Density of Middle Turbinate Subepithelial Mucous Glands in Patients with Chronic Rhinosinusitis

OBJECTIVE: Histologic changes have not been systematically assessed in chronic rhinosinusitis. Quantitative histochemical studies evaluated the extent of sinus disease and gland density in the middle turbinates.

STUDY DESIGN AND SETTING: Sinus computed tomography scans of 34 patients with chronic rhinosinusitis were retrospectively graded 0 to IV according to the May classification. Middle turbinates from patients with chronic rhinosinusitis (n = 46) and normal patients (n = 7) were harvested during endoscopic sinus surgery. The areas of Alcian blue-stained glands were assessed in paraffin sections using a computer-assisted microscopy video system.

RESULTS: Alcian blue-stained glands occupied 7.94% of normal mucosa. The staining in all grade III rhinosinusitis subjects was increased to 12.94% ( P < 0.01). In contrast, grade IV pansinusitis was associated with nasal polyposis (6 of 6) with decreased gland area (3.04%, P < 0.01). When polyp patients were excluded from grade III rhinosinusitis, the Alcian blue-staining area was 17.68% ( P < 0.01).

CONCLUSIONS: Distinct polypoid and glandular histopathologic patterns are present in chronic rhinosinusitis.

[Morphogenesis of the stromal tissue of nasal polyps]

The objective of the present work was to study various stages of morphogenesis of the stromal tissue of nasal polyps. The materials for the investigation were harvested during endoscopic polypotomies in the nose. They were used to obtain the preparations that were stained by the histological and histochemical methods. The immunochemical studies were carried out using monoclonal antibodies against differentiation clusters, such as CD20, CD31, and vascular endothelial growth factor (VEGF). The study has demonstrated that the growth and evolution of the nasal polyps are accompanied by sequential alterations in the morphological structure of their stromal tissue. The results of the investigations were used to develop the original classification of the selected stages of morphogenesis of the stromal tissue of nasal polyps. The following stages were distinguished: edematous one, inflammatory cellular infiltration, fibrous cirrhotic alterations, and vasculogenesis or neoangiogenesis.

The Lund-Mackay staging system for chronic rhinosinusitis: how is it used and what does it predict?

OBJECTIVES

The Lund-Mackay score is widely used in assessment of chronic rhinosinusitis. We aimed to describe its relationship to other measures of pre- and post-treatment health status.

STUDY DESIGN

Multicenter prospective study of 1840 patients undergoing surgery for chronic rhinosinusitis in the UK.

RESULTS

There was no absolute threshold for surgery, but patients with higher Lund-Mackay scores underwent more extensive surgery. There was no correlation between Lund-Mackay and SNOT-22 scores. The Lund-Mackay increased with increasing grade of polyposis. The Lund-Mackay score was associated with symptom reduction (coefficient = 0.24, P = 0.02) complication rates (odds ratio, 1.08, 95%CI 1.06 to 1.1), and revision rates (odds ratio, 1.03, 95% CI 1.001 to 1.06).

CONCLUSIONS

The Lund-Mackay score measures a different aspect of disease to "subjective" symptom scores. However, it correlates well with other markers of disease severity, the nature of surgery offered, and its outcome.

SIGNIFICANCE

This demonstrates the strengths and limitations of a commonly used staging system.

[Polyposis nasi--improvement in quality of life by the influence of leukotrien receptor antagonists]

BACKGROUND

Sulfido-Leukotrienes are important inflammatory mediators of bronchial asthma, intolerance of acetylsalicylic acid (ASA), polyposis nasi and allergic rhinitis. Receptorantagonists like Montelukast constitute a well-established asthma- and ASA intolerance-therapy. The aim of our study was to evaluate changes in patients Health-Related-Quality-of-Life (HRQL) during Montelukast-monotherapy of nasal polyposis.

METHODS

The study was performed in a prospective, double blind and placebo-controlled matter. The study included 30 patients of our ENT outpatient's dept. (77 % male, mean age 49 yrs), suffering from nasal polyposis grade II to IV. Polyps were endoscopically graded, nasal Eosinophilic Cationic Protein (ECP) was measured, and HRQL-score was taken prior to and four weeks after Montelukast-(0 - 0 - 10 mg) compared to placebo. An established HRQL-questionnaire - including 25 items, summarized in 6 symptom-groups - was used. Given was a symptom-score of 1 (not troubled) to 4 (extremely troubled).

