Nasal polyps: medical or surgical management?

Does the Preoperative Administration of Steroids Reduce Intraoperative Bleeding during Endoscopic Surgery of Nasal Polyps?

OBJECTIVES

Corticosteroids are frequently used in a range of otorhinolaryngologic conditions due to their anti-inflammatory and antiedematous properties. In this meta-analysis, we aimed to assess the role of preoperative steroids for attenuating intraoperative bleeding during endoscopic sinus surgery among patients with nasal polyps.

DATA SOURCES

PubMed, SCOPUS, EMBASE, the Web of Science, and Cochrane database.

METHODS

Literature was screened from January 1980 to January 2016. Five articles comparing patients who were preoperatively administered steroids (steroid groups) with patients who received a placebo or no treatment (control group) were included for analysis, which encompassed intraoperative bleeding, endoscopic surgical field visibility, operative time, and side effects during endoscopic sinus surgery.

RESULTS

Intraoperative bleeding and operative time during endoscopic sinus surgery in the steroid group were significantly reduced as compared with the control group. Additionally, the preoperative administration of steroids had a significant effect on improving endoscopic surgical field visibility during sinus surgery. There were no significant adverse effects reported in the enrolled studies. In subgroup analyses of these results, steroids showed similar effects on intraoperative bleeding regardless of administration type (topical or systemic).

CONCLUSION

This study demonstrated that the preoperative administration of steroids in patients with nasal polyps could effectively reduce intraoperative bleeding. However, the duration of treatment and dosing standard require further investigation, and more trials need to be included.

Interleukin-4, Interleukin-8 and E-selectin Levels in Intranasal Polyposis Patients with and without Allergy: A Comparative Study

Intranasal polyposis is a chronic inflammatory upper airway disease with unknown aetiology. Interleukin (IL)-4 and IL-8 play very significant roles in allergic events and infectious inflammation, respectively. In contrast, E-selectin is important in the initiation and organization of inflammation. In this study, levels of IL-4, IL-8 and E-selectin were measured in nasal mucosa specimens of intranasal polyposis patients with and without allergic rhinitis, and healthy controls. Healthy controls had significantly higher IL-4 levels than allergic patients and non-allergic patients; IL-4 levels were similar in allergic and non-allergic patients. Allergic and non-allergic patients had significantly higher IL-8 levels than healthy controls; IL-8 levels were comparable in allergic and non-allergic patients. E-selectin levels were similar in all groups. The infection-based theory, represented by IL-8, seems to be more likely than the allergy-based theory, represented by IL-4, for the pathogenesis of nasal polyposis.

Comparison of montelukast and mometasone furoate in the prevention of recurrent nasal polyps

BACKGROUND

The aim of our study was to compare the effects of montelukast and mometasone furoate nasal spray on the postoperative course of patients with nasal polyposis.

PATIENTS AND METHODS

Fifty patients diagnosed with nasal polyposis between March 2006 and August 2007 were included in the study. All patients underwent bilateral endoscopic sphenoethmoidectomy and were randomized postoperatively into two groups. Group A (n = 25) received 10 mg montelukast per day and group B (n = 25) received 400 µg mometasone furoate nasal spray twice daily. All patients were followed up for 6 months. Sino-Nasal Outcome Test (SNOT)-22 scores, polyp grades, computerized tomography (CT) scores (Lund-Mackay), eosinophils in peripheral blood and polyp tissue were evaluated before and after surgery.

RESULTS

There was a significant reduction in SNOT-22 scores in both groups throughout the study period. There was a significant difference in the recurrence rate between both groups with a marginal advantage of mometasone furoate nasal spray. Eosinophils in peripheral blood were found to be effective on the recurrence rate (p < 0.05).

CONCLUSIONS

In conclusion, both drugs seem to have a complementary action and further studies are needed to determine which patients should receive which treatment.

