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BackTable / ENT / Podcast / Transcript #13
Podcast Transcript: Treatment of Nasal Polyps
with Dr. Patricia Loftus
We speak with Dr. Patricia Loftus from UCSF Otolaryngology - Head & Neck Surgery discussing her clinical and surgical approach to treating Nasal Polyps. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Diagnosis of Nasal Polyps & Sinusitis
(2) Obtaining Nasopharyngeal Cultures & Prescribing Antibiotics
(3) Medical Management of Nasal Polyps: Prednisone, Flonase & Budesonide
(4) Using CT & MRI Scans to Visualize Nasal Polyps
(5) Using Lab Tests to Diagnose Broader Conditions Causing Nasal Polyps: Cystic Fibrosis (CF) & Primary Ciliary Dyskinesia (PCD)
(6) Testing Allergy-Related Nasal Polyps: RAST & Skin Prick
(7) Functional Endoscopic Sinus Surgery (FESS) Techniques for Nasal Polyps
(8) Post-operative Management of Nasal Polyp Surgery: Rinses, Topical Steroids & SINUVA
(9) Biologics as Emerging Treatments for Nasal Polyps
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[Dr. Ashley Agan]
Welcome to the BackTable ENT Podcast, where we provide a platform to dive into and discuss all sorts of topics related to otolaryngology. We hope to bring you relevant and timely information that you find can help you in your daily life and in your practice. We've got a great show for you today. I'm your host--my name is Ashley Agan, and I am joined by the lovely Gopi Shah. Gopi, how are you today?
[Dr. Gopi Shah]
I'm doing good, Ash. I'm feeling a little nosy today. I'm just kidding. We're talking about nasal polyps today so I thought I'd throw it in. I'm super excited. We have an awesome guest today. We have Dr. Patricia Loftus. I met Patricia when I was a resident and she was a medical student at Jefferson. So, I'm even more excited to have her here today. Dr. Patricia Loftus is an assistant professor in rhinology and skull base surgery in the department of otolaryngology at UCSF, University of California, San Francisco.
She obtained her medical degree from Jefferson Medical College in Philadelphia. She completed her residency in otolaryngology at Albert Einstein College of Medicine, Montefiore Medical Center in the Bronx, New York. She completed her fellowship training in rhinology and endoscopic skull base surgery at Emory University Hospital, Atlanta, Georgia. She's here to talk to us today about chronic rhinosinusitis with nasal polyps, so welcome to the show, Patricia.
[Dr. Patricia Loftus]
Hello. Thank you so much for having me. This is exciting.
[Dr. Ashley Agan]
You want to just first tell us a little bit about yourself and your practice.
[Dr. Patricia Loftus]
Yeah, so I grew up actually in Scranton, Pennsylvania. We were put on the map a few years ago when The Office was based in Scranton. That's how people know where I'm from. More recently, Scranton is in the news because of Joe Biden. He lived there until he was 10 years old. So, we have two reasons why people know about Scranton these days. I grew up there, did high school and college there. I'm the oldest of five kids and decided to go to medical school. I think that, like many of us, we just decided, what's going to be really hard? What's going to take the longest, what's going to put us most in debt?
No, I'm just kidding. I just felt like, from the beginning, I was just drawn to medicine and I just knew I wanted to be a doctor. It helped my four younger siblings--after seeing what I went through, they all decided that they were not going to do that, so I helped that out too. But yes, like Gopi said, I did my medical training at Jefferson and Philadelphia. I will say that it's so nice to reconnect with her.
I've always remembered you, Gopi. You were always so kind to the medical students, like for real, you have no idea how it changes the environment and what you might want to go into, and when you have like residents being kind to you, and I will always remember that.
[Dr. Gopi Shah]
Well, having kind medical students that are supportive when you're the PGY2 in service is very helpful, right back as well.
[Dr. Patricia Loftus]
Well, I am just so appreciative of how you treated me and all the other medical students. Then yeah, Montefiore Medical Center in the Bronx for residency, which was really great training. And then I decided to do a fellowship in rhinology and skull base. So, I spent a year in Atlanta at Emory, and then my first job out of residency was at UCSF--where I am now. I've been there for a little over four years, which is crazy. I am used to using the excuse: “Oh, I'm just out of training, can I ask you a question?” Now I feel like I can't always do that.
I mean, I can always ask questions, but I feel like I can say I'm just out of training anymore. But yeah, I am mostly rhinology. I do mostly inflammatory stuff. I do a little bit of skull base. There are two other skull base surgeons on faculty that do the bulk of it, but I do get to do a little bit, which is great. I work half of the time at our county hospital, Zuckerberg San Francisco General Hospital, where I do all of the sinus stuff there and get to do a little bit of general stuff too, which is nice.
I actually recently took and passed the Written & Oral boards for allergy, so we're hoping to maybe start up a little bit of an allergy practice at Zuckerberg Hospital. That's not part of my practice yet, but I hope that it will be in the future. Right now, I am doing mostly sinus inflammatory stuff, a little bit of skull base and a little bit of general.
(1) Diagnosis of Nasal Polyps & Sinusitis
[Dr. Ashley Agan]
Very cool. We're particularly interested in talking about nasal polyps. How does that patient present to your practice? I assume you see plenty of polyps every day.
[Dr. Patricia Loftus]
Yeah, definitely. A lot of polyps, because chronic sinusitis itself is pretty common. We quote around 10% to 15% of the population, and about 20% of people with sinusitis have nasal polyps. So, it is a good chunk of people. I would say that a lot of the chief complaints coming into my clinic are nasal obstruction or nasal congestion. Usually, that's just what it says, and then you have to figure out if this is allergies, is it turbinate hypertrophy? Is it sinusitis without polyps or sinusitis with polyps?