RESULTS

Patients treated with Montelukast improved their nasal symptoms (Delta HRQL-score 0.58 +/- 0.94, P < 0.01), practical problems (Delta HRQL-score 0.42 +/- 0.71, P < 0.05), headaches (Delta HRQL-score 0.38 +/- 0.56, P < 0.05), non-nasal symptoms (Delta HRQL-score 0.35 +/- 0.92, P < 0.05), sleep (Delta HRQL-score 0.26 +/- 0.71) and emotional problems (Delta HRQL-score 0.18 +/- 0.75). Intranasal ECP (Delta 210.67 ng/ml +/- 332.68) and polyp grading (Delta 0.72 +/- 1.77) tended to improve as well, but did not reach statistical significance. Patients treated with placebo revealed no significant changes neither in HRQL-score, ECP, nor polyp grading.

CONCLUSIONS

Montelukast-therapy of nasal polyposis significantly improved patient's HRQL in 4 out of 6 symptom-groups. Measuring HRQL proofed to constitute a more sensitive tool than looking at eosinophilic parameters of inflammation or polyp size.

Pathophysiological classification of chronic rhinosinusitis

Background

Recent consensus statements demonstrate the breadth of the chronic rhinosinusitis (CRS) differential diagnosis. However, the classification and mechanisms of different CRS phenotypes remains problematic.

Method

Statistical patterns of subjective and objective findings were assessed by retrospective chart review.

Results

CRS patients were readily divided into those with (50/99) and without (49/99) polyposis. Aspirin sensitivity was limited to 17/50 polyp subjects. They had peripheral blood eosinophilia and small airways obstruction. Allergy skin tests were positive in 71% of the remaining polyp subjects. IgE was<10 IU/ml in 8/38 polyp and 20/45 nonpolyp subjects (p = 0.015, Fisher's Exact test). CT scans of the CRS without polyp group showed sinus mucosal thickening (probable glandular hypertrophy) in 28/49, and nasal osteomeatal disease in 21/49. Immunoglobulin isotype deficiencies were more prevalent in nonpolyp than polyp subjects (p < 0.05).

Conclusion

CRS subjects were retrospectively classified in to 4 categories using the algorithm of (1) polyp vs. nonpolyp disease, (2) aspirin sensitivity in polyposis, and (3) sinus mucosal thickening vs. nasal osteomeatal disease (CT scan extent of disease) for nonpolypoid subjects. We propose that the pathogenic mechanisms responsible for polyposis, aspirin sensitivity, humoral immunodeficiency, glandular hypertrophy, eosinophilia and atopy are primary mechanisms underlying these CRS phenotypes. The influence of microbial disease and other factors remain to be examined in this framework. We predict that future clinical studies and treatment decisions will be more logical when these interactive disease mechanisms are used to stratify CRS patients.

[Rational treatment of nasal polyposis]

Despite the therapeutical advances of the last decade, nasal polyposis represents still a problem for rhinology, practitioners. A number of hypotheses have been formulated about its etiopathogenesis, but no one is confirmed, so that nowadays therapy continues to be only symptomatic and does not cure definitively the underlying pathology. Recurrences are frequent and discourage both the practitioner and the patient. Purpose of this paper is to illustrate Authors' therapeutical rationale aimed to reestablish nasal flow, reduce rhinorrhea, improve olfaction, decrease rhinosinusinusal infection rate and maintain as long as possible such a symptomatic improvement. These targets are best achieved by a combination of medical and surgical treatments in order to optimize the results and reduce the side-effects of both the therapeutical options. Moreover the treatment should be tailored on each patient and follow up should be careful and performed at regular interval. Authors reviewed the clinical records of patients who underwent surgery for nasal polyposis between 2002 and 2004 at Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy, with a minimum follow-up of 12 months. All patients underwent the complete set of diagnostic work-up. The choice between surgical or medical options was based on both the kind of the polyposis and the staging of the pathology. The therapy was as more "personalized" as possible, but a homogeneity of treatment was maintained. The results show that a correct "staging" of the patient allows an appropriate therapy and reduces recurrence rate. In conclusion, authors report their experience and propose a scheme of diagnostic work-up in order to define grading/staging of the pathology and establish a "tailored" therapeutic protocol aimed to control a pathology which is rarely definitively treated.