Nasal polyps and the severity of asthma

BACKGROUND AND OBJECTIVES

Upper airway pathologies often accompany asthma. Because this represents a single airway, the diagnosis, follow up and treatment of both upper and lower respiratory diseases is essential. Samter Syndrome (SS) is known to be associated with more severe asthma. The presence of nasal polyps (NPs) is also associated with asthma. However, the incidence of NPs in asthma and the effect of NPs on asthma severity are not well documented.

METHODS

Three hundred and forty-two asthma patients were evaluated by endoscopic nasal examination, pulmonary function test, skin prick tests and paranasal sinus tomography.

RESULTS

Three hundred and eleven patients with asthma without NP, 19 asthma patients with NP and 12 patients with SS were included. It was found that 54.3% of patients without NPs, 63.2% with NP and 66.7% with SS were at step 3 on the Global Initiative for Asthma scale of severity, and 1.9%, 15.8% and 33.3% were at step 4, respectively.

CONCLUSIONS

The presence of NPs in asthma patients is associated with an increase in asthma severity. In patients with asthma, the possibility of NPs should be investigated and treatment planned accordingly.

Ultrastructural investigation of epithelial damage in asthmatic and non-asthmatic nasal polyps

Nasal polyposis is a poorly understood chronic inflammatory disease often associated with asthma. As nasal polyps and asthma both are associated with massive eosinophil infiltration, they may share a common pathophysiological mechanism. Many genetic and autoimmune diseases may result from altered expression or function of cell adhesion molecules such as desmosomes. A transmission electron microscopical study was carried out on tissue from 15 patients suffering from nasal polyps, to investigate if there are changes in desmosomes in nasal polyps from asthmatic and/or allergic patients versus non-asthmatic versus non-allergic patients. In allergic patients the damage to columnar cells was more extensive than in non-allergic patients. Massive infiltration of eosinophils was observed in epithelium and connective tissue in all groups. No significant difference in thickness of the basal lamina was found between any of the groups. All patients had dilated capillaries in the connective tissue. The intercellular space between the epithelial cells was smallest in the asthmatic non-allergic group. The relative length of columnar cell or basal cell desmosomes was reduced in patients with asthma or allergy, compared to non-allergic, non-asthmatic patients. Hence, there appears to be a weakness in the desmosomes in asthmatics and allergics. Epithelial shedding may play an important role in the pathophysiological process of a multifactorial disease such as asthma.

Fluticasone propionate aqueous nasal spray does not influence the recurrence rate of chronic rhinosinusitis and nasal polyps 1 year after functional endoscopic sinus surgery

BACKGROUND

Local corticosteroids are widely used in the treatment of nasal polyps and chronic rhinosinusitis both before and after nasal surgery. Their efficacy after functional endoscopic sinus surgery (FESS) has not been fully established by placebo-controlled trials.

OBJECTIVE

This double-blind placebo-controlled randomized study was performed in order to investigate whether fluticasone propionate aqueous nasal spray (FPANS) reduces the recurrence rate of nasal polyps and chronic rhinosinusitis during the first year after FESS.

PATIENTS AND METHODS

The trial looked at 162 patients aged 18 years and older requiring FESS for chronic rhinosinusitis or nasal polyps. After FESS combined with peri-operative systemic corticosteroids, patients were randomized and given FPANS 400 microg b.i.d., FPANS 800 microg b.i.d. or placebo b.i.d. for the duration of 1 year. Patients were withdrawn from the trial (but still included in the study for statistical purposes) if there were recurrent or persistent diseases, defined as progressive regrowth of nasal polyps, recurrent signs and symptoms of chronic sinusitis combined with abnormalities on computed tomography scan and persistent complaints for at least 2 months after FESS.

RESULTS

A significant reduction of symptoms was seen after FESS. After 1 year, 46 patients had been withdrawn from the trial because of recurrent diseases and 32 patients because of persistent symptoms. No differences in the number of patients withdrawn because of recurrent or persistent diseases were found between the patients treated with FPANS and patients treated with placebo. We were also unable to find a positive effect of FPANS compared with placebo in several subgroups such as patients with nasal polyps, high score at FESS or no previous sinus surgery.

