Advances in Medical and Surgical Therapy

Woodworth BA, Poetker DM, Reh DD (eds): Rhinosinusitis with Nasal Polyposis.
Adv Otorhinolaryngol. Basel, Karger, 2016, vol 79, pp 148–157 (DOI: 10.1159/000445153)

Advances in Surgery: Extended Procedures for

Sinonasal Polyp Disease
Jessica E. Southwood · Todd A. Loehrl · David M. Poetker 
Division of Rhinology and Sinus Surgery, Department of Surgery, Zablocki VA Medical Center, Milwaukee, Wis., USA

Abstract Introduction
In the standard functional endoscopic sinus surgery
(FESS) procedure, the amount of dissection is often deter- Sinonasal polyp disease has a prevalence estimat-
mined by the extent of disease with the goal to preserve ed at 0.2–4% in worldwide studies with a peak in-
as much normal mucosa as possible while restoring ven- cidence in the fifth decade of life [1, 2]. Nasal pol-
tilation and reestablishing mucociliary clearance. A sub- yps are often associated with chronic rhinosinus-
set of patients with chronic rhinosinusitis with nasal pol- itis, categorized in the broad phenotype of
yposis (CRSwNP), however, may continue to have chronic rhinosinusitis with nasal polyposis
persistent mucosal inflammatory and aggressive polyp (CRSwNP), a chronic disease with a prolonged
regrowth despite standard FESS and maximal pharma- clinical course. Curative treatment is difficult to
cology therapy, leading to recurrent and recalcitrant dis- achieve in CRSwNP and management is primar-
ease. Advanced endoscopic surgery techniques such as ily aimed at reducing symptom severity. The
the modified endoscopic medial maxillectomy, endo- mechanism by which surgery improves symptom
scopic modified Lothrop procedure, otherwise known as control in CRSwNP is incompletely understood.
a Draf 3 frontal sinusotomy, and nasalisation or radical The lack of high-quality evidence focusing on
ethmoidectomy are extensive surgical procedures to CRSwNP as well as the heterogeneity of the dis-
maximize disease clearance while providing sizeable ease itself leads to significant practice variation in
drainage pathways for effective postoperative surveil- planning the extent of surgery [3, 4]. Further-
lance and topical delivery of medications. Studies have more, the rate of postoperative polyp recurrence
shown a decreased risk of revision surgery as well as a has been reported to be as high as 60% [5, 6].
longer time interval for revision surgery in patients with Widespread mucosal inflammation with diffuse
refractory CRSwNP who have undergone extensive sinus polyposis, or more severe inflammatory disease
surgery for polyps. © 2016 S. Karger AG, Basel like that associated with cystic fibrosis (CF), may
144.82.108.120 - 8/17/2016 1:11:09 AM
Downloaded by:
UCL
be better treated with more extensive surgery to tient with polyps up to 8 years following initial
increase access for delivery of topical therapies in surgery.
the postoperative period [7]. The following chap- Soler et al. [13] performed a multi-institution-
ter focuses on extensive endoscopic surgical tech- al observational study which demonstrated no
niques for treating recalcitrant CRSwNP. difference in quality-of-life status after bilateral
middle turbinate (BMT) resection versus turbi-
nate preservation. Endoscopic exam, olfactory
Middle Turbinate Resection function using the Smell Identification Test and
three quality-of-life instruments (Rhinosinusitis
Controversy exists as to the decision to resect the Disability Index, Chronic Sinusitis Survey and
middle turbinate due to the described risks of Medical Outcomes Study Short Form-36 Health
atrophic rhinitis, cerebrospinal fluid leak, anos- Survey), were used to evaluate outcomes. There
mia, loss of surgical landmarks, postoperative ep- were 47 patients representing the BMT resection
istaxis and iatrogenic frontal sinusitis [8–10]. group and 195 patients representing the BMT
Those who advocate resection discuss improve- preservation group with an average follow-up of
ment in intraoperative and postoperative visual- 17.4 months for all subjects. The decision to re-
ization, decreased synechiae, improved patency sect or preserve the middle turbinate was based
of sinus ostia allowing for improved ventilation on the surgeon’s judgment, taking into account
and enhanced delivery of topical medications [11, the disease process as evidence by symptoms, CT
12]. It is theorized that the mucosa of the middle imaging and intraoperative findings. The tech-
turbinates itself may act as a conduit for potential nique of middle turbinate resection was described
polyp formation and the removal of this surface as removal of the anteroinferior two-thirds of the
area of mucosa may help to control polyp re- middle turbinate using through-cutting instru-
growth [11, 13]. Marchioni et al. [14] performed ments, leaving the superior sagittally oriented
a prospective study in a homogeneous case series portion as a landmark and a small posterior
of patients that underwent surgery exclusively for stump in the area of the sphenopalatine foramen.
severe nasal polyposis, comparing the results of Patients undergoing BMT resection were statisti-
those whose middle turbinate was resected and cally more likely to have comorbidities associated
those whose middle turbinate was preserved. with inflammatory processes and increased dis-
There was a statistically significant difference in ease burden with higher incidence of nasal pol-
proportion and time to relapse between the pa- yposis (BMT resection 55.3% vs. BMT preserva-
tients who underwent turbinate resection and tion 37.4%, p  = 0.025), and prior sinus surgery
those with turbinate preservation. Three of 22 pa- (BMT resection 85% vs. BMT preservation 61.5%
tients in the turbinate resection group had recur- p = 0.002) as well as asthma and aspirin intoler-
rence of polyposis on nasal endoscopy versus 17 ance. Patients undergoing BMT resection also
of 34 patients in the preservation group. The pa- tended to undergo more extensive sinus surgery
tients who underwent surgery with middle turbi- with a higher rate of concurrent total ethmoidec-
nate preservation were 4 times more likely to de- tomy, sphenoidotomy and frontal sinusotomy
velop recurrent disease than the patients who un- than those with BMT preservation. There were
derwent middle turbinate resection (hazard ratio greater improvements in endoscopy and Smell
4.06 with 95% CI 1.19–19.89) over the 36 month Identification Test scores following BMT resec-
follow-up period. Wu et al. [11] found the benefi- tion compared to turbinate preservation after
cial effect of middle turbinate resection to signifi- controlling for confounding factors. Soler et al.
cantly delay the time until revision surgery for pa- [13] conclude that the decision to preserve or re-
144.82.108.120 - 8/17/2016 1:11:09 AM

