Evolution of symptoms associated to nasal polyposis following oral steroid treatment and nasalization of the ethmoid--radical ethmoidectomy is functional surgery for NPS.

PURPOSE: The effects on the symptoms of nasal polyposis (NPS) of 1) a 7-day systemic steroid treatment and 2) radical ethmoidectomy (nasalisation) were compared. PATIENTS AND METHODS: Twenty-four patients with NPS whose symptoms failed to respond to medical treatment were included in the study. Symptoms were recorded on Visual Analog Scales (VAS) before (Q1) and the day (Q2) after a 7-day treatment of oral prednisolone (60 mg/day), and a few weeks later the day before surgery (Q3). All patients were operated on bilaterally according to the nasalization principles, i.e. endoscopic radical ethmoidectomy without mucosal preservation, with middle turbinate resection, antrostomy, sphenoidotomy and frontal ostium exposure, and a depot injection of triamcinolone 80 mg the day after surgery. The fourth questionnaire (Q4) was fulfilled one month after surgery, the day of the first postop visit. The following questionnaires were returned by mail at 3 months (Q5), 6 months (Q6), 9 months (Q7), and 12 months (Q8) post-operatively. Patients stayed on topical steroids throughout the study. RESULTS: Nasal obstruction was a major complaint at entry in the study. Following the short-systemic steroid course the obstruction score improved significantly. However, at 2 months after the oral steroid treatment the obstruction score had deteriorated again. Following surgery, obstruction scores ameliorated again and remained stable over the full year of follow-up. Similar results were observed for anterior and posterior rhinorrhea, sneezing and itching. None of the patients reported any intake of systemic steroids during follow-up. CONCLUSION: These data show that 'nasalization' i.e. radical ethmoidectomy with middle turbinate resection and mucosa removal is effective functional surgery for patients with nasal polyposis if medical treatment fails. The subjective effects on the sense of smell are reported in a separate paper published in this issue.

Olfaction in patients with nasal polyposis: effects of systemic steroids and radical ethmoidectomy with middle turbinate resection (nasalization).

AIM: In this prospective study the effect of medical and surgical treatment on subjective olfaction was studied in patients with nasal polyposis (NPS). The effects on nasal obstruction, anterior and posterior rhinorrhea, sneezing and itching are reported in another article in this issue. PATIENTS AND METHODS: Protocol 1. Twenty-four patients with NPS who complained about anosmia were treated with a 7-days course of systemic steroids. Their subjective overall sense of smell was determined with a visual analog scale (VAS) before treatment, immediately after treatment, and two months later. Subsequently all patients underwent surgery bilaterally according to the nasalization principles. The sense of smell was re-evaluated at 1, 3, 6, 9, and 12 months postoperatively. Protocol 2. Thirty-two patients with NPS not responding to medical therapy who, for different reasons, did not receive oral steroid treatment, received surgery only and were followed up during one year after nasalization. Of these patients, 25 were anosmic and 7 normosmic. RESULTS: Protocol 1. Following the 7-day treatment with systemic steroids the olfactory score increased significantly. During the waiting time for surgery (64 +/- 39 days) this score deteriorated again in a significant way. One month after nasalization which included a depot injection of triamcinolone 80 mg the day after surgery, the olfactory score ameliorated again and remained stable at 3, 6, 9, and 12 months. None of the patients reported any intake of systemic steroids during the one-year of follow-up. Statistically, there was a trend suggesting that the 12 month post-nasalization score was better than the immediate post-oral steroid score. A good correlation between the improvement of the sense of smell after 7 days of systemic steroids and one year after nasalization was found. Protocol 2 One month after the nasalization protocol, olfaction in patients of the hypo-anosmic group had improved considerably. Scores at 3, 6, 9, and 12 remained very stable. The sense of smell in the normosmic group did not change after surgery and remained stable during the year of follow-up. In total, 49 patients with a severe loss of smell showed a significant improvement at 12 months after surgery. CONCLUSION: The present study shows that 1) long-lasting correction of olfactory dysfunction produced by nasal polyposis can be achieved through the combination of nasalization and low dose of nasal steroids, 2) middle turbinate resection does not alter the possibilities to restore the sense of smell.

Surgical anatomy of the turbinal wall of the ethmoidal labyrinth.

The upper part of the lateral nasal wall is formed by a common structure or conchal lamina that is attached all along the junction between the ethmoidal roof and the cribriform plate. From this continuous conchal lamina, the different ethmoidal turbinates take their origin. All these structures form a well defined wall that encloses the ethmoidal cells medially and that deserves the name of "turbinal wall of the ethmoidal labyrinth". The objectives of this paper were: 1) to precisely define the anatomical landmarks of the turbinal wall of the ethmoidal labyrinth, and 2) to study, from an anatomical point of view, the consequences of the surgical resection of the middle turbinate. We performed an anatomic study on 12 frozen human heads, cut in a median-sagittal plane, and then photographed with a millimetre scale in order to perform several measurements. The surface of the turbinal wall of the ethmoidal labyrinth can range from 6.1 to 11.3 cm2. The resection of the middle turbinate preserves approximately half of the turbinal wall, this being around 4.3 cm2 (range 2.6 to 6.3 cm2). The conchal lamina appears as the noble sensorial element of the turbinal wall. It can be described as a continuous bone plate, grossly rectangular in shape, measuring approximately 1 cm in height and 3.5 cm in length that forms the lateral wall of the olfactory groove. The anatomic study shows that its dimensions can vary from simple to double in different individuals. It seems to us that instead of considering the difference of height between the cribriform plate and the ethmoidal roof (Keros classification), we should consider the vertical height of the conchal lamina as a potential risk factor in ethmoidal surgery.