A study of functional endoscopic sinus surgery technique

Endoscopic sinus surgery has become a widely accepted surgical procedure for the treatment of chronic inflammatory sinus diseases. In our study 100 patients were suffering from polyposis treated by functional endoscopic sinus surgery in MMCH. Out of 100 patients 53 patients were suffering from ethmoidal polyp and 47 patients were suffering from antrochoanal polyp between the ages 7 to 45 years. Among antrochoanal polyp 2 patients were found with inverted papilloma and came with recurrence. 40% of the patients came with a follow up visit up to 1 year. 7 out of 53 cases of ethmoidal patient came with recurrence requiring revision FESS. There was no history of patient suffering from asthma or aspirin intolerance. Overall success rate was observed in 91%. Four patients were found with periorbital haematoma and 5 with fat coming out from orbit due to injury of lamina papyraceae.

[Expression and distribution of aquaporin-2 in nasal polyps]

OBJECTIVE

To study the distribution and expression of aquaporion-2 (water channel protein; AQP-2) in nasal polyps and to evaluate the role of AQP-2 in the formation of nasal polyps.

METHODS

Eleven samples of normal inferior turbinates and forty-six samples of nasal polyps were used. In the group of nasal polyps, there were ten cases of type II phase 1, twelve type II phase 2, ten type II phase 3 and fourteen type III. The expression of AQP-2 in both groups was studied with immunohistochemical technique.

RESULTS

1. Both the number of AQP-2 positive cells and the area density in the epithelial cell layer from nasal polyps were higher than those from inferior turbinates (P < 0.01, P < 0.05 respectively); In the group of nasal polyps, the area density from type III, type II phase 2 and type II phase 3 was significantly higher than that from type II phase 1 (P < 0.05); 2. Both the number of AQP-2 positive cells and the area density in the subepithelial tissue from type III, type II phase 2 and type II phase 3 nasal polyps were higher than those from type II phase 1 nasal polyps and inferior turbinates(P < 0.05), whereas the difference between the latter two was not significant(P > 0.05).

CONCLUSION

The high expression of AQP-2 protein in nasal polyps may contribute to the genesis and development of nasal polyps.

[Multifactorial analysis of preoperative functional symptoms in nasal polyposis (report of 403 patients)]

PURPOSE

Nasal polyposis is an invading disease whose evolution is dominated by functional symptoms. The aim of this study was to evaluate in cortico-resistant patients with nasal polyps the pre-operative functional symptoms in order to define factors that might increase them.

METHODS

403 patients were included in this study. All of them met the inclusion criteria of follow-up and initial examination. Anosmia, pain, nasal obstruction, rhinorrhea and sneezing were evaluated by patients themselves. Radiological data, respiratory function test results and histological data were matched.

RESULTS

In our series, functional symptoms were dominated by anosmia, nasal obstruction and rhinorrhea. Pain and sneezing appeared to be less frequent. Analysis of co-variables allowed us to define factors which increased pre-operative functional symptoms. Some of them are well known (such as Fernand-Widal triad or stage 3 nasal polyposis), while others appear new or surprising. The same is true for frontal sinus involvement on CT-scan and glandular hyperplasia on histological study.

CONCLUSION

Analysis of the complete clinical, radiological and histological picture has allowed us to emphasise the importance of certain factors on the functional symptoms of 403 patients with polyps of the nose and sinuses, resistant to steroid treatment. The same is true for Widal's disease, for a higher endoscopic grading, for frontal sinus involvement, and for histological evidence of glandular hyperplasia.

Nasal polyposis in children with cystic fibrosis: a long-term follow-up study

The incidence of nasal polyposis among children 5 to 18 years of age with cystic fibrosis (CF) was investigated with a systematic examination of all children on the local CF register. Out of 23 children with CF, 13 had endoscopic evidence of nasal polyposis. Four children had grade 2 polyposis, and 9 children had grade 3 polyposis. Complete opacity of the maxillary sinus was identified on a computed tomographic sinus scan in all but 2 of the children. Only 1 child had a developed frontal sinus. Between 1989 and 2000, 12 children underwent radical endoscopic sinus surgery for their nasal polyposis. There was good postoperative improvement in all of the children; however, 7 eventually required revision surgery because of recurrence of the nasal polyps. The median interval between repeated sinus surgeries was 4 years (range, 18 months to more than 6 years). This information can help in the counseling of parents when sinus surgery is considered for children with CF.