You can't always tell just from the history, because these patients will mostly complain of congestion and facial pressure drainage, and you can see that in other diseases. I will say that it probably is more common or is more common for people with polyps to have smell loss or decrease in smell as one of their major presenting symptoms, which can happen in allergies, but definitely isn't as common. When people describe smell loss in conjunction with some of these other symptoms, that's what kind of gets me thinking.
Of course, allergic rhinitis can be associated with asthma as well, but if patients have a history of asthma, I'll definitely ask about NSAID allergy, things like that, and we'll get into that a little bit more. And then, there are some people who present saying that they had a bad URI and then never got better. That's an interesting thing. We actually tend to see that in patients having AERD, which is aspirin exacerbated respiratory disease, that I think their polyps and inflammation had been growing and maybe they were getting used to it. Then they kind of had an inciting event and they sort of just started noticing it and it kind of got worse since then. That definitely makes me think that I might be looking for polyps.
Sometimes people will actually say, obviously they see something kind of getting bigger and smaller in their nose. It's variable whether these patients respond to topical steroids because a lot of them will have already tried Flonase, but it's kind of variable whether it helps, so I don't think that necessarily helps me that much.Also, that can improve allergic rhinitis or turbinate hypertrophy.
Those are the symptoms I'm looking for with polyps and then really your physical exam with your nasal endoscopy is going to be the gold standard. Even on CAT scan, you can think that you might see polyps, but it can sometimes be hard. As you know, it's just kind of grayed out, so that exam is really what is going to be helpful for that.
[Dr. Gopi Shah]
For your primary patients, never had a surgery, do you usually start, do a flex? Or do you usually just do rigids?
[Dr. Patricia Loftus]
I do rigids. The symptoms that people are presenting with are really pretty much all sinonasal. And of course, there will be cases where they have a cough from post-nasal drip. If that seems a little bit different than maybe just related to their drainage, I might take a look at their larynx. Most of the time, I'm doing a rigid because if there's something to culture, it's easier to do that with a rigid. Also, if there's potentially something to biopsy, it's easier to do with a rigid. Sometimes the 30 is nice to try to get in there into the middle meatus. You can do that with the flex as well.
But I think that the rigid, it tends to be nice for the nasal cavity. It's just kind of a straight shot. If you're moving around, you might sometimes kind of lose your view of where you are with the flex, so I tend to like the rigid, but specifically for a potential culture biopsy.
(2) Obtaining Nasopharyngeal Cultures & Prescribing Antibiotics
[Dr. Ashley Agan]
How often are you culturing? Anytime you see pus or in patients who are particularly refractory or?
[Dr. Patricia Loftus]
Yeah. Good question. Any person that comes into my clinic and I see something that doesn't look just typical like nasal secretions. I think that it may take a little bit of experience to know what should be cultured and what shouldn't. But you guys know that typical thick mucus that people have from congestion, from polyps--that stuff is not helpful to culture. Because that's just going to grow a lot of stuff or grow something that we don't really know what to do with. It's just basically their baseline and we're not just constantly giving them antibiotics.
But if they come in complaining of an acute worsening, that's when the mucus might be a little bit different. Or if you can kind of tell that it's purulent, rather than just being the typical thick secretions, that's something that I'll culture. And it will guide me. I think there's a lot of papers out there kind of saying, does it matter too if we culture these people? Should we be doing it? Is it just kind of a waste?
But I do think that it will guide me if I'm planning to treat these people pre-op before or do medical management prior to offering surgical management. Definitely, if they have exacerbations like in the postoperative period, I think it's helpful to have a culture to kind of go back to, which is the reason that I would also culture in the operating room. It's more that, if they are having a tough healing process post-operatively, I kind of have that culture to go back to.
[Dr. Ashley Agan]
What are the common bugs that you're seeing, is there a theme?
[Dr. Patricia Loftus]
I tend to see more of the chronic patients, as you know. With the acute, we always know that it's kind of the same thing as when you have a middle ear infection--like the staph and the strep. But when patients tend to be chronic, there's more of a mixed group of bugs in there--anaerobic, aerobic. These are the patients that might have more staph, they might have more pseudomonas. Again, that's why a culture is sort of nice with these patients, but I do tend to treat them if I don't have a culture.
I like to use Augmentin. I think that it does get the bugs that are likely to be the ones there. Obviously, if it ends up being staph or something like that, then it wouldn't be helpful. If they fail Augmentin, then I’ll look for something else. However, Augmentin is the first go-to that tends to treat most of the bugs that are going to be in the sinuses.
[Dr. Gopi Shah]
What's your alternative for penicillin in allergy patients?
[Dr. Patricia Loftus]
Doxycycline is a good one, I would say. People respond pretty well to doxycycline. People ask about macrolides a lot too, because they have an anti-inflammatory component as well. That's definitely not wrong. Where I tend to use the macrolides would be more in a neutrophilic type of sinusitis. So, we'll probably get into this a little bit, but polyps are usually eosinophilia-driven. But for those sinuses that are kind of chronically infected by odontogenic infections or just CRS without polyps that tend to be kind of refractory infectious looking cavities, they tend to be the ones that are neutrophilic. We think that macrolides kind of work best on these types of infections. So, what people will do is like a low dose of a macrolide for about three months and see if they can get things under control with that.
That does tend to be more in the post-operative period, because if you fail all the medical management, including antibiotics prior to that, we do usually offer surgery. Then if they're still having issues with their cavity healing, that's when you might do a macrolide. For me, at least. There are different ways that people do it. That's a question a lot of people have about macrolides and that's sort of how I use them.
[Dr. Ashley Agan]
And you said three months of a macrolide?
[Dr. Patricia Loftus]
Yeah, I'll actually do about 12 weeks--8 to 12 weeks and see if the cavity sort of calms down after that. This is not super common, but there are some people who do end up on an antibiotic for a very long time just to kind of keep the inflammation under control. It's obviously not something that we do easily, but there are people with really tough cavities that might be on an antibiotic for a while.
[Dr. Ashley Agan]
Do they end up having a lot of GI upset from that? Like disrupting the microbiome of the GI tract? Do you put them on a probiotic?
[Dr. Patricia Loftus]
Yeah. That's the worry for sure. I always obviously talk to the patients about that. If this is going to start causing any issues, just call me and let me know. I say, “Yeah, we could try a probiotic. We can put you on something, and if you're really not tolerating it, we might just have to do something else.” It's definitely not something that I do right off the bat with the long-term antibiotics. You definitely try the best that you can to get them under control with topical medication. That's the main reason that we do sinus surgery in the first place, obviously we want to relieve the obstruction and clean out all the mucus and everything like that.
But really, the main reason that we do it is to have this nice open cavity that you can get topical medication in there. The goal is to get them under control with saline or steroid rinses. Really, long-term antibiotics are kind of just if you're looking for something else.
(3) Medical Management of Nasal Polyps: Prednisone, Flonase & Budesonide
[Dr. Ashley Agan]
Yeah. Backing up to when these patients walk into your clinic and you're seeing them for the first time, and you look in there and you're like, oh, you've got polyps. What happens after that? I assume if they haven't had a scan, they probably get a CT scan and you probably send them out on some topical therapies, maybe prednisone. What does that look like?
[Dr. Patricia Loftus]
Yeah. Like you said, we always try medical management first, and for CRS with nasal polyps, this is a disease where prednisone is actually recommended. We have guidelines that give us different options. However, patients with polyps, which are eosinophilia-driven, tend to do well with prednisone because they respond well to steroids. So, this is something that's recommended if the patient doesn't have any contraindications to it. In a patient who is treatment-naive and can take prednisone, I will do a steroid taper.
There's no specific taper that you should do. What I like to do is 40 milligrams for four days, 30 for four days, 20 for four days, 10 for four days. So, it's 40 pills over a 16 day taper. I would say that most rhinologists tend to not go higher than 40. From what I read, someone looked into it like about the dosage that you hit that kind of had side effects and might've created lawsuits, or something along that line. They kind of found that 40 was okay to go up to. That's what most of us do. Also, I will definitely tell them, do saltwater rinses. We know there's a recommendation for that and we know there's a recommendation for intranasal corticosteroids. Intranasal corticosteroids that are FDA approved are Flonase or the sprays. But as you guys know, we do tend to add our steroids to rinses. I use budesonide for that. It is off-label technically. There's not robust data and I think mostly because it is off-label, but we know that it does work. What's nice about adding the budesonide is that with the rinse, it's higher volume, can kind of get into the nose and sinus cavities a little bit better.
I think pre-operatively the budesonide and the rinse doesn't matter as much just because you don't have that open space yet. I think it's very important post-operatively. My patient who hasn't had surgery yet, I’ll prescribe a steroid taper, a saline rinse, an intranasal corticosteroid--whether it's Flonase or whether you add it into the rinse. I won't do a CAT scan unless there is something concerning to me, just because there are some people who respond really well and can keep their polyps under control on topical steroids.
If they feel good, we might just have them come back in a couple months and see if the polyps have come back or if they're still doing okay on the topical medication. If they quickly come back, that's when we'll potentially discuss surgery and that's when I would get a CAT scan.
[Dr. Gopi Shah]
Do you do any steroids for your patients that are diabetics? Do you get in touch with endocrine or is that just not an option? Do you talk to the endocrinologist about budesonide rinses? Can those patients take that?
[Dr. Patricia Loftus]
Yeah, that's a great question. I think that what I really like about having an EMR now, is that it's really easy to send a quick message to these patients’ PCPs. For anybody who has diabetes, I'll usually check if their A1C isn't too bad. They seem pretty controlled. Usually, these patients are actually fine to take prednisone, but I'll always send a message to the PCP and just kind of ask them to check on how they're doing in a week or two. I pretty much always get the go-ahead from the PCPs when the patients are pretty controlled.
I think it's the patients that are not controlled. You know those patients, you kind of know the patients that you see that it’s not a good idea to give them a steroid. There are patients that can’t take prednisone. I will still give them topical because we do know that there's not great systemic absorption and we don't really have anything to show that there's bad systemic side effects from doing the topical. Patients with diabetes who can't take oral, I will definitely give them topical. But they potentially might be someone who doesn't respond that well and would be going to surgery a little bit sooner.
(4) Using CT & MRI Scans to Visualize Nasal Polyps
[Dr. Gopi Shah]
Then, in terms of imaging, we think CAT scan and we think ANCA, because we think image guidance usually with polyps. Is there ever an indication for contrast in your CT or an MRI?
[Dr. Patricia Loftus]
For a straight up polyp patient, no. I would say the only time I would get contrast in a CT is if I'm worried about a complication, like an abscess or something like that. If they're having vision changes, I'm worried about it or a subperiosteal abscess or something like that.
MRI, also no. I think if there is concern that it's not just a no, not just polyps, if we think it might be a tumor or something like that, MRI is definitely indicated. Sometimes you can be unsure if it's polyp versus inverted papilloma. So, sometimes, obviously a biopsy in clinic would tell you the difference between that.Some people might get an MRI for inverted papilloma. I think you don't have to, but so I would say MRI would mostly be just if there's a mass there. Another reason actually might be allergic fungal sinusitis. Allergic fungal sinusitis has those typical imaging characteristics where it could actually be pretty worrisome. It's like the pushing borders that widen and almost look like a mucus seal. On a CT, you might see thinning or even absence of some of the bone, like on the skull base or the orbit.
In those cases, it might potentially be helpful to just get an MRI, make sure you're not missing anything, such as an encephalocele. But we know, with these patients, that they don't actually really get CSF leaks or anything like that, because it's not an invasive process with allergic fungal sinusitis. It's locally "destructive," so it will push against the skull base and into the orbit. But it doesn’t intend to invade. What you would just see on the MRI is an interesting void, which I think is really cool. That's why I like getting the MRIs to kind of go over them with the residents because we know that fungus has a lot of water content. Those sinuses full of fungus will just be completely black, which is pretty cool.
[Dr. Gopi Shah]
This is just an aside. So, I do peds, so I see mostly kids. Once, we had a child that came into the ER with a little proptosis with a nasal obstruction. They got a CT with contrast because they were concerned in the ER for an acute sinusitis with some sort of oral abscess. He also got an MRI. Again, when you're not familiar, it gets very confusing because like you said, on MRI, everything drops out. I agree with the AFS because it usually expands out and thins it. You'll see CTs where sometimes maybe it's just the planum or something that you might have thin areas.
I discussed it with some of my adult rhinology partners, and they were like, you'll be fine. And you go in and it's thin, but things are pretty intact.
[Dr. Patricia Loftus]
Yeah, you're absolutely right. I miss these cases a lot because you probably definitely see it in Texas. I saw it a ton in Atlanta, but we don't see it really much in San Francisco. It tends to be with the climate that you have in like the Mississippi Basin Area. So, it was very common in fellowship, but I don't see it as much now. It can be concerning if somebody were to get a CT that wasn't familiar with the disease, and they would probably get an MRI based on the CT findings, so that's why you might see in MRI.
(5) Using Lab Tests to Diagnose Broader Conditions Causing Nasal Polyps: Cystic Fibrosis (CF) & Primary Ciliary Dyskinesia (PCD)
[Dr. Patricia Loftus]
That also goes along with your question of like, what my thoughts are when I do diagnose a polyp patient? You also sort of have to think about whether they fit into one of these other polyp categories that tend to be a little bit harder to treat. The things that I'm thinking of are allergic fungal and AERD.
If there's a patient with polyps, you definitely want to ask about asthma. You want to ask about aspirin or NSAID sensitivity. Now, of course, AERD pateints don't always have all three of those. They don't all develop the polyps, asthma and aspirin sensitivity. They don't develop at the same time. So, we actually think that AERD is probably kind of grossly underdiagnosed because we may be seeing the patients earlier on and they haven't started to develop the aspirin or NSAID allergy yet. But it's important to kind of have that in your mind, because these are the patients that are difficult to treat. The polyps come back pretty quickly. These are actually the patients that I might consider doing something like a Draf III up front. So, it does actually potentially change management.
Same thing with AFS. If you know that you have an AFS patient, you know that you really have to work to get all of that mucin out of there or everything's just going to come back. They also tend to be recurrent, and you definitely want to treat them with post-op prednisone. We know that it’s helpful to AFS patients, which is not something that is technically recommended. It's an option for other types of polyps, but for AFS, we definitely recommend it. Then, if the patients are recurrent, you might consider immunotherapy to the fungal allergens that they are allergic to.
Going along with your question, I would say most of the nasal polyps I see are your typical eosinophilic CRS, but there are these subtypes that are very important to know whether you're dealing with those or not.
[Dr. Ashley Agan]
When you're working up these patients, are there other studies or labs or testing that you do, like allergy testing, testing for CF or primary ciliary dyskinesia?
[Dr. Patricia Loftus]
Yeah. I think in terms of CF, if you're seeing a younger patient with polyps, we know that your typical eosinophilic CRS polyps kind of tend to come into clinic in the third, fourth, fifth, decade of life. So, in young kids, there's usually a reason for that. So, either AFS if it's unilateral, or CF if it's bilateral. If I'm seeing a child or a young person with polyps, definitely you want to think about CF. And if you're seeing any type of patient who comes in with also a history of recurrent pneumonia, bronchiectasis, the ones with five tubes in their life because they get a lot of ear infections, I definitely have them see immunology if they haven't already.
PCD is definitely a possibility, although it's pretty rare. What would be kind of more common is that these people might have common variable immunodeficiency. They might have an IgG or IgA type deficiencies. If patients come in with that history, I definitely think they deserve an immunology workup. I wouldn't necessarily send off all those labs myself just because we have such a great allergy and immunology department, but you can do that. You can definitely do that if you're prepared to be able to deal with the results.
Another thing is that we know that CF patients tend to t have a genesis of the frontal sinuses because they have this like arrest in their sinus development due to the chronic infection, but also the cilia not working correctly. I have a patient who kind of has that. She's in her 20s. She has hypoplastic maxillary sinuses. It's not a silent sinus picture--it is just like underdevelopment of the sinuses. And she does say, “oh yeah, I've gotten ear infections and that kind of thing.” I'm actually going to do a brush to send off or PCD when I am in the OR. They use electron microscopy. You do have to kind of talk to pathology before because that’s a specific test that they don't do super often.
There are maybe some CTs findings like that, that would alert you to work up for CF or for PCD. And then also the immunology part of it.
(6) Testing Allergy-Related Nasal Polyps: RAST & Skin Prick
[Dr. Patricia Loftus]
Then the other thing that I had wanted to mention is allergy. You asked about allergy, and that's a great question. People say, “Why do I have polyps?” I always say, well, allergy is one of the reasons, but actually, our data shows that it's definitely not like a huge factor in polyps. There's a lot of patients with polyps that do not have allergies, right? So, it's definitely not a one-to-one thing. When do I have them tested for allergies?
There is actually an entity that is kind of becoming a little bit more believed in recently, something called central compartment atopic disease. You've probably seen those CTS where the disease looks centralized, right? So, you have these polypoid middle turbinates. You have a kind of polypoid posterior septum and the disease tends to move centrally to laterally. So, you might have kind of sparing of the ethmoids around the orbit, and you might have sparing of the maxillaris in the beginning of the process and kind of everything centralized.
I'm sure like, as I talk about it, you say, oh, I remember seeing CAT scans like that before. And we actually do think that those types of presentations are related to allergies and there has definitely been some work done with that, where patients with those types of scans are tested for allergies and they're pretty much all 100% positive for allergic rhinitis. That might be a patient that I would say, “It doesn't mean that allergy treatment will cure it without surgery. They probably will still need surgery, but they're the patients that I definitely have see allergy.”
[Dr. Gopi Shah]
Just two points. I agree. Again, I see kids, so this whole workup is part of the repertoire and being thoughtful about who gets what. Every once in a while, I'll have a young kid who's like four with a polyp. Majority of the time, they already have that diagnosis at CF, but every once in a while, you might still be that first person.
I think PCD is something that's not as commonly diagnosed. We don't screen for it, for example, at birth. That can be a tough diagnosis to get. The brush biopsy, like you said, I let pathology know. There is a nitric oxide screener that some of the centers have that's supposed to be able to be another way to screen for it, and there is obviously genetic testing.
I agree for the immuno work up, a lot of people will get their own blood work. In a kid, my goal is to stick them once. So, I'll usually send them to immunology so that they can, not just check the immunoglobulins and the titers for pneumococcal titers, etc, but they can check for anything else that they might be interested in. One question for you, in terms of allergy. Do you have a preference in terms of RAST and skin? Then second question, since you're seeing adults. So, sometimes adults will say, “Oh, well, I had allergy testing in my 20s,” and now they're 40. In terms of positive results or new allergens, or do you ever outgrow allergies? What's the timeframe between your allergy testing, I guess?
[Dr. Patricia Loftus]
Yeah, that's a good question, because I do get the question of re-testing from a lot from patients. The answer is yes, you can develop new allergens, and especially if they've kind of moved to a new place. I definitely see a lot of people in the Bay Area that have moved from elsewhere and they may have had their allergy testing elsewhere. So, I will tell people who have moved to do it. However, if they haven't had any recent moves or if the symptoms are season-dependent, I don't think it's wrong to have them retested.
In terms of skin prick testing versus RAST, we do know that the skin prick is a little more sensitive. That's why we offer that first line. RAST though, it's also a great option for people with dermatographism, or if they can't come off certain medications that they need. Obviously you know you need to be off antihistamines, tricyclics, and other medications like that. Some people actually can't come off some of those things, so RAST is a great option for them. It's a great option for people with a history of anaphylaxis. You don't want to maybe skin prick pregnant women either. So, it's definitely a good option, but we do tend to do the skin prick first, just because of the sensitivity of it.
If you mix the skin prick with some other types of testing, you can actually figure out the dilution to actually start their treatment with. That's a nice thing about it. For RAST, you can't really tell what the dilution should be. There is an algorithm that you can use depending on how positive RAST was to decide where you're going to start with the dilutions, but with the skin prick testing, there are some things you can do to decide exactly where you're going to start if you were planning to do immunotherapy, so that's a nice part of it too.
(7) Functional Endoscopic Sinus Surgery (FESS) Techniques for Nasal Polyps
[Dr. Ashley Agan]
If these patients end up needing surgery, are most patients with nasal polyps, are you doing a full house FESS? Do you think, are you a fan of big antrostomies, or is a balloon dilation enough to ventilate the sinuses? Tell us what you think about that.
[Dr. Patricia Loftus]
I don't do a ton of balloons. I do think that there is a place for balloons, and I know there is data out there showing that they work in the right type of situation. I don't think that polyps are one of those situations though. You need to get in there and remove the polyps. Just dilating the sinus is not going to help if there's still a lot of edema and polyp in the way. If there's a lot of mucus in the sinuses that needs to be cleaned out, obviously an AFS patient would not be a candidate for a balloon.
I don't do balloons commonly, but definitely not for polyp. My goal with them is to treat their current symptoms with medications and to surgically make a nice wide open cavity so that they could get topical treatment in there so that they don't have to be dependent on taking a course of prednisone every time they're having a really bad flare. Even if not all sinuses are fully involved--meaning that they might not all have mucosal thickening--we know the polyps mostly come from the ethmoid, so I do think to make a nice big open cavity, you do need to open all of the sinuses.
A polyp patient is someone that I would do a full house FESS, septum if needed. My residents ask me a lot about doing turbinate reductions. What's interesting is that, like we were saying, for most of these patients, it's actually not allergies. So, if their inferior turbinates are swollen, they are sort of just going along with the whole like chronic rhinosinusitis thing. As the inflammation in the sinuses go down, the inflammation in the inferior turbinates tends to go down too. I don't usually do inferior turbinate reduction at the same time, but I will just start the full house FESS.
I do like big antrostomies. The data out there shows that you don't have to make these huge antrostomies, but I just like them because they look nice. I do think that medication gets in there well. And you have to think about when you're doing the surgery, how can I make this easier for me in the office when I'm debriding them or when I'm monitoring? So, I kind of just think big holes make it easier for me, but I don't necessarily go straight to Draf III. Like I was mentioning, in an AERD patient, I might actually consider that, but in a straightforward polyp patient, I will just do a normal frontal sinusotomy. If they were to recur quickly and topical medication wasn't helping, then in a revision surgery, I would consider doing a Draf III.
People also asked me about mega antrostomies, which I think is interesting. I really don't do mega antrostomies for eosinophilic CR nasal polyp patients. Where I would do mega antrostomies would be for the patients that we were recently talking about with the ciliary disorders. Maybe a CF patient or a primary ciliary dyskinesia patient, because they actually have issues with their cilia moving the mucus out of the sinuses correctly. If you can make that cavity kind of flush with the nasal floor, the rinses could get in there better, but patients who don't have those issues, their cilia should start working well again once you open everything up and you ventilate the sinuses.
They shouldn't really have issues doing that once everything is healed and no longer inflamed. I don't necessarily do mega antrostomies just for your normal nasal polyp patient, but would consider that in like a cystic fibrosis polyp patient or primary ciliary dyskinesia patient with polyps.
[Dr. Gopi Shah]
Patricia, just for our listeners, can you define mega antrostomy and define Draf III?
[Dr. Patricia Loftus]
Yeah. For a mega antrostomy, really, all you're doing is you're removing the posterior two-thirds of the inferior turbinate, and you are drilling that medial wall all the way down flush to the nasal floor. I always leave the anterior one-third of the turbinate there for empty nose purposes, and I do leave kind of like a little nub of the posterior inferior turbinate. One, to cauterize, because we know what vessel comes in through there that can bleed and cause problems, but also kind of to leave it as a landmark as well. And then you just drill the floor down. So, you're not taking the whole turbinate. You're not cutting coming through the nasolacrimal duct. You're really just bringing that wall all the way down, flush with the floor.
In medial maxillectomy, that's a little different because you are coming all the way anteriorly, sort of flush with the anterior wall of the sinus. In that case, the nasolacrimal duct is removed.
Then for Draf III, what's included in that is a superior septectomy, and basically drilling out the intersinus septum and the floor of the frontal sinuses over to the orbit. So, you want to go laterally enough that actually when you sort of push on the nasal bone or kind of the medial portion of the eye, your two periosteum. So, you'll see movement on the sides laterally, and that's when I know that I'm lateral enough. Bringing it back to the skull base where your landmark is, you want to find the first olfactory neuron. So, you see that, and that's as far back as you go. Then, anteriorly, you want to drill the frontal beak out. You're basically making this nice wide open cavity that rinse can really get in there very nicely.
[Dr. Ashley Agan]
After surgery, I feel like everything looks nice and we've opened everything up. And then I'm always worried about scarring and those spaces closing back off. For the middle turbinate, I like to pexy it with a stitch to the septum to keep it medial. Do you have any tips or tricks? Do you leave a stent? Do you like the drug eluting stents, like the PROPEL, or do you like ... I've seen people like plastic sense in the frontals, or what are your thoughts on that?
[Dr. Patricia Loftus]
I will say that I'm a hundred percent with you with suturing the middle turbinate. I've tried different ways, NasoPore, other things like that, and I don't think there's anything that sutures those turbinates tightly to the septum. I'm completely with you on that. I think that really keeps the ethmoid cavity open. It's a good question that you bring up because with Draf III, some people will actually do mucosal grafting for the exposed bone from drilling. It does heal so nicely because it heals faster, quicker because you have that mucosal graft in there.
[Dr. Ashley Agan]
Where do they get the graft?
[Dr. Patricia Loftus]
They will either take it from maybe part of the septum that they removed. You can also get it from the inferior turbinate and you can get it from the nasal floor. Probably most people would just try to reuse that septal mucosa that they removed from the superior septectomy. And you do, I forgot to mention too, with the Draf III, you do have to take the middle turbinates back to the skull base. So, you could potentially use some middle turbinate mucosa as well. Some people will do that and it does heal very nicely. You can put a silicone or silastic stent up there to hold the grafts, or just in general, to help the healing process. I do think that is quite important when you do a Draf III, because you have exposed bone that is going to want to kind of scar down. I've done the silastic, and I think it works fine. I've actually recently been putting a PROPEL up into the Draf III cavity, and I do think that that works well too. It's kind of like an eluting steroid at the same time. I do think that that has been helpful. I don't actually do mucosal grafts because I think it will also heal without a mucosal graft, but you do have to debride these people frequently because the crusting of the exposed bone can get pretty bad.
Now, if you didn't do a Draf III, for just a frontal sinusotomy, the goal is to not strip the mucosa circumferentially, like you might have for a Draf III. If the AP diameter is pretty wide, a lot of times you actually don't need anything in there. I do know that there's people who will infuse Kenalog and some Stammberger foam and kind of shoot that up there, which is nice. It kind of gives just some topical stuff laying in there. If this was a polyp case, and I do think that polyps, well, we know that polyps do tend to mostly recur in the frontal recess ethmoid cavity area.
I do like to put up a PROPEL stent into the sinus frontal recess area after a polyp case to elute that steroid and keep things open. I don't use them in the ethmoid cavity ever. I never used the regular PROPEL stents because I think we do a good enough job opening the ethmoid cavity that we don't necessarily need the "stenting" effect of it. Irrigation does tend to get into that cavity pretty well, but where it doesn't always get is up into the frontal recess. That's why I do like to put something up there for polyp cases.
(8) Post-operative Management of Nasal Polyp Surgery: Rinses, Topical Steroids & SINUVA
[Dr. Gopi Shah]
And then, what's your post-op management? I assume that you do rinses the next day. Do you have them start their Pulmicort the next day? Do you wait that out? Do you feel like the bottle is better than the Neti pot? Do you have something different you tell your patients to use?
[Dr. Patricia Loftus]
Yeah. Something that I do for polyp patients, and this is another question that people will ask about like a perioperative steroid taper. In our literature, it's an option. There have been some studies to show that maybe it decreases blood loss by a little bit, kind of decreases time in the OR by a little bit. It's definitely nothing significant that it's like, oh, definitely do preoperative steroids or periop steroids. But anecdotally, I do feel like if I sort of start their steroid taper a couple of days before surgery, the surgery is a little bit less bloody. It's less inflamed in there.
Another thing is that people, some people think that a lot of the times, there are patients that obviously have asthma, or even if they don't have a diagnosis of asthma, they have, obviously upper airway issues--so putting them on some steroids before surgery can actually be helpful for the anesthesia part of it and everything like that. I do start a steroid taper a couple of days before the surgery and have them continue it after the surgery. Now, you don't have to do it preoperatively or perioperatively. You don't even necessarily have to do it postoperatively, but I think that most people do for polyp patients.
I have them start their rinses the next day. Actually, if it was a bad polyp case, I'll have them add the Pulmicort to it starting the next day. Definitely we know that debridements are necessary. They're a good thing. They help you heal faster. They help the scarring to not happen. Like I was saying before, there are few things that we can recommend, but saline rinses are one, intranasal steroids are one, and debridements are one.
Definitely bring them in a week or two later, and follow them closely until they're healed. Another question I get a lot of is about weaning the patients off budesonide. We don't have really long-term data about being on topical steroids. We know from the data that we have that we really don't think that it's bad to be on it for that long, and that's what I tell my patients. Like, we really don't have anything to tell us that you can't be on this for a really long time without consequences. But if you don't need to be on it, we want to try to wean you off of it.
It takes about three months for everything to look pretty healed. Obviously it depends on the patient, but I usually tell patients three months. We know that it takes like 12 weeks for the mucosa to kind of heal itself and regenerate. I will see how they're doing at three months, and if everything looks really nice, I would probably say at that point, “Okay, let's do budesonide once a day and then have you do just a regular saline rinse for the other one, then have them follow up in about three months, and they're looking good. Okay, now let's do it once every other day.” Then until we can kind of get them off of it fully, but I always tell them, “If you start to feel congested or if you get a URI before your appointment with me, just go ahead and go back up to twice a day. Then once you're feeling better, we can restart the process.” I have been able to get patients off of budesonide, polyp patients, and they're fine, and their polyps don't come back, but it's nice to always have that, when you start to wean them off, you do always have the option of, if things start to look not so great again, you can add them back onto it.
That's why I do like to follow these patients--You obviously can pick up on endoscopy, polyp changes, polypoid changes coming back before the patients might notice it, especially if the nasal cavities are really open now. It would take things to get pretty bad for them to notice their smell is gone, they're congested, and they can't breathe again.
Another one of the things we can do is a SINUVA implant. What SINUVA is, it's similar to Propel, except it has kind of three times the amount of mometasone that, and you leave it in the ethmoid cavity for three months. This is a nice thing to have for patients who don't really stick to their regimen. So, it's hard for them to do their rinses or maybe they can't afford the budesonide, or something like that. The SINUVA is good. What I have found is that it might not work as well if you're sticking it into a cavity that's just full of polyps. That's why I like to have the patients come back sooner because it tends to work better when you start to sort of notice the polypoid changes come back. I have no financial relationship with them at all, but they did recently say that it works a little bit better if you use it before things get really bad in there. That's an option that we have if the topical stuff is not working or if patients just aren't sticking to the regimen.
Gopi, you asked about the best way to do it. This has been looked at. There's really no great difference between neti pot, NeilMed, the lavage, anything like that. It's really just about a higher volume getting in there. So, really whatever the patient can tolerate, I think that all of those choices are fine. Another option we actually have for the preop postop cavity is you've probably heard about this thing called XHANCE, which is an interesting tool where there is a part that goes in your mouth and then part that goes up your nose and you blow into it. The point is that this closes your palate so that the steroid gets further up into your sinus cavities then your typical Flonase. Again, no financial relationship with them either. Just talking about some of the options that we have out there.
(9) Biologics as Emerging Treatments for Nasal Polyps
[Dr. Patricia Loftus]
These are all options that I would talk about with the patient. Biologics is a very new thing that we've been trying to do. We, as ENTs, have only been able to prescribe DUPIXENT since June of last year. It has not been that long that we've even been able to prescribe these biologics. There was a meeting with the NIH where everybody kind of met and they said, “Okay, when do we use these?” Because they are very expensive. It's like 38 grand a year to be on this medication. So, it's not something that you just kind of throw at anybody.
We feel that you really should fail all of the other stuff that we have. Definitely surgery first. Of course, there are those patients that may not be surgical candidates ever, and they could potentially be someone who can start on Dupixent without having surgery, but your typical patient, you want them to have had full surgery--meaning give them a revision surgery if there's ethmoid septations left or give them a revision surgery if they haven't had a Draf III. Try all the topical stuff, whether it's budesonide rinses, XHANCE, or stents with a steroid on them. So, try all that stuff, and if they are refractory to all of that, I have seen DUPIXENT work wonders.
DUPIXENT it's an IL-4 receptor medication that works on IL-4 and IL-13 since they share a receptor. That's what's really interesting about biologics in general. What we're trying to figure out is how we can work sort of downstream before polyp formation even happens. We used to just kind of just call sinusitis either, without polyps, right? But we know that it's so much more than that. We know there's TH1 inflammation where the cytokines tend to be IL-2 and tumor necrosis factor beta and interferon, and then TH2, which is polyp, which is your IL-4, 5 and 13.
We're trying to look at these cytokines and see if we can intervene at that portion of development of polyps. That's what DUPIXENT does. It works on these cytokines that you see in TH2 inflammation. I have seen it work wonders. It doesn't work for everyone, and there's still a lot of questions about it. For instance, how long do you give it a try until you decide it hasn't worked? Right now, we're kind of going off the asthma literature, because in asthma, they've had biologics for a much longer time for allergic asthma AND atopic dermatitis. They've been dealing with biologics a lot longer than us, so we kind of look to them.
They usually do about four months or 16 weeks, and if there's been no change, we don't think it's going to work. But then there's also things like: how long do you leave the patients on for it? What we know so far is that, once the patients come off, the polyps tend to come back. So, is this a lifelong thing? So, you have to talk about that with the patients. Like, if we start you on this, this is going to be a shot every two weeks for what we think will be the rest of your life. That's a big deal, and then also, are there markers to decide who's going to respond and who isn't? Going back to one of your other questions, Ashley, was like, what things do you test for?
People will ask me like, oh, do you test for IgE, and do you test for some of this eosinophilia? These types of markers, if you're thinking about, oh, maybe they would be a biologic candidate in the future. Actually, currently, those things are not necessary to prescribe it. You really just have to show that they've tried other things, they failed, and that this is severely affecting their quality of life, and that you have polyps on endoscopy. So, quality of life would be smell loss and that kind of thing. You don't need to actually check those things to go on DUPIXENT. I don't usually check those early on, but if they were to see allergy or immunology, they might check them. There's still a lot that we don't know about DUPIXENT, but it is something that we should know about as ENTs treating polyps because there are those patients that will benefit from it.
[Dr. Gopi Shah]
Is there anything else that you would want to leave our listeners with? Any other topics that we didn't hit you think that are big take home points?
[Dr. Patricia Loftus]
I think the main take home point with polyp patients is just that they're kind of your patient forever and they're all different. It's a kind of an individualized treatment. What do you think? How are you feeling? Or what do you want to try next? These are patients that you should be seen forever to make sure that they're doing okay and trying new things. It's not just a one and done thing. That would kind of be my last take home point: build that relationship, and you guys will figure out a way together to get them feeling at least better than they did when they walked in.
[Dr. Ashley Agan]
Oh, and I wanted to ask you, do you sit or stand?
[Dr. Patricia Loftus]
Oh, I stand. That's a great question. Yeah. I'm too jittery to be able to sit down. I need to walk and move my pedals around.
[Dr. Gopi Shah]
Do you sit, Ash?
[Dr. Ashley Agan]
No. Marple and Ryan, they stood. They stand, they're still around. I did my training here at UT, UT Southwestern. They taught me how to stand, but I've done it both ways. The argument to stand was that, from a posture and energy standpoint, you should sit when you can because of these long cases. So I have done it both ways, but now, in my practice I stand just because that was how I did it the most.
[Dr. Gopi Shah]
It's interesting because endoscopic ear surgeons in Italy, like Marciano, those guys stand. Yes. So, you're right.
[Dr. Ashley Agan]
Well, I was doing a case the other day where I was going back and forth between the nose and the ear, and so I was standing because I had started the case standing. I was in the ear standing, and I had that thought. I was like, I wonder if I would enjoy doing my ear surgery standing.
[Dr. Gopi Shah]
Well, We used to do ear tubes standing up at Jeff.
[Dr. Ashley Agan]
That's how I do mine. I'd leave them on the bed and then I stand.
[Dr. Gopi Shah]
I sit for all of them now.
[Dr. Ashley Agan]
So I can keep it going. I got to save those minutes.
[Dr. Patricia Loftus]
I love it. I've actually, anytime I need to do tubes anymore, I use the endoscope now.
[Dr. Gopi Shah]
Do you really use it to put ear tubes? I love it.
[Dr. Patricia Loftus]
Isn't it so ridiculous? When you're just doing the same thing, I'm totally that surgeon that doesn't know how to use a microscope anymore. I hold this all day, so I'm going to do everything with it.
[Dr. Ashley Agan]
Your left hand is the scope now.
[Dr. Patricia Loftus]
I totally do tubes with the endoscope now. But it is interesting, when I was doing my fellowship interviews, you're right. When we would go into the OR and some people would be sitting, some were standing, it seems to be that more of the old school people tend to sit. I feel like that has recently changed, but you're right. I think also, maybe the cases used to be a lot longer. We have such nice tools now too. Obviously the microdebrider is nice. But you can attach a bar to the microdebrider and do things really fast. I think our cases are not as long now and it's a little bit easier to come in and out if you have a resident and stuff, but yeah, it is interesting, but I definitely stand.
[Dr. Ashley Agan]
Awesome. If listeners want to learn more about you or reach out to you, any social media outlets or?
[Dr. Patricia Loftus]
Yeah. Yeah, please. You can directly contact me. My email is patricia.loftus@ucsf.edu. I would love to chat. We're also, for any women ENTs out there, Gopi and I are part of the Women in Rhinology. I wanted to put a plug in for that. I mean, anybody can join the Women in Rhinology, men too, but it does tend to be a nice place for women generalists and rhinologists, especially early in practice to join. So, if you are interested in that, please reach out to me as well.
[Dr. Ashley Agan]
Yeah, thanks. This was awesome. For listeners, we'd love to hear your feedback. Let us know what you thought. We're on social media on Twitter and Instagram. Handles are @_backtableent.
Podcast Contributors
Dr. Patricia Loftus
Dr. Patricia Loftus is Assistant Professor in the Rhinology & Skull Base Surgery division in the Department of Otolaryngology – Head and Neck Surgery (OHNS) at the University of California, San Francisco.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2021, January 1). Ep. 13 – Treatment of Nasal Polyps [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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