CONCLUSION

This placebo-controlled study does not show that treatment with FPANS up to 1 year after FESS had a positive effect compared with placebo.

Intercellular adhesion molecule-1 expression in nasal polyps treated with corticosteroid

PURPOSE

The aim of this study was to compare intracellular adhesion molecule-1 (ICAM-1) expression in nasal polyp cases who were administered topical corticosteroid and in middle turbinates.

MATERIALS AND METHODS

Twenty-four patients with nasal polyps were included in the study group. These patients were treated with 100 microg budesonide in each nostril twice daily for 2 months before the surgery. Twenty-one nonatopic patients with concha bullosa were included in the control group. The specimens were taken from patients undergoing endoscopic surgery.

RESULTS

In polyps, significantly higher mean ICAM-1 intensity scores were found by comparison with the control turbinates.

CONCLUSIONS

Corticosteroid treatment in patients with nasal polyps does not diminish ICAM-1 to that of turbinate tissue. The initiating events in the formation of nasal polyps still occur in these patients despite treatment with the topical nasal steroid.

Nasal polyps

Nasal polyps are as common as adult onset asthma and unilateral polyps require histological examination. Medical therapy with corticosteroids should be tried before surgery. The anatomy should be demonstrated with computed tomography before endoscopic surgery.

Eosinophilia in nasal polyposis: its objective quantification and clinical relevance

BACKGROUND

Eosinophilia within nasal polyps is often taken as a criterion for adjuvant medical treatment postoperatively such as topical steroids.

OBJECTIVE

This study was performed in order to validate a new technique for objective quantification of eosinophilia by using laser scanning cytometry (LSC), to compare these results with manual scoring and routine histopathology, and to correlate them with the history of allergy or recurrence.

METHODS

LSC was used for semi-automated analysis of single-cell preparations from representative ethmoidal polyps obtained during routine paranasal sinus surgery (n=41). This microscope-based instrument scans the cells after immobilization of cells on a glass slide and after triple staining of cytokeratin, eosinophilic granula, and DNA. The location of each cell is stored with the fluorescence data. Therefore, the morphology of every cell can be documented by re-staining with haemotoxylin and eosin and re-localization on the slide. Subsequently, slides were subjected to manual scoring. The remaining polyps were analysed by routine histopathology.

RESULTS

Data from LSC and manual scoring showed good correlation (r=0.81, P<0.001), whereas there were discrepancies with histopathology. Eosinophilia scored by LSC and histopathology was neither correlated with the history of allergy nor with recurrence as determined by Fisher's exact test independent of the definition of eosinophilia (> or =2%, > or =3%, or > or =5% of all cells).

CONCLUSION

Scoring eosinophilia by LSC in comparison with histopathology does not contribute to a more reliable basis for adjuvant medical therapy in nasal polyposis. Instead, functional parameters (cytokine production, apoptosis) may serve better.

Localization and quantitation of eotaxin mRNA in human nasal polyps

Nasal Polyps (NPs) are the most common mass lesions found in the nose. NPs cause airway obstruction, prevent normal sinus function, and can lead to infection of the eye, facial bones and central nervous system. The predominant cell type inhabiting NPs is the eosinophil, and the chemokine eotaxin is believed to play an important role in NP eosinophilia. The objective of this study was to localize and quantitate expression of eotaxin mRNA in human NPs. Total RNA was isolated from NPs that were collected from 5 patients who had undergone polypectomy. Portions of these polyps were also fixed in formalin, embedded in paraffin, and sectioned onto slides for use in in situ hybridization. Total RNA from one patient was used in a reverse transcriptase polymerase chain reaction using eotaxin specific primers to generate a human eotaxin cDNA. The eotaxin cDNA was cloned and used to generate probes for Northern blot analyses and for use in in situ hybridization (ISH). Eotaxin mRNA was detected by Northern analyses in all patient samples, though the relative expression level in each patient varied. ISH localized the expression of eotaxin mRNA specifically in eosinophils in 2 of the 3 patients in the study for whom the embedded polyp tissue appeared sufficiently well preserved for mRNA localization. Our findings suggest that eosinophilia in NPs is likely a self-amplification process whereby increasing numbers of eosinophils are recruited to enter the polyp as a result of production of eotaxin by eosinophils already within the polyp.

