Nasal polyps

Nasal polyps treatment

If a patient with nasal polyps is diagnosed with Kartagener's syndrome (triad: nasal polyposis, bronchiectasis and the opposite arrangement of internal organs) or Walk's syndrome (juvenile recurrent nasal polyposis accompanied by deformation of the external nose and intestinal damage), greater persistence in treatment is required (repeated operations, etc. ).

 

Polypotomy and cryopolypotomy of the nose

After conventional surgical interventions (especially radical type) for nasal polyps, atrophic changes with the formation of crusts are often subsequently observed, which, of course, affects nasal breathing and other physiological functions of the nose. Therefore, in children with nasal polyps, it is better to limit oneself to sparing surgical intervention - removal of polyps and only in more stubborn cases combine it with the opening of the ethmoid sinus cells.

Even the most radical surgical interventions do not prevent the recurrence of nasal polyps. From this point of view, cryotherapy may be the preferred treatment for nasal polyps. In this case, preliminarily remove the bulk of the polyps in the usual way, and then, by means of cryotherapy, more thorough removal of the remains is carried out. Small polyps are frozen under the control of an operating microscope using a thin cryoprobe. If the olfactory gap is freed during cryoinfluence, the sense of smell improves, and after the removal of polyps from the area of the natural openings of the paranasal sinuses, the function of the latter is often restored.

Anesthesia during cryopolypotomy of the nose can be carried out with weaker anesthetics than usual: 0.5-1% dicaine solution or 3-5% cocaine solution with the addition of 0.1% adrenaline solution. Not only polyps and their attachment sites are anesthetized, but also the entire half of the nasal cavity, since the instruments will touch its various parts. At the same time, the spread of polyps in the nose is determined and a plan for cryotherapy is outlined.

The cryoprobe with the selected removable tip is removed cooled from the Dewar vessel (thermos) and applied to the polyp. The cryoprobe is immediately frozen to it. Traction is performed, the polyp is removed and, together with the cryoprobe, is immersed in a previously prepared vessel with hot water - the polyp frozen to the cryoprobe is quickly rejected. Then the procedure is repeated. Smaller polyps can be removed by successive cryotherapy. If the leg of the polyp is very thick, but it is large, a slight rotation of the polyp around the axis helps the extraction. The cryoprobe is placed between the branches of the nasal dilator, which protects the mucous membrane of the nasal cavity from the effects of cold. In some cases, after the intervention, it is possible to refuse nasal tamponade, which is painful for children and sometimes complicates the course of the postoperative period. Usually, 9-12 cryotherapy sessions are performed.

 

Endoscopic surgery

Endoscopic surgery is performed at any age. After a conventional nasal polypotomy or cryopolypotomy, sometimes not only nasal breathing but also the sense of smell improves. If hypo- or anosmia remains, the reason for this may be small polyps or their remnants, not visible, deep in the nasal cavity. If the operation aims to improve not only nasal breathing, but also the sense of smell, then first remove the bulk of the polyps without the use of surgical optics, and then - their remnants under the control of an operating microscope. It is generally better to remove small polyps under the control of a microscope, which allows maintaining the integrity of the unchanged mucous membrane. Polyps originating from the upper posterior part of the nasal cavity, where the sieve plate of the ethmoid bone is located, is removed with special care and caution (without traction) under the control of vision and surgical optics.

Before the endonasal opening of the ethmoid sinus, the child's nasal cavity is carefully examined. If it is wide, the middle turbinate can serve as a guide for the intervention. With a narrow nasal cavity, it is advisable to first provide wide access to the ethmoid sinus (by submucosal resection of the nasal septum, redressing the inferior turbinate). The middle turbinate can be displaced by the branches of the Killian's nasal speculum to the nasal septum and the cells underneath can be opened. The anterior, middle, and then posterior groups of ethmoid sinus cells are opened in turn to the sphenoid sinus, creating a single cavity. To open the ethmoid sinus, the middle turbinate is often resected at its base, some of the cells are removed, forming a wide communication between the sinus and the nasal cavity. External methods of opening the ethmoid sinus in children are rarely used.

In adolescents and adults, nasal polyps are understood as changes in which normal mucous tissue, increasing, forms a thin connective tissue cavity with intertwining strands, while a large volume of mucous contents is determined in the cells. Typically, polyps have a slender stem extending from the lateral surface of the middle turbinate or surrounding parts. They protrude from the middle nasal passage - the area where the exit mouths of the maxillary and frontal sinuses are located.

It should be remembered that, in addition to polyps, curvature, and protrusions of the nasal septum, diffuse or limited hypertrophy of the mucous membrane, as well as an increase in the pharyngeal tonsil can lead to difficulty in nasal breathing. It is with these conditions that the differential diagnosis of polyps is primarily carried out, although this list could be continued.

The histological examination allows confirming the presence of polyps. Also, with the development of polyps from childhood and a significant number of them, the bony parts of the nose increase in size, which gives the face a typical appearance. Removal of nasal polyps is carried out not by pulling them out with forceps, but by more gentle separation with a loop. Removing all polyps in one step (cases of single polyps are extremely rare) usually fails. The operation carried out with cocaine anesthesia, is almost painless and is accompanied by minor bleeding.

Nasal polyps often grow again in terms of several months to tens of years. Recurrence of nasal polyps can be caused by:

1. insufficient complete removal of polyps;
2. deep inflammation reaching the bone marrow;
3. undetected inflammatory condition of the paranasal sinuses;
4. polypous degeneration of the mucous membrane of the lining cavity.

What is the difference between the treatment of hypertrophy of the mucous membrane of the nasal concha and polyps? Nasal polyps are removed exclusively by surgery, while local drug treatment gives favorable results in case of thickening of the mucous membrane. Several sessions are needed to remove polyps; hypertrophic enlargements of the turbinate can be removed in one go (with preliminary anesthesia with cocaine and exsanguination with appropriate drugs). When removing polyps, they do not resort to tamponade of the nose, and after removing even small-sized hypertrophied parts of the turbinates for 1-2 days, the nose is left tamponized (although, if the patient remains under constant supervision in the clinic, some surgeons do not tamponade, which is very risky) ... After a properly performed operation to remove hypertrophic enlargements of the nasal mucosa, relapse is rare.

 

Ethmoid sinus microscopic surgery

Ethmoid sinus microsurgery is performed after lubrication of the middle turbinate and middle nasal passage with 0.1% adrenaline solution. 2% pyromecaine solution and mucosal infiltration with 0.5% novocaine solution. With a tendency to psychomotor agitation, it is advisable to use combined anesthesia: neuroleptanalgesia with droperidol and fentanyl in combination with local anesthesia.

The cells of the ethmoid sinus are opened with microinstruments under the control of an operating microscope. The use of this technique intervenes as gently as possible, avoids various complications, and helps to improve the rest of the sinuses. Under the control of surgical optics, only pathologically altered tissues are removed. Using various magnifications during the operation, the condition of the membrane of the sinus cells is assessed. Both ethmoidotomy and ethmoidectomy are best performed using surgical optics, since ethmoid sinus cells, especially in the posterior region, are difficult to distinguish when viewed with the naked eye and may not be completely removed.

In the postoperative period, the mucous membrane of the cells of the opened sinus is anemised, washed with various antiseptic solutions, and drug therapy and physiotherapy are continued.