In‐clinic endoscopic polypectomy for chronic rhinosinusitis with polyps: a treatment strategy pilot study in ten adults

Dear Editor, Chronic rhinosinusitis is a common problem that is estimated to affect at least 5% of the Canadian population.1 It is a chronic disease that is associated with significant morbidity.2 In general, surgical treatment for chronic rhinosinusitis has been demonstrated to profoundly modify the impact of the symptoms of this disease, and its overall impact on the affected individual.3 Chronic rhinosinusitis with polyps has as its primary symptom, severe nasal obstruction. This is often accompanied by hyposmia or anosmia and significant nasal congestion.4 Sinus surgery relieves the most prominent symptom, nasal obstruction, but the symptom of dysosmia improves in only 50% of patients.5 Endoscopic polypectomy performed in clinic (EPIC) is a treatment strategy utilised at the Ottawa Hospital Rhinology clinic. Anecdotally, patients who have undergone the procedure report subjectively significant improvement in most of their symptoms of CRS and satisfaction with the treatment. A review of current literature reveals that there is no published literature that prospectively evaluates the effects of in-clinic endoscopic nasal polypectomy in patients with chronic rhinosinusitis with polyps. The objective of this pilot study was to gain insight into the symptomatic change that occurs with the EPIC procedure for patients with CRS with polyps and the institutional cost of this procedure. The ethics review board of the Ottawa Hospital approved the study (protocol No. 20130104-01H) so that clinical measures of CRS could be collected that are not part of the routine care associated with the EPIC procedure. Written consent was obtained from all participants. A prospective case series pilot study was performed from May 2013 to January 2014 at a tertiary care academic centre in Ottawa, Canada. The primary investigator was responsible for enrolment, consent and performance of the endoscopic polypectomy procedure. Postoperative data were collected at 3 months. Patient selection included a current diagnosis of chronic rhinosinusitis with unilateral or bilateral grade 3 or 4 nasal polyps and the primary symptom of nasal obstruction, 18 years of age or older and having failed medical treatment for chronic rhinosinusitis.4 Study participants were already awaiting a scheduled EPIC procedure. Patients were asked to participate in the study to evaluate their clinical response to this treatment. Reasons for exclusion from undergoing the EPIC procedure included hyperplastic polyps, a known untreated bleeding disorder, known sensitivity to local or topical analgesics, allergic fungal sinusitis, cystic fibrosis, or underlying systemic vasculitis. The EPIC procedure was performed in the outpatient clinic with a sinus microdebrider using a 4-mm straight blade under both topical and local anaesthesia for analgesia. Injectable 1% lidocaine with 1:200 000 adrenaline was endoscopically infiltrated into polyps in the nasal cavity and middle meatus using a 25-ga needle. Topical 4% lidocaine mixed equally with 1:1000 topical adrenaline (10 mL in total) was applied to the nasal cavity and middle meatus on cotton pledgets soaked with the solution. Ten to fifteen minutes was allowed to pass prior to commencing the polypectomy. The entire procedure was performed with the participant in an upright sitting position. A 2.9-mm endoscope with video tower was used for visualisation during the procedure. A complete polypectomy was performed of all polyps within the nasal cavity, middle meatus and sphenoethmoidal recess without sinus dissection. Patients were not asked to be NPO prior to the procedure. The primary outcome of interest for this pilot study was the change in the Sinonasal Outcome Test(SNOT)-22.6 It was completed in clinic prior to the EPIC procedure and again at 3 months following the procedure. Peak nasal inspiratory flow was a secondary outcome measure and it was measured with a Youlten-type nasal flow meter (Clement Clarke International, Essex, UK), an objective measure of nasal airflow. The peak nasal inspiratory flow was measured immediately before and after the EPIC procedure and again at the 3-month follow-up evaluation. The mean of three attempts was calculated. Discomfort associated with the polypectomy procedure was another secondary outcome of interest. This was evaluated using a 100-mm visual analogue scale with 0 mm corresponding to ‘no pain’ and the 100 mm corresponding to ‘extreme pain’.7 The scale was completed immediately following endoscopic polypectomy. An enterprise case costing system of analysis was used to estimate the institutional cost of the EPIC procedure. This includes all costs for the procedure for the institution; this does not include physician billing, which is not part of the institutional expenses. Given there are no publications on the clinical effects of endoscopic polypectomy for patients with chronic rhinosinusitis with nasal polyps performed in the clinic, this pilot study was designed as a