Surgical treatment of nasal polyposis in patients with aspirin intolerance

It is not fully understood why humans possess paranasal sinuses and for many years there has been speculation as to their physiological significance.1 Much the same uncertainty holds true for the pathophysiology of chronic paranasal sinusitis, a disease which represents a major therapeutic challenge despite recent medical and surgical progress.2 3 There are probably several distinct subtypes of chronic paranasal sinusitis ranging from remote mucosal thickening to diffuse polyposis. All types of symptomatic chronic sinusitis call for surgical intervention if medical treatment fails. Corresponding to the diversity of chronic sinusitis, different microsurgical operative techniques have been developed during the last 15 years, all of which share the endonasal access route. Transfacial or transoral surgery has therefore become obsolete for treatment of uncomplicated paranasal mucositis. Many cases with circumscribed hyperplastic changes of the remote paranasal sinus mucosa need only limited surgery of the superordinate anatomical ostiomeatal unit. Removing defined microanatomical narrow passes around this functional key area of the middle nasal meatus (“isthmus surgery”) facilitates drainage and ventilation of the dependent paranasal sinuses (fig 1). Even severe changes in the peripheral sinus mucosa may heal subsequently without being specifically treated.4 5 Figure 1 Scheme depicting the different surgical concepts: “isthmus surgery”, “compartment surgery”, and radical surgery. In isthmus surgery (functional endonasal sinus surgery, FESS) defined anatomical narrow passes are eliminated under optical control using microsurgical techniques. Areas of secondary and moderate tissue remodelling are left for spontaneous regeneration. Tissue ablation and tissue trauma are minimised and the postoperative healing period is reduced. On the other hand, small irregularities of the microanatomical operative field may become significant factors in delayed healing. Defined narrow passes or inflammatory foci may fail to be addressed during surgery. Chronic sinusitis caused by defined microanatomical aberrations is the main indication for this type of surgery.4 …