ORLANDO, FL-Eosinophils are the bane of nasal mucosa, and no one knows better than Fredrick A. Kuhn, MD, of the Georgia Nasal and Sinus Institute in Savannah, GA-a region where it is not uncommon for otolaryngologists to see patients presenting with polyps. At the ARS section of the recent annual Combined Otolaryngology Spring Meeting, he described the role eosinophils play in polyps and inflammatory sinusitis.
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August 2008Sinus inflammation is due to the release of eosinophilic inflammatory mediators from the cytoplasmic granules in eosinophils. In sinus disease, the primary problem is the recruitment of the eosinophils to the sinus wound. The secondary problem then is what the eosinophils do to the sinus mucous membrane after they release their inflammatory mediators. They do this in the quest to destroy some offending invading organism, he said.
Once inflammatory mediators are in the sinus mucosa, they can induce tissue damage, edema, the production of sticky thick mucus, and polyp formation.
Although surgery is an important part of managing polyps, it’s not the key form of managing the problem, and postoperative management is hugely important.
We begin oral steroids when we discharge the patient from the hospital; we continue them until the patient is healed and at stage zero. And then we choose some alternate medical management plan to switch the patient over to, and taper them off their steroids, he said.
There is no ideal way of removing polyps-they all bleed. Vasodilation effects of anesthetic gas and mucosal inflammation don’t help, but they cannot readily be changed. For one, anesthesiologists aren’t likely to change how they do things, and as for controlling inflammation, steroids don’t always work.
One could try to reduce the eosinophilic mediators, but this is problematic because if we really treat the patient well, we may end up missing the diagnosis-and that is either finding the eosinophils in tissue and mucus or perhaps not finding the fungus, he said.
For surgery, Dr. Kuhn’s center used a KTP laser from 1985 to 1993. It works great-it coagulates the tissue and cuts it off, and you don’t get any bleeding. But it is unbelievably slow, he said. Radiofrequency debrider blades were effective, too, but they clog easily, the contacts get covered with char…there is thermal injury, and it’s relatively slow, he said.
Recently, Dr. Kuhn has tried using coblation, with an instrument that has been modified by the manufacturer to fit into the nose. He described using the device on a patient who underwent a bilateral procedure: One side was treated with the coblation device, the other using a standard technique. We did the right side without the coblation device, and used a debrider. We lost between two and 400 cc’s of blood doing the ethmoidectomy. On the left side, we used the coblation device, and we had zero blood loss….I think that this is something that’s kind of exciting and has some promise for taking polyps out of the ethmoid, he said.
Postsurgery Management and Mucosal Staging
Medical management of patients postsurgery is vital, and is the hard part, Dr. Kuhn said. His key words of advice were, Use long-term regular office follow-up with nasal endoscopy-that’s an absolute must. In his own practice, patients are followed monthly for a year, then, if they are doing well, every second month. If the inflammation stays low, then follow-up visits can slowly become further apart.