What is the role of surgery in the treatment of pediatric nasal polyps?

Updated: Oct 25, 2019
  • Author: John E McClay, MD; Chief Editor: Ravindhra G Elluru, MD, PhD  more...
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Answer

Surgical intervention is required for children with multiple benign nasal polyposis or chronic rhinosinusitis in whom maximal medical therapy fails. Simple polypectomy is effective initially to relieve nasal symptoms, especially for isolated polyps or small numbers of polyps. (See the image below.) In benign multiple nasal polyposis, polypectomy is fraught with a high recurrence rate.

Scale is in inches. The left side of the lesion wa Scale is in inches. The left side of the lesion was the portion of the polyp in the nasal cavity. The right was a stalk attached to the medial maxillary wall.

ESS is a better technique that not only removes the polyps but also opens the clefts in the middle meatus, where they most often form, which helps decrease the recurrence rate. The exact extent of the surgery needed, whether complete extirpation (ie, Nasalide procedure) or simple aeration of the sinuses, is not entirely known, simply because of the dearth of studies. Rare comparisons show that complete extirpation procedures are as effective as or superior to aeration of the sinuses; complication rates are low with experienced surgeons. The use of a surgical microdebrider has made the procedure safer and faster, providing precise tissue cutting and decreased hemostasis with better visualization. (See the images below.)

A surgical microdebrider entering the middle meatu A surgical microdebrider entering the middle meatus. The septum is on the far left. The middle turbinate is in the left center. The surgical microdebrider is on the inferior center. Inferior turbinate is seen on the bottom right. Some blood overlying the ethmoid cavity is noted where polyps were present in the center of the picture.
Endoscopic view of the left middle meatus, showing Endoscopic view of the left middle meatus, showing the septum on the left, the middle turbinate in the center superiorly, and a large maxillary antrostomy with a curved suction on the right. This is following antral-choanal polyp removal.

Surgery is directed at diseased tissue that is apparent on computed tomography (CT) at the time of surgery. Patients with diseases such as CF, primary ciliary dyskinesia syndrome, or Young syndrome may proceed to surgery without extensive medical treatment because these diseases usually do not respond well to corticosteroid treatment. Once diseased tissue has been removed from the nasal cavity and sinuses, the pulmonary systems usually improve.

Use of an image-guided system should be considered for defining the exact location of intranasal, sinus, orbital, and intracranial structures for massive polyposis or revision surgery because surgical landmarks may be absent or altered.

For specific techniques in pediatric sinus surgery, with and without polyps, see Pediatric Sinusitis, Surgical Treatment.

Nasal polyposis occurs in 6-48% of children with CF. Surgery is performed when children become symptomatic. Recurrence of polyps in CF is almost universal, necessitating repeat surgery every few years. In fact, recurrence is typical for many diseases that cause nasal polyps; patients should receive preoperative counseling about this possibility.

For lesions other than benign nasal polyps that result in a nasal polyp, the polyp should be biopsied or removed, depending on the disease process.


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