Extended Procedures for Sinonasal Polyp Disease 149

Downloaded by:

Woodworth BA, Poetker DM, Reh DD (eds): Rhinosinusitis with Nasal Polyposis.
UCL

Adv Otorhinolaryngol. Basel, Karger, 2016, vol 79, pp 148–157 (DOI: 10.1159/000445153)
sect the middle turbinate can be left to the discre- access. Inflammatory maxillary disease is im-
tion of the surgeon with little or no negative con- proved likely as a result of increased delivery of
sequences after sinus surgery. intranasal irrigation and improved access and
Keys to the middle turbinate resection include drainage of the inferior and dependent portions
taking the turbinate superiorly at the anterior at- of the maxillary sinus [20, 21]. Unlike gravity-aid-
tachment and performing a frontal sinusotomy ed drainage pathways of the frontal and ethmoid
(Draf 2A or B) to prevent lateralization of the sinuses, mucociliary clearance must work against
middle turbinate remnant and obstruction of the gravity in the maxillary sinus. The MEMM allows
frontal recess. Additionally, take great care to vi- more proficient gravity dependent drainage of
sualize the tips of the endoscopic scissors to avoid the maxillary sinuses postoperatively.
penetrating the skull base. Finally, consider elec- MEMM involves resection of the medial wall
trosurgical cautery of the posterior stump to of the maxillary sinus and a subtotal inferior tur-
avoid post-operative hemorrhage. binectomy [21]. Some authors advocate for pres-
ervation of the anterior one-third of the inferior
turbinate to prevent atrophic rhinitis and that a
Modified Endoscopic Medial Maxillectomy posterior stump of the inferior turbinate is main-
tained to allow cauterization of the branches of
Standard maxillary antrostomy is greater than the sphenopalatine artery [20]. The mucosa of the
90% effective in managing chronic maxillary si- lateral nasal wall of the inferior meatus is elevated
nusitis [15], allowing for improved aeration and in a subperiosteal plane with the base of the flap
drainage of the maxillary sinus as well as in- on the floor of the nose. After the medial maxil-
creased delivery of topical medications. Despite lary wall is resected, the appropriate boundaries
the high efficiency rates of this procedure, some of the MEMM are the floor of the nose inferiorly,
patients with CRSwNP fail standard maxillary an- the posterior wall of the maxillary sinus posteri-
trostomy for reasons still incompletely under- orly (with care to avoid the descending palatine
stood. Some theories suggest failure is related to nerve), and the lacrimal duct anteriorly. After
the underlying pathophysiology of dysfunctional completion of the MEMM, wide access to the
mucociliary transport as well as obstructed ostia maxillary sinus is achieved and polyps are re-
with polyp regrowth as well as chronic inflamma- moved without stripping the mucosa. Finally, the
tory mucosal disease [16]. The modified endo- previously raised mucosal flap is laid across the
scopic medial maxillectomy (MEMM) surgical exposed bone of the inferior maxilla into the max-
technique is an accepted approach to benign si- illary sinus (fig. 1).
nonasal tumor resection such as inverted papil- Konstantinidis and Constantinidis [22] re-
lomas and juvenile nasopharyngeal angiofibro- viewed the indications for a medial maxillectomy
mas [17, 18], however its role in recalcitrant in- and suggest various modifications of the proce-
flammatory disease specifically polypoid disease dure such as preserving the anterior aspect of the
is less well defined. MEMM has been shown to medial maxillary wall, which can be performed
increase the total sinus irrigation delivery in topi- depending of the pathology and extent of disease.
cal distribution studies in comparison to standard For more anterior access of the maxillary sinus,
maxillary antrostomy [19]. The increased access the medial maxillary wall may be removed, how-
to the maxillary sinus after MEMM permits large- ever this is not without the risk of nasolacrimal
volume, positive-pressure application of topical duct injury. Cho and Hwang [23] describe the en-
medications and affords increased mechanical re- doscopic maxillary mega-antrostomy which in-
moval of mucus to an area otherwise limited by volves extending the antrostomy through the
144.82.108.120 - 8/17/2016 1:11:09 AM

