, an anti-inflammatory drug-eluting stent, in the sinus frontal recess area. She notes that silastic and silicone grafts are available as alternate stent options as well. In Draf III patients who have exposed bone from drilling, a mucosal graft can help the bone heal faster.
[Dr. Ashley Agan]
After surgery, I feel like everything looks nice and we've opened everything up. And then I'm always worried about scarring and those spaces closing back off. For the middle turbinate, I like to pexy it with a stitch to the septum to keep it medial. Do you have any tips or tricks? Do you leave a stent? Do you like the drug-eluting stents, like the PROPEL? I've seen people like plastic stents in the frontals. What are your thoughts on that?
[Dr. Patricia Loftus]
I will say that I'm a hundred percent with you with suturing the middle turbinate. I've tried different ways, NasoPore, other things like that, and I don't think there's anything that sutures those turbinates tightly to the septum. I'm completely with you on that. I think that really keeps the ethmoid cavity open. It's a good question that you bring up because with Draf III, some people will actually do mucosal grafting for the exposed bone from drilling. It does heal so nicely because it heals faster, quicker because you have that mucosal graft in there.
[Dr. Ashley Agan]
Where do they get the graft?
[Dr. Patricia Loftus]
They will either take it from maybe part of the septum that they removed. You can also get it from the inferior turbinate and you can get it from the nasal floor. Probably most people would just try to reuse that septal mucosa that they removed from the superior septectomy. And you do, I forgot to mention too, with the Draf III, you do have to take the middle turbinates back to the skull base. So, you could potentially use some middle turbinate mucosa as well. Some people will do that and it does heal very nicely. You can put a silicone or silastic stent up there to hold the grafts, or just in general, to help the healing process. I do think that is quite important when you do a Draf III, because you have exposed bone that is going to want to kind of scar down. I've done the silastic, and I think it works fine. I've actually recently been putting a PROPEL up into the Draf III cavity, and I do think that that works well too. It's kind of like an eluting steroid at the same time. I do think that that has been helpful. I don't actually do mucosal grafts because I think it will also heal without a mucosal graft, but you do have to debride these people frequently because the crusting of the exposed bone can get pretty bad.
Now, if you didn't do a Draf III, for just a frontal sinusotomy, the goal is to not strip the mucosa circumferentially, like you might have for a Draf III. If the AP diameter is pretty wide, a lot of times you actually don't need anything in there. I do know that there's people who will infuse Kenalog and some Stammberger foam and kind of shoot that up there, which is nice. It kind of gives just some topical stuff laying in there. If this was a polyp case, and I do think that polyps, well, we know that polyps do tend to mostly recur in the frontal recess ethmoid cavity area.
I do like to put up a PROPEL stent into the sinus frontal recess area after a polyp case to elute that steroid and keep things open. I don't use them in the ethmoid cavity ever. I never used the regular PROPEL stents because I think we do a good enough job opening the ethmoid cavity that we don't necessarily need the "stenting" effect of it. Irrigation does tend to get into that cavity pretty well, but where it doesn't always get is up into the frontal recess. That's why I do like to put something up there for polyp cases.
Dr. Patricia Loftus
Dr. Patricia Loftus is Assistant Professor in the Rhinology & Skull Base Surgery division in the Department of Otolaryngology – Head and Neck Surgery (OHNS) at the University of California, San Francisco.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, January 1). Ep. 13 – Treatment of Nasal Polyps [Audio podcast]. Retrieved from https://www.backtable.com
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