case series of ten consecutive patients as an initial evaluation of the procedure's clinical effects. Statistical analysis was performed using spss software (version 15.0, Chicago, IL, USA, SPSS, Inc.). Paired Student's t-test was used to compare the mean Sinonasal Outcome Test-22 score. Wilcoxon sign-rank test for paired samples was used to compare peak nasal inspiratory flow values. Spearman correlation coefficient was used to investigate association between change in scores for each of the four subscales of the Sinonasal Outcome Test-22 and the change in the overall score after treatment. Ten patients were enrolled in the study and all participants completed all of the study procedures (see Table 1). Sixty per cent of patients resumed the use of their intranasal corticosteroid spray (mometasone furoate 50 mcg/spray, 100 mcg/nasal cavity daily) following the procedure, despite all participants being advised to do so. No other medications were prescribed to participants before or after the procedure. There was a substantial reduction in both the subjective and objective levels of nasal obstruction following endoscopic polypectomy. The mean SNOT-22 score dropped significantly (P < 0.001) between the baseline (46.3, sd = 13.62) and follow-up measures (18.9, sd = 14.91) (Table 2). The change in the sleep function subscale of the SNOT-22 was the only subscale to be highly correlated with the change in the overall score with treatment (Table 3). Objective measures of nasal airflow showed similar significant improvements (P = 0.005) with the median peak nasal inspiratory flow before the endoscopic polypectomy of 30 L/min (range: 30-78.33 L/min) improving to a median of 92.14 L/min (range: 44.70–116.7) 3 months following treatment (Fig. 1). There was no significant difference between the median postoperative (96.67 L/min) and 3-month follow-up peak nasal inspiratory flow values (P = 0.114). There was minimal discomfort associated with the procedure (mean = 1.93; sd = 14.9), and there were no complications during or after the procedure. The institutional cost for an endoscopic polypectomy was $279 Canadian Dollars. This pilot study demonstrated benefit to patients through a substantial improvement in nasal obstruction that was sustained over the follow-up period. In fact, the SNOT-22 and peak nasal inspiratory flow results both before and 3 months following polypectomy are not dissimilar from results in the literature for patients with chronic rhinosinusitis with polyps who have undergone formal endoscopic sinus surgery.5, 8 Given the procedure was performed on patients with considerable nasal polyps, one may expect the nasal airflow to improve. However, the substantial change seen in the SNOT-22 score associated with the EPIC procedure was not expected. The EPIC procedure was performed with adequate patient analgesia as participants rated their procedural discomfort to be mild. It should be noted that an appointment for a patient presenting for the EPIC procedure takes about an hour in total. The actual EPIC procedure may take 5 to 20 min depending on the nature of a patient's disease and whether there is septal pathology to work around. Patients are ambulatory to leave clinic following the procedure and receive a moustache dressing, to be removed once home. In this study, and generally, the EPIC procedure has been used for patients with considerable nasal obstruction related to their polyp size (at least grade 3); however, the procedure could be performed for patients with smaller nasal polyps should they be sufficiently symptomatic. Comparatively, the institutional cost of endoscopic polypectomy was calculated at $279 Canadian dollars per treatment versus the total institutional cost for endoscopic sinus surgery which is estimated at $1800.9 Endoscopic sinus surgery is performed in an operating room, utilising significant human resources, equipment and space necessary for the entire operative visit to be completed. Endoscopic polypectomy uses limited clinical space and few human resources. Given the current study was a pilot study, the findings must be interpreted with caution. Although the Lund–MacKay scores of participants were similar to cohorts in the literature that undergo endoscopic sinus surgery, the size of the pilot study does impact its generalisability and the lack of a comparator group does not allow for direct comparisons with the current standard of treatment. However, the current study does provide an initial insight into the clinical benefits of endoscopic polypectomy performed in clinic for this patient population. This pilot study has shown substantial benefit in performing endoscopic polypectomy in clinic for effective symptom relief in patients with CRS with nasal polyps and a primary symptom of nasal obstruction. However, the effects of this procedure require further evaluation for the duration of effect and for comparison to endoscopic sinus surgery. Finally, the EPIC procedure can be completed for a much lower institutional cost in comparison with traditional endoscopic sinus surgery. None to declare.