150 Southwood · Loehrl · Poetker

Downloaded by:

Woodworth BA, Poetker DM, Reh DD (eds): Rhinosinusitis with Nasal Polyposis.
UCL

Adv Otorhinolaryngol. Basel, Karger, 2016, vol 79, pp 148–157 (DOI: 10.1159/000445153)
 a b

c d

Fig. 1. MEMM technique. a Prior maxillary antros-

tomy, total ethmoidectomy, and middle turbinate
resection. b The left inferior turbinate was resected
leaving a 1.5 cm segment anteriorly and a stump
posteriorly which was cauterized. c A medially
based nasal flap from the medial wall of the maxil-
lary sinus and nasal floor was raised using a suction
elevator. d The superior mucosa was cut to release
the nasal flap. The medial wall of the maxillary sinus
was removed down to the floor of the nose with a
combination of through-cutting, grasping, and
powered instruments. The mucosa on the maxillary
sinus lumen side was removed. e The medially
e based nasal flap was laid over the underlying bone.
144.82.108.120 - 8/17/2016 1:11:09 AM

Extended Procedures for Sinonasal Polyp Disease 151

Downloaded by:

Woodworth BA, Poetker DM, Reh DD (eds): Rhinosinusitis with Nasal Polyposis.
UCL

Adv Otorhinolaryngol. Basel, Karger, 2016, vol 79, pp 148–157 (DOI: 10.1159/000445153)
posterior half of the inferior turbinate down to gic fungal rhinosinusitis (AFRS). CF patients rep-
the floor of the nose in recalcitrant maxillary si- resent a cohort of patients with disturbed muco-
nusitis. In their series, 74% of patients reported ciliary clearance who may continue to display
complete resolution of symptoms with no pa- problematic sinus disease after multiple previous
tients requiring revision during the 11-month fol- functional endoscopic sinus surgery (FESS) even
low-up. with patent maxillary antrostomy [25]. The sever-
In addition to greater topical drug delivery for ity of polypoid disease in patients with CF may
treatment of inflammatory paranasal sinus dis- predict the future likelihood of requiring revision
ease and affording improved dependent drainage FESS. The normal mucociliary clearance pathway
postoperatively, resection of the medial maxillary works against gravity and is impaired in CF pa-
wall allows for intraoperative access to the infe- tients leading to the accumulation of mucopuru-
rior and dependent portions of the maxillary si- lence in the largest of the sinus cavities despite
nus, an otherwise difficult area to clear polypoid previous adequate maxillary antrostomy. The
mucosa. MEMM has been shown to improve the maximum beneficial treatment and goals of the
surgical success rate for persistent inflammatory patients that require intervention are to provide a
sinus disease of the maxillary sinus [20, 21]. The permanent accessible means for medicinal and
canine puncture technique described by Sathan- mechanical removal of inspissated mucus and
anthar et al. [24] is also an effective method for polyps. Virgin et al. [25] prospectively evaluated
removal of maxillary sinus polyps and inflamma- 22 CF patients after undergoing MEMM who had
tory disease in the inferior aspect of the maxillary previously failed multiple FESS (mean of 4.9 prior
sinus. However, the MEMM procedure has the sinus operations). Aggressive sinus surgery com-
continued advantages of improving access to the bined with medical therapy improved not only
maxillary sinus in the postoperative setting and symptom and endoscopic scores, but also signifi-
improving gravity dependent drainage. cantly reduced the frequency of pulmonary exac-
Woodworth et al. reported a success rate of erbations requiring hospitalization (2.0 ± 1.4 vs.
MEMM in 18 out of 19 patients who had failed 3.2 ± 2.4, respectively; p < 0.05). Review of inves-
prior sinus surgery with an average follow-up of tigations regarding the use of MEMM in patients
19.5 months [21]. The majority of patients (14) with CF and chronic rhinosinusitis show low
had previously undergone Caldwell-Luc proce- complication rates for this procedure [26].
dures at outside institutions and were predis- AFRS patients represent another cohort of
posed to abnormal mucociliary clearance. The CRSwNP patients who may potentially benefit
only complication was one nasolacrimal duct in- from more extensive sinus surgery. Although
jury. Another study demonstrated resolution of medical therapy such as systemic and topical ste-
recalcitrant maxillary sinusitis in 37 out of 46 pa- roids and immunotherapy seem to be beneficial
tients (80%) who failed on average 3.4 prior sur- in disease management, endoscopic sinus surgery
geries before undergoing MEMM [20]. The aver- is the mainstay of treatment in the setting of per-
age time to recurrence of maxillary sinusitis was sistent obstruction with nasal polyposis and ac-
11.7 months for the remaining 20% of patients, cumulation of allergic fungal mucin. The goals of
however no patients in the series required revi- surgery include extirpation of allergic mucin and
sion surgery within the 37 month follow-up pe- fungal debris, permanent ventilation of drainage
riod [20]. pathways while maintaining intact mucosa, and
MEMM has been studied in certain subgroups postoperative access for monitoring of previously
of patients with CRSwNP known to have refrac- diseased areas [27]. Thulasidas and Vaidyanathan
tory disease such as cystic fibrosis (CF) and aller- performed MEMM in 37 maxillary sinuses of 24
144.82.108.120 - 8/17/2016 1:11:09 AM

