Letters to the Editor
To the Editor: Dr Salman,’ in his article on the complications of endoscopic sinus surgery (ESS), reports that significant bleeding occurred in 10 patients with nasal polyposis. Seven of these patients underwent previous surgery. I understand the advantage of magnification in ESS procedures, which allows the surgeon to visualize the ostial areas of the sinuses. However, in the presence of nasal polyposis, one is excising relatively large masses of tissue from a nasal cavity in which the landmarks are distorted or no longer present, especially in patients who underwent previous surgery. An endoscope, in this situation, presents disadvantages rather than advantages. Bolger and Kennedy,’ in their review of current approaches to managing sinusitis, describe the endoscope as permitting “clear visualization of key intranasal structures and controlled, safe, surgical resection.” They describe medical treatment with steroids as the primary modality in management of nasal polyposis, mentioning that steroids can be useful in both preparing a patient for surgery and in postoperative management. They emphasize the endoscopic exposure of landmarks in the ostiomeatal complex in the management of sinusitis but do not describe the use of the endoscope in the removal of the polyps themselves. Dr Salman’ leads one to believe that the endoscope was used extensively during the procedures described. My concern is that the endoscope is being used inappropriately in excising nasal polyps, converting a rather simple operation into a hightech procedure with increased complications and costs. The preferred approach, as voiced by Bolger and Kennedy,2 is the topical or short systemic use of steroids followed by excision, if necessary. The landmarks of most importance are the roof and lateral wall of the nose, both of which can easily be identified without magnification. Violation of these areas should not be risked in order to excise the last vestige of polypoid tissue, as regrowth is best controlled with topical steroids rather than aggressive excision. Enlargement of the natural ostium of the maxillary sinus may be helpful and could be facilitated with the endoscope, but the role of the endoscope should be limited in these cases and its actual use defined in any reports. I would be most interested in knowing whether
394
American Journal of Otolaryngology,
Dr Salman used the endoscope when he removed the nasal polyps in the patients described, or whether he limited the use of the endoscope to identification of landmarks on the lateral nasal wall. I would hope that his use of ESS is limited in patients with nasal polyposis, and I would hope that those performing ESS limit its use in patients with such pathology. This will make the surgery safer and allow for better visualization of key intranasal structures, an end to be desired in intranasal surgery. JOEL F. LEHRER, MD Clinical Associate Professor of OtoJaryngoJogy University of Medicine and Dentistry of New Jersey Newark, NJ
REFERENCES 1. Salman SD: Complications of endoscopic sinus surgery. Am J Otolaryngol 12:326-328, 1991 2. Bolger WE, Kennedy DW: Current perspectives on sinusitis in adults. J Respir Dis 13(3):421-448, 1992
Reply:
I appreciate the opportunity to respond to Dr Lehrer’s comments and questions. I think the rigid scopes have improved sinus surgery and reduced its complications. Their successful use, however, requires familiarity and training. In addition to their excellent optics, they allow a deeper access and an angular vision. Once the scopes are available in the office and in the operating room, and with experience, the slight increase in cost (sterilization and wear and tear) is outweighed by the gains. At present, I tend to use them to advantage almost routinely in polyp surgery and in sinus surgery, both functional and ablative. I certainly agree that nasal polyps need to be treated medically first. Surgery is to be recommended only if the treatment fails partially or totally and if the polyps are symptomatic.
Massachusetts
Vol 13, No 6 (November-December),
SALAH D. SALMAN, MD Eye and Ear Infirmary Harvard Medical School Boston, MA
1992: p 394
To the Editor: Dr Salman,’ in his article on the complications of endoscopic sinus surgery (ESS), reports that significant bleeding occurred in 10 patients with nasal polyposis. Seven of these patients underwent previous surgery. I understand the advantage of magnification in ESS procedures, which allows the surgeon to visualize the ostial areas of the sinuses. However, in the presence of nasal polyposis, one is excising relatively large masses of tissue from a nasal cavity in which the landmarks are distorted or no longer present, especially in patients who underwent previous surgery. An endoscope, in this situation, presents disadvantages rather than advantages. Bolger and Kennedy,’ in their review of current approaches to managing sinusitis, describe the endoscope as permitting “clear visualization of key intranasal structures and controlled, safe, surgical resection.” They describe medical treatment with steroids as the primary modality in management of nasal polyposis, mentioning that steroids can be useful in both preparing a patient for surgery and in postoperative management. They emphasize the endoscopic exposure of landmarks in the ostiomeatal complex in the management of sinusitis but do not describe the use of the endoscope in the removal of the polyps themselves. Dr Salman’ leads one to believe that the endoscope was used extensively during the procedures described. My concern is that the endoscope is being used inappropriately in excising nasal polyps, converting a rather simple operation into a hightech procedure with increased complications and costs. The preferred approach, as voiced by Bolger and Kennedy,2 is the topical or short systemic use of steroids followed by excision, if necessary. The landmarks of most importance are the roof and lateral wall of the nose, both of which can easily be identified without magnification. Violation of these areas should not be risked in order to excise the last vestige of polypoid tissue, as regrowth is best controlled with topical steroids rather than aggressive excision. Enlargement of the natural ostium of the maxillary sinus may be helpful and could be facilitated with the endoscope, but the role of the endoscope should be limited in these cases and its actual use defined in any reports. I would be most interested in knowing whether
394
American Journal of Otolaryngology,
Dr Salman used the endoscope when he removed the nasal polyps in the patients described, or whether he limited the use of the endoscope to identification of landmarks on the lateral nasal wall. I would hope that his use of ESS is limited in patients with nasal polyposis, and I would hope that those performing ESS limit its use in patients with such pathology. This will make the surgery safer and allow for better visualization of key intranasal structures, an end to be desired in intranasal surgery. JOEL F. LEHRER, MD Clinical Associate Professor of OtoJaryngoJogy University of Medicine and Dentistry of New Jersey Newark, NJ
REFERENCES 1. Salman SD: Complications of endoscopic sinus surgery. Am J Otolaryngol 12:326-328, 1991 2. Bolger WE, Kennedy DW: Current perspectives on sinusitis in adults. J Respir Dis 13(3):421-448, 1992
Reply:
I appreciate the opportunity to respond to Dr Lehrer’s comments and questions. I think the rigid scopes have improved sinus surgery and reduced its complications. Their successful use, however, requires familiarity and training. In addition to their excellent optics, they allow a deeper access and an angular vision. Once the scopes are available in the office and in the operating room, and with experience, the slight increase in cost (sterilization and wear and tear) is outweighed by the gains. At present, I tend to use them to advantage almost routinely in polyp surgery and in sinus surgery, both functional and ablative. I certainly agree that nasal polyps need to be treated medically first. Surgery is to be recommended only if the treatment fails partially or totally and if the polyps are symptomatic.
Massachusetts
Vol 13, No 6 (November-December),
SALAH D. SALMAN, MD Eye and Ear Infirmary Harvard Medical School Boston, MA
1992: p 394