Topical corticosteroids in nasal polyposis

Nasal polyps are the common end-point of a number of conditions characterised by inflammation and are rarely 'curable' in its true sense. After consideration of the underlying aetiology and confirmation of the diagnosis, they are normally managed by a combination of medical and surgical interventions. Of these, topical corticosteroids have proved to be the medical treatment of choice. The objectives of the medical management are to eliminate or reduce the size of polyps, re-establish nasal airway and nasal breathing, improve or restore the sense of smell, and prevent recurrence of nasal polyps. The mechanism of action of corticosteroids may be by a multifactorial effect on various aspects of the inflammatory reaction, the effect being initiated by their binding to a specific cytoplasmic glucocorticoid receptor. At a cellular level, there is a reduction in the number of antigen-presenting cells, in the number and activation of T cells, in the number of mast cells, and in the number and activation of eosinophils. When polyps are large (grade 3) topical medication is difficult to instil in a very blocked nose and surgery or short term systemic corticosteroids may be required. Topical corticosteroids are of use in the primary treatment of nasal polyps when they are of a small or medium size (grades 1 and 2) and in the maintenance of any therapeutic improvement. The efficacy of topical corticosteroids such as betamethasone sodium phosphate nose drops, beclomethasone dipropionate, fluticasone propionate and budesonide nasal sprays in reducing polyp size and rhinitis symptoms has been demonstrated in several randomised, placebo-controlled trials. Beclomethasone dipropionate, flunisolide and budesonide sprays have also been shown to delay the recurrence of polyps after surgery. Placebo-controlled studies of agents that have shown a significant clinical effect in the management of nasal polyposis are reviewed.

[A new variant of choanal polyps]

Seven cases of ethmochoanal polyps, a form of nasal polyps, originating from mucosa of the back ethmoidal labyrinth and lowering into the nasopharynx are described. Such polyps are diagnosed primarily by computed tomography and endoscopy of the nasal cavity. Histologically, ethmochoanal polyps are similar to other polyps from paranasal sinuses. Surgical treatment of ethmochoanal polyps is made under the control of endoscope via approach through the superior nasal passage. The polyp part situated in posterior compartment of the ethmoidal labyrinth was removed with a microdebrider. 1 to 3 year follow-up registered no cases of recurrence.

Does the severity of sinus computed tomography findings predict outcome in chronic sinusitis?

OBJECTIVES

We studied the association between the severity of pretreatment CT scan findings and the improvement in symptoms of chronic sinusitis after treatment.

METHODS

We analyzed data from an ongoing prospective, nonrandomized clinical outcomes study of patients treated for chronic sinusitis at a tertiary-care academic medical center (n = 57, mean age 46.8 years). Disease-specific symptom severity was measured with a validated health status instrument, and CT stage was quantified with the Harvard CT staging system.

RESULTS

In a multivariate analysis, symptom severity based on CT findings emerged as a strong predictor of both improvement in symptom score outcome (beta = 0.47, P = 0.01) and absolute symptom level after treatment (beta = -0.58, P = 0.001).

CONCLUSIONS

Severity as assessed by a pretreatment CT scan is a strong predictor of outcome. Patients with higher symptom severity based on CT scans showed significantly larger improvement and lower absolute levels of symptom severity after treatment. This study links CT scan findings and subjective patient-based outcomes (symptom scores) using a validated outcomes instrument.

A prospective treatment trial of nasal polyps in adults with cystic fibrosis

This is the first prospective, randomised, double-blind trial of the treatment of nasal polyps in cystic fibrosis. We found that betamethasone nasal drops showed a statistically significant reduction in polyp size in comparison to placebo.

[A new system for the classification of ethmoid polyposis. Effect of combined local and systemic steroid therapy]

BACKGROUND

Nasal polyps are a common disease with in the majority of cases unknown origin. Both the medical and surgical treatment of nasal polyps present a challenge in Otorhinolaryngology.

METHODS

We developed a four-stage grading system for nasal polyps based on the endoscopic aspect of more than 300 patients. In a study of 37 patients, treated by systemically (Methylprednisolon 64 mg p.o., decreasing amounts for the first 11 days) and locally (Budesonid 400 micrograms intranasal) applied steroids for 90 days, this staging-system was tested.