Comparison of medical and surgical treatment of nasal polyposis

Nasal polyposis is the end result of a variety of pathologic processes. The aims of treatment are to relieve nasal blockage, restore olfaction, and improve sinus drainage. Treating any accompanying rhinitis is also an aim, which requires that medical treatment be given to all patients with an inflammatory problem. Most forms of nasal polyp recur after treatment, whether medical or surgical. There are few direct comparisons of medical and surgical treatment in the literature. Those that exist suggest that most patients should be treated medically, with surgery reserved for patients who respond poorly. Large prospective randomized trials of surgical versus medical therapy are needed in groups of well-characterized patients to determine the optimum approach for each and to decrease relapse rates. Topical corticosteroids are the mainstay of treatment. All patients with inflammatory polyps should receive topical corticosteroid treatment in the long-term, unless there is a compelling contraindication. Adverse effects of surgery are rare but can be devastating. The major side effects of medical therapy are those of oral corticosteroids, which need to be used carefully. The choice of topical corticosteroid is important because long-term use is necessary; the least absorbed should be used. No cost-benefit analysis has been undertaken in this area, although medical therapy is probably cheaper and involves less work/school absence than sinonasal surgery, even when the latter is performed with an endoscope.

[Nasal polyposis: postoperative long term results (5 years) after endoscopic sinus surgery]

The purpose of this study is to evaluate the results after endoscopic sinus surgery in cases of nasal polyposis. We include 54 patients with diffuse nasal polyposis suffering from nasal obstruction. An endoscopic sinus surgery under general anesthesia with excision of the polyposis was performed. There were no complications. The patients were followed closely and treated with local and systemic steroids. After 5 years, the 75% of these patients were free of nasal symptoms and in the 67% the mucosa appeared normal. We also review the influence of some factors (ASA triad, anosmia, allergy...) in the recurrence of the disease.

Expression and localization of the inducible isoform of nitric oxide synthase in nasal polyp epithelium

BACKGROUND

The pathogenesis of nasal polyp disease is poorly understood. Recent evidence has suggested that nitric oxide (NO), an endogenous soluble gas vasodilator and inflammatory mediator, may be synthesised within the nasal cavity. Three nitric oxide synthase isoforms have been identified in humans, with the inducible isoform (iNOS) generally expressed in the setting of inflammation.

OBJECTIVE

The aim of this study was to detect and localize iNOS expression in nasal polyp tissue, and compare these findings with normal nasal turbinate tissue.

METHODS

We examined the expression and localisation of inducible nitric oxide synthase (iNOS) in human nasal airway specimens from patients undergoing elective nasal turbinectomy (n = 5) or nasal polypectomy (n = 5). iNOS mRNA expression was determined by semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) followed by Southern blot analysis and localised by in situ hybridization. Densitometric data were analysed using Student's unpaired t-test. Adjacent sections were also examined for iNOS protein expression by immunohistochemistry.

RESULTS

Semi-quantitative RT-PCR/Southern analysis of RNA obtained from the 10 surgical specimens demonstrated that iNOS mRNA expression was significantly increased in the five nasal polyps (P < 0.05). In situ hybridization studies revealed strong iNOS mRNA signal localized to the respiratory epithelium of nasal polyps, but not nasal turbinates. This pattern was confirmed by immunohistochemistry. Localization to inflammatory cells or other subepithelial structures was not seen.

CONCLUSIONS

We conclude that iNOS expression is upregulated in nasal polyp disease, and is localized to the polyp epithelial layer. These data reinforce the concept that the epithelial layer may be important in the pathogenesis of nasal disease, and suggest a potential role for NO in the formation of nasal polyps.