152 Southwood · Loehrl · Poetker

Downloaded by:

Woodworth BA, Poetker DM, Reh DD (eds): Rhinosinusitis with Nasal Polyposis.
UCL

Adv Otorhinolaryngol. Basel, Karger, 2016, vol 79, pp 148–157 (DOI: 10.1159/000445153)
patients with recalcitrant maxillary sinusitis, four
of which had a diagnosis of AFRS [27]. The aver-
age time for follow-up in the AFRS patients was
19 months. All patients in the series including
those with AFRS had disease control without evi-
dence of recurrence.

Draf 3 Frontal Sinusotomy

The endoscopic modified Lothrop procedure

(EMLP), otherwise known as a Draf 3 frontal si-
nusotomy or frontal drillout, is a salvage proce-
dure for failed frontal sinusotomy or Draf 2b.
Frontal ostium size has previously been reported
as a risk factor for failure of the Draf 2b proce-
dure. The smaller the ostia, the greater the risk of Fig. 2. Completed Draf 3.
adhesion formation or risk of polyp recurrence
leading to complete occlusion of the frontal sinus
Table 1. Surgical steps for the outside-in modified endo-
ostium. The smaller ostium is also less likely to act scopic lothrop procedure modified from Chin et al. [28]
as a conduit for saline irrigations or other topical
therapies. Surgical Description
The surgical borders of the endoscopic Lothrop step
cavity are well characterized. Laterally the bound- 1 Clear mucosa over frontal process using the
aries are the orbital plates of the frontal bone and medial orbital wall as the lateral border
the periosteum of the skin overlying the frontal
2 Create a septal window
process of the maxilla. The first olfactory fasicle of
the olfactory bulb marks the posterior border. The 3 Clear mucosal lining of the nasal cavity
underneath the floor of the frontal sinus
anterior table of the frontal sinus demarcates the
anterior limit of dissection. Traditionally angled 4 Drill the remaining superior bony septum
endoscopes are used to identify one frontal recess 5 Develop the periosteal plane on each side
which is then followed by bony removal (fig. 2). In 6 Remove bone between the lateral borders
severe inflammatory disease however, identifying
7 Dissect bone anterior to the frontal recess
the frontal recess may prove challenging. Chin et
al. describe an ‘outside-in’ EMLP technique in 8 Complete the cavity by removing bone
between the cavity and the true frontal recess
which dissection of the frontal recess is initially (using a 2-mm Kerrison rongeur)
avoided until bone removal below the frontal si-
nus floor to the periosteum of the skin permits
wide access [28]. The frontal recess is actually dis-
sected last and the development of the Lothrop to minimize bleeding as well as to improve visual-
cavity occurs en route with early limits of dissec- ization of the ethmoid roof in relationship to the
tion defined during surgery (table 1). One advan- posterior frontal table or anterior skull base. The
tage of this technique is the avoidance of inflamed authors state that the risk of injury to the skull base
mucosa in the frontal recess early in the procedure is avoided during this anterior to posterior ap-
144.82.108.120 - 8/17/2016 1:11:09 AM

Extended Procedures for Sinonasal Polyp Disease 153

Downloaded by:

Woodworth BA, Poetker DM, Reh DD (eds): Rhinosinusitis with Nasal Polyposis.
UCL

Adv Otorhinolaryngol. Basel, Karger, 2016, vol 79, pp 148–157 (DOI: 10.1159/000445153)
proach by identification of the first olfactory fas- this patient cohort. Only 12 patients developed
cicle and the posterior edge of the septal window disease recurrence and persistence of symptoms
anterior to the cribriform. Stereotactic image requiring revision EMLP. The average length of
guidance, while helpful in confirming surgical follow-up was 45 months. All patients noted an
landmarks, is not significantly helpful in identify- improvement in overall postoperative symptom
ing the periosteum during this method. Chin et al. score which included nasal obstruction, facial
[28] describe 15 out of 30 patients that had a diag- pain, anosmia, anterior rhinorrhea and post nasal
nosis of CRSwNP, all with at least one prior sinus drip. No patient complained of worsening in their
surgery, 11 underwent the outside-in EMLP tech- symptoms following surgery. Of the 12 patients
nique and 3 underwent the standard Lothrop pro- requiring revision surgery, half (6 of 12) devel-
cedure. Other patients in their study had various oped recurrent polyposis occluding the frontal
pathology including chronic rhinosinusitis with- neo-ostium. Allergic fungal sinusitis with recur-
out nasal polyposis as well as benign and malig- rence of fungal debris and polyposis was noted to
nant sinonasal tumors. In the CRSwNP patients, be a significant risk of failure in the EMLP revi-
the frontal recess was either occupied by polyps or sion group, occurring in 7 of 12 patients. The un-
scarred off. Patients with CRSwNP undergoing derlying immunologic dysfunction in AFRS pa-
the outside-in EMLP had on average a shorter tients leads to recurrent polyposis which may oc-
procedure time than the standard Lothrop for all clude the frontal sinus and inhibit ventilation and
surgical patients (34.6 ± 11.56 vs. 69.6 ± 64.5 min). adequate delivery of topical steroid therapy. Oth-
The procedure time was not explicitly stated for er factors such as persistent colonization of the
the three CRSwNP patients who underwent the sinuses which is influenced by antibiotic sensitiv-
standard Lothrop procedure. The mean operative ity, environmental and immune factors, may lead
time included the time point from the commence- to scar tissue or osteogenesis and narrowing of
ment of drilling to connection to the frontal re- the frontal neo-ostium.
cess. Other operative components such as creation One technique, aimed at improving outcomes
of the anterior septal window and removal of mu- includes the use of mucosal grafts to cover the ex-
cosa over the frontal recess were not included. posed bone at the anterior border of the dissec-
There were no complications other than one pa- tion (fig. 3). Illing et al. [30] describe their tech-
tient with transient skin edema and no major nique of using either mucosa harvested from a
complications. turbinate or from the planned septectomy site to
Naidoo et al. [29] reviewed the long-term out- cover the exposed bone. They recently reported a
comes of the Draf 3 or frontal drill-out over a 10- 100% clinical success rate in patients at least 12
year time period. AFRS and recurrent Staphylo- months out from the technique.
coccus aureus infections were stated as potential The Draf 3 procedure has been shown to de-
risk factors for failure of the EMLP. In this study crease the risk of revision sinus surgery in CRSwNP,
229 patients underwent EMLP with a success rate especially in asthma and aspirin intolerant pa-
of 95% (217 of 229). Patients had undergone on tients. In a study by Bassiouni and Wormald [31],
average 3.8 standard ESS procedures prior to the the group of patients undergoing the Draf 3 proce-
EMLP. Over half of the patients (135 of 229) had dure had undergone previous complete spheno-
a diagnosis of CRSwNP. Patients underwent an ethmoidectomies and had medically resistant
EMLP only after standard FESS had failed and frontal sinus polyps. In addition to the Draf 3 pro-
had evidence of recurrent polypoid disease with cedure, these patients underwent a revision sphe-
persistence of symptoms despite maximal medi- noethmoidectomy and partial removal of the mid-
cal therapy. Patients with CF were excluded from dle turbinate. The middle turbinate was always
144.82.108.120 - 8/17/2016 1:11:09 AM

154 Southwood · Loehrl · Poetker

Downloaded by:

Woodworth BA, Poetker DM, Reh DD (eds): Rhinosinusitis with Nasal Polyposis.
UCL

Adv Otorhinolaryngol. Basel, Karger, 2016, vol 79, pp 148–157 (DOI: 10.1159/000445153)
 Radical ethmoidectomy is advocated by some
authors in the presence of very extensive polyps
in the paranasal cavities to decrease the likelihood
of early recurrence and functional failure [6, 32,
33]. The goal of nasalisation surgery is to trans-
form the ethmoid labyrinth into an open corridor
that can be reached by topical steroids [33]. The
essential elements to nasalisation are (1) a large
antrostomy and sphenoidotomy, (2) resection of
the middle turbinate, (3) removal of as much of
the ethmoid partitions and mucosa as safely as
possible and (4) procession of the dissection an-
teriorly towards the frontal ostium [33].
Jankowski et al. [6] compared the improvement
of symptoms associated with radical ethmoidecto-
my or nasalisation to functional standard ethmoid-
Fig. 3. Completed Draf 3 with a mucosal graft covering ectomy in patients with severe sinonasal polyposis
the anterior exposed bone. A Propel® drug eluding stent
5 years after the respective surgery. The criteria for
is used to hold the graft in place.
comparison were the recurrence rate of nasal pol-
yps using visual assessment on nasal endoscopy
partially removed in the Draf 3 procedure; how- and CT imaging, and functional symptom results
ever, it was never removed in the standard ESS from patients free of revision surgery who respond-
group. The overall revision rate reported in this ed to a questionnaire using visual analogue scales.
retrospective cohort study in 338 consecutive op- The questionnaire included symptoms of nasal ob-
erations was 18% (follow-up duration >12 months, struction, rhinorrhea, post-nasal drip, anosmia and
median of 29 months), with a 37% revision rate in the severity of each with 0 = disabling or severely
the FESS group versus 7% in the Draf 3 group (p < persistent symptoms and 10 = normal or complete
0.001). Survival analysis showed that the Draf 3 absence of symptoms. The overall nasal functional
significantly reduced the risk of revision surgery benefit was scored 8.41 ± 0.40 after nasalisation and
(hazard ratio = 0.258, p = 0.0026). 5.69 ± 0.83 after ethmoidectomy p = 0.002 in pa-
tients who did not require revision surgery. The to-
tal recurrence rate was 22.7% in the nasalisation
Nasalisation or Radical Ethmoidectomy group and 58.3% in the ethmoidectomy group (χ2 =
10.41, p < 0.01). The nasalisation group underwent
Nasalisation (or nasalization) is described as a significantly less revision procedures compared to
radical ethmoidectomy whereby all the bony la- the ethmoidectomy group (4 revision procedures
mellae and mucosa of the ethmoid is removed in in 3 of 33 patients of the nasalisation group vs. 14
addition to a large maxillary antrostomy, spe- revision procedures in 7 of 25 patients of the eth-
noidotomy, frontal ostium exposure and resec- moidectomy group, χ2 = 10.3, p < 0.01). Results of
tion of the middle turbinate [6]. The mucosa on this study must be considered with the clear limita-
the walls of the large sinuses and around the fron- tion that no validated outcome measures were used.
tal ostia is preserved. Septal deviation may also be Bonfils discussed the functional results of 194
addressed at the time of sinus surgery if thought patients with nasal polyps after complete spheno-
to impede delivery of topical steroid sprays. ethmoidectomy and inferior resection of the mid-
144.82.108.120 - 8/17/2016 1:11:09 AM

Extended Procedures for Sinonasal Polyp Disease 155

Downloaded by:

Woodworth BA, Poetker DM, Reh DD (eds): Rhinosinusitis with Nasal Polyposis.
UCL

Adv Otorhinolaryngol. Basel, Karger, 2016, vol 79, pp 148–157 (DOI: 10.1159/000445153)
dle turbinate [32]. Clinical symptoms and steroid roids decreased significantly from 4.31  ± 0.23
use were monitored before and after surgery us- courses preoperatively to less than one per year in
ing an actuarial analysis via the Kaplan–Meier life the seven years following nasalisation surgery.
table method 3- and 5-years post-operatively. The
5-year nasal obstruction control rate was 65.8%,
the severe posterior rhinorrhea control rate was Conclusion
82.9% and the anosmia control rate was 65.8%.
Patients considered to have secondary polyposis The goals of polyp management in CRSwNP are to
disease such as granulomatosis with polyangiitis, improve the airway and facilitate delivery of medi-
formerly known as Wegener’s granulomatosis, cations. Aggressive disease calls for aggressive sur-
Churg–Strauss syndrome or CF were excluded gery in order to remove obstructive polyps, create
from this study. There were 55 patients who had an open cavity for topical medication delivery and
undergone a previous sinonasal surgery including mechanical debridement, as well as postoperative
simple polypectomy (n = 16, 8.2%), Caldwell–Luc monitoring of polyp reoccurrence. Advanced en-
(n = 5, 2.6%), middle meatus antrostomy (n = 6, doscopic sinus surgery such as middle turbinate re-
3.1%), partial ethmoidectomy (n = 25, 12.9%) or section, MEMM, Draf 3 and nasalisation may not
septoplasty (n = 3, 1.5%). Only 8 patients (4.1% be appropriate for the majority of CRSwNP pa-
study population) developed recurrent nasal pol- tients; however, those with recalcitrant disease who
yposis requiring additional surgery with a mean have failed prior FESS and those with underlying
delay between the two procedures of 74 ± 13 mucociliary dysfunction have shown improve-
months. The number of short courses of oral ste- ment in disease control with these techniques.

References
1 Lange B, Holst R, Thilsing T, Baelum J, 6 Jankowski R, Pigret D, Decroocq F, 11 Wu AW, Ting JY, Platt MP, Tierney HT,
Kjeldsen A: Quality of life and associated Blum A, Gillet P: Comparison of radical Metson R: Factors affecting time to revi-
factors in persons with chronic rhinosi- (nasalisation) and functional ethmoid- sion sinus surgery for nasal polyps: a
nusitis in the general population: a pro- ectomy in patients with severe sinonasal 25-year experience. Laryngoscope 2014;
spective questionnaire and clinical polyposis. A retrospective study. Rev 124:29–33.
cross-sectional study. Clin Otolaryngol Laryngol Otol Rhinol (Bord) 2006;127: 12 Toffel PH: Secure endoscopic sinus sur-
2013;38:474–480. 131–140. gery with partial middle turbinate modi-
2 Johansson L, Akerlund A, Holmberg K, 7 Chin D, Harvey RJ: Nasal polyposis: an fication: a 16-year long-term outcome
Melén I, Bende M: Prevalence of nasal inflammatory condition requiring effec- report and literature review. Curr Opin
polyps in adults: the skövde population- tive anti-inflammatory treatment. Curr Otolaryngol Head Neck Surg 2003;11:
based study. Ann Otol Rhinol Laryngol Opin Otolaryngol Head Neck Surg 2013; 13–18.
2003;112:625–629. 21:23–30. 13 Soler ZM, Hwang PH, Mace J, Smith TL:
3 Hopkins C, Browne JP, Slack R, et al: 8 Kennedy DW: Middle turbinate resec- Outcomes after middle turbinate resec-
The national comparative audit of sur- tion: evaluating the issues – should we tion: revisiting a controversial topic.
gery for nasal polyposis and chronic resect normal middle turbinates? Arch Laryngoscope 2010;120:832–837.
rhinosinusitis. Clin Otolaryngol 2006; Otolaryngol Head Neck Surg 1998;124: 14 Marchioni D, Alicandri-Ciufelli M, Mat-
31:390–398. 107. tioli F, et al: Middle turbinate preserva-
4 Sharma R, Lakhani R, Rimmer J, Hop- 9 Nurse LA, Duncavage JA: Surgery of the tion versus middle turbinate resection
kins C: Surgical interventions for chron- inferior and middle turbinates. Otolar- in endoscopic surgical treatment of na-
ic rhinosinusitis with nasal polyps. Co- yngol Clin North Am 2009;42:295–309, sal polyposis. Acta Otolaryngol 2008;
chrane Database Syst Rev 2014; ix. 128:1019–1026.
11:CD006990. 10 Vleming M, Middelweerd RJ, de Vries 15 Kennedy DW, Zinreich SJ, Shaalan H,
5 Wynn R, Har-El G: Recurrence rates N: Complications of endoscopic sinus Kuhn F, Naclerio R, Loch E: Endoscopic
after endoscopic sinus surgery for mas- surgery. Arch Otolaryngol Head Neck middle meatal antrostomy: theory, tech-
sive sinus polyposis. Laryngoscope 2004; Surg 1992;118:617–623. nique, and patency. Laryngoscope 1987;
114:811–813. 97(8 pt 3 suppl 43):1–9.
144.82.108.120 - 8/17/2016 1:11:09 AM

156 Southwood · Loehrl · Poetker

Downloaded by:

Woodworth BA, Poetker DM, Reh DD (eds): Rhinosinusitis with Nasal Polyposis.
UCL

Adv Otorhinolaryngol. Basel, Karger, 2016, vol 79, pp 148–157 (DOI: 10.1159/000445153)
16 Richtsmeier WJ: Top 10 reasons for en- 22 Konstantinidis I, Constantinidis J: Me- 28 Chin D, Snidvongs K, Kalish L, Sacks R,
doscopic maxillary sinus surgery failure. dial maxillectomy in recalcitrant sinus- Harvey RJ: The outside-in approach to
Laryngoscope 2001;111(11 pt 1):1952– itis: when, why and how? Curr Opin the modified endoscopic lothrop proce-
1956. Otolaryngol Head Neck Surg 2014;22: dure. Laryngoscope 2012;122:1661–
17 Fyrmpas G, Konstantinidis I, Constan- 68–74. 1669.
tinidis J: Endoscopic treatment of juve- 23 Cho DY, Hwang PH: Results of endo- 29 Naidoo Y, Bassiouni A, Keen M,
nile nasopharyngeal angiofibromas: our scopic maxillary mega-antrostomy in Wormald PJ: Long-term outcomes for
experience and review of the literature. recalcitrant maxillary sinusitis. Am J the endoscopic modified lothrop/draf III
Eur Arch Otorhinolaryngol 2012;269: Rhinol 2008;22:658–662. procedure: a 10-year review. Laryngo-
523–529. 24 Sathananthar S, Nagaonkar S, Paleri V, scope 2014;124:43–49.
18 Carta F, Verillaud B, Herman P: Role of Le T, Robinson S, Wormald PJ: Canine 30 Illing EA, Cho DY, Riley KO, Wood-
endoscopic approach in the manage- fossa puncture and clearance of the worth BA: Draf III mucosal graft tech-
ment of inverted papilloma. Curr Opin maxillary sinus for the severely diseased nique: long-term result. Int Forum Al-
Otolaryngol Head Neck Surg 2011;19: maxillary sinus. Laryngoscope 2005;115: lergy Rhinol 2016;6:514–517.
21–24. 1026–1029. 31 Bassiouni A, Wormald PJ: Role of fron-
19 Harvey RJ, Goddard JC, Wise SK, 25 Virgin FW, Rowe SM, Wade MB, et al: tal sinus surgery in nasal polyp recur-
Schlosser RJ: Effects of endoscopic sinus Extensive surgical and comprehensive rence. Laryngoscope 2013;123:36–41.
surgery and delivery device on cadaver postoperative medical management for 32 Bonfils P: Evaluation of the combined
sinus irrigation. Otolaryngol Head Neck cystic fibrosis chronic rhinosinusitis. medical and surgical treatment in nasal
Surg 2008;139:137–142. Am J Rhinol Allergy 2012;26:70–75. polyposis. I: functional results. Acta
20 Wang EW, Gullung JL, Schlosser RJ: 26 Chaaban MR, Kejner A, Rowe SM, Otolaryngol 2007;127:436–446.
Modified endoscopic medial maxillec- Woodworth BA: Cystic fibrosis chronic 33 Jankowski R, Bodino C: Evolution of
tomy for recalcitrant chronic maxillary rhinosinusitis: a comprehensive review. symptoms associated to nasal polyposis
sinusitis. Int Forum Allergy Rhinol Am J Rhinol Allergy 2013;27:387–395. following oral steroid treatment and
2011;1:493–497. 27 Thulasidas P, Vaidyanathan V: Role of nasalization of the ethmoid – radical
21 Woodworth BA, Parker RO, Schlosser modified endoscopic medial maxillec- ethmoidectomy is functional surgery for
RJ: Modified endoscopic medial maxil- tomy in persistent chronic maxillary NPS. Rhinology 2003;41:211–219.
lectomy for chronic maxillary sinusitis. sinusitis. Int Arch Otorhinolaryngol
Int Forum Allergy Rhinol 2006;20:317– 2014;18:159–164.
319.

David M. Poetker, MD, MA

Division of Rhinology and Sinus Surgery
Department of Otolaryngology and Communication Sciences
Medical College of Wisconsin
9200 West Wisconsin Avenue
Milwaukee, WI 53226 (USA)
E-Mail [email protected]
144.82.108.120 - 8/17/2016 1:11:09 AM

Extended Procedures for Sinonasal Polyp Disease 157

Downloaded by:

Woodworth BA, Poetker DM, Reh DD (eds): Rhinosinusitis with Nasal Polyposis.
UCL

Adv Otorhinolaryngol. Basel, Karger, 2016, vol 79, pp 148–157 (DOI: 10.1159/000445153)