RESULTS

The mean stage of polyps decreased significantly (p < 0.01) from 2.8 at day 0 to 1.7 at day 7 and further to 1.2 and to 0.7 at day 28 and day 90 respectively. The mean nasal symptom score decreased equally from 1.14 on day 1 to 0.19 and to 0.14 on day 7 and day 28 respectively. To summarize, we observed a significant (p < 0.01) decrease in polyp stages of 75% respectively a significant (p < 0.01) reduction of symptom scores of 93%.

CONCLUSIONS

Thus, we present a suitable new grading system for nasal polyps which we applied directly to assess the efficacy of combined local and systemic steroid therapy. It was shown that this treatment can reduce polyps and prevent their recurrence over the observed time.

[Nasal polyps. Definitions and development of pathogenesis theory]

This paper presents definitions and types of classifications of nasal polyps. The precise pathogenesis of nasal polyps is not known, although there are several important factors: chronic and recurrent infection of nasal mucose, abnormal vasomotor response, airflow blockade of the middle meatus and ostia of the paranasal sinuses. Since 1843 several pathogenic theories have been introduced.

Surgical treatment of nasal polyps: past, present, and future

Considerable changes have taken place over the last two decades in the surgical approach to nasal polyposis. The advent of the endoscope has enabled earlier detection and less traumatic and more precise surgical treatment of diseases presenting with nasal polyps. The concept of functional endoscopic sinus surgery (FESS) offers individualized surgery according to the respective patient's disease, and routine radical surgical procedures can be avoided with good functional results. In patients with aspirin intolerance, allergic fungal sinusitis and asthma, nasal polyposis is histologically dominated by dense eosinophilic infiltration and requires a more aggressive approach, often involving combined therapy with corticosteroids. In these cases, extensive postoperative care and follow-up is required to preserve the good postoperative result and to prevent regrowth of polyps.

Quantitative glycohistochemical characterization of normal nasal mucosa, and of single as opposed to massive nasal polyps

A series of 41 nasal polyps (23 single and 18 massive) and 6 normal nasal mucosa specimens was glycohistochemically investigated. Five plant lectins were used, i.e., the peanut agglutinin (PNA), the wheat germ agglutinin (WGA), the gorse seed agglutinin (UEA-I), the Maackia amurensis agglutinin (MAA), and the elderberry bark agglutinin (SNA). A neoglycoconjugate and 2 animal lectins (CL-14 and CL-16) were also used. Three quantitative features were calculated by means of computer-assisted microscopy: the percentage of tissue area specifically stained by the histochemical probe, the staining intensity, and the heterogeneity level of the staining distribution. The results show that with respect to sialic acid-glycoprotein binding characteristics as determined by SNA, MAA, and WGA probes, the normal nasal mucosa differed markedly (p<.00001) from the polyposal one. The single nasal polyps exhibited glycohistochemical characteristics that differed markedly (p = .0004) from those exhibited by the massive ones. These differences related mainly to the UEA-I, PNA, and the Thomsen-Friedenreich antigen-exposing neoglycoprotein binding characteristics. In conclusion, the present study shows unambiguously that polyposal mucosa, whether of the single or the massive type, exhibits markedly distinct glycohistochemical characteristics when compared to normal nasal mucosa, and that single nasal polyps also differ markedly from massive ones.

[Study on relative factors in endoscopic sinus surgical procedure]

OBJECTIVE

In order to investigate the factors which affect the operative treatment effect of FESS.

METHOD

215 cases suffered functional endoscopic sinus surgery (FESS) from May 1994 to December 1997 were analysed.

RESULT

The clinical curative rate was 75.8% and the improving rate was 96.3%.

CONCLUSION

The effect shows that surgical procedure is closely related to following factors: mechanic of operation, drugs taken in pre-operation, kinds of anesthsia, clinical stage of chronic sinusitis, nasal poplys and skill of surgeons.

[Nasal polyps of olfactory sulcus]

To explore the origin of olfactory sulcus polyp (OSP) and observe the recovery of olfaction after functional endoscopic sinus surgery, fifty-nine olfactory sulcus polyps in 31 patients were reviewed. The origin of OSP was carefully observed. In these patients 69.5% (41 sides) originated from the mucosa of posterior ethmoid sinus, including the superior meatus (23 sides) and ethmoid cells near the ostia (18 sides). OSP originated from middle turbinate (8 sides) and superior turbinate (4 sides). Six OSP originated from the mucosa of both ethmoid and sphenoid sinus. Olfactory changes were dynamically observed after endoscopic sinus surgery in 26 patients. The smell improved significantly in 26 sides (52.0%) within three months. The olfaction improved slowly in those patients with recurrent polyps and polysinusitis associated with polyps. We suggest that minimal endoscopic sinus surgery is the treatment of choice for OSP.

Sinusonasal polyposis

The histological aspects and general disorders related to nasal polyps are reviewed. The origin and physiopathology of nasal polyposis are discussed. The influence of morphology in polyp classification and the contribution of glycohistochemistry are emphasized.

Algorithm analysis of lectin glycohistochemistry and Feulgen cytometry for a new classification of nasal polyposis

The aim of this study is to present a new classification of nasal polyps. This classification is based both on morphologic criteria relating to morphonuclear features from isolated Feulgen-stained nuclei and on glycohistochemical characteristics from histologic slides submitted to three lectins (peanut, wheat germ, and gorse seed agglutinins) and one neoglycoconjugate glycohistochemical stain. While the morphonuclear features (including 30 variables) relate essentially to chromatin pattern, the glycohistochemical stains (including 16 variables) are linked to the presence of specific carbohydrate moieties in cell membranes and cytoplasm. Forty-nine nasal polyps, including single polyps, diffuse polyposis, cystic fibrosis-related polyposis, and aspirin idiosyncracy-related polyposis associated with asthma, were thus characterized. All the variables were obtained quantitatively by means of computer-assisted microscopy. Two complementary methods of data classification were used to determine the actual diagnostic value contributed by each quantitative variable, namely, discriminant analysis, which forms part of multifactorial statistical analysis, and the decision tree technique, which is an artificial intelligence-related algorithm. The data so obtained show that our morphologic classification of nasal polyps fits in with the classification of nasal polyps defined on the basis of clinical criteria.

Choanal polyps: one entity, one surgical approach?

Twenty consecutive patients (ten women and ten men; 14 - 66 years old) operated on from September 1993 to November 1995 were included in this study. The only inclusion criterion was a large polyp protruding from the nasal cavity into the nasopharynx. CT, MRI and endoscopic sinus surgery identified sites of choanal polyp (CP) origin as follows: maxillary sinus (n = 11), sphenoid sinus (n = 3), posterior ethmoids (n = 4), anterior ethmoids (n = 1), and lateral aspect of the head of the middle turbinate (n = 1). Light microscopy demonstrated no correlation between the site of CP attachment and its morphological appearance, but in two cases of CP (one originating from the sphenoid sinus and the other form the middle turbinate) morphological examination confirmed the diagnosis of inverted papilloma. Long-term follow-up in 15 patients revealed no cases of recurrence. The results obtained allow us to define three types of CP: antrochoanal, sphenochoanal, and ethmochoanal. In case of an unusual site of CP origin, the diagnosis of inverted papilloma should be considered.

[Histological and immunohistochemical study of nasal polyps]

Nasal polyps, in general, have been histologically classified as edematous, adenocystic and fibrous types. It has recently been pointed out that eosinophilic infiltration in nasal polyps has increased along with an increase in nasal allergy. The purpose of this study was to classify the nasal polyps histologically and to examine the mode of infiltration and activation of eosinophils by means of immunohistochemistry. The subjects were 101 patients who underwent surgery for nasal polyps. There were 66 males and 35 females ranging in age from 12 to 76 years. Resected polyps were fixed in formalin, embedded in paraffin, and sliced at a thickness of 4 microns. Hematoxylin-eosin staining and streptavidin- biotinyl peroxidase complex staining were used to detect eosinophils. The results were as follows: 1) The nasal polyps were, histologically, edematous in 88.1%, adenocystic in 47.5%, and fibrous in 19.8%. 2) The number and distribution of EG1-positive cells and EG2-positive cells were almost the same in the superficial layer of the lamina propria. This study suggests that eosinophilic infiltration into nasal polyps occurs mainly in edematous polyps and that the majority of the infiltrating eosinophils are activated.

Nasal polyps update. Histopathology

Sinonasal polyps are benign mucosal swellings that occur in four different histological patterns. The most common type is the edematous, eosinophilic (so-called "allergic") nasal polyp, which constitutes 85-90% of nasal polyps. The edematous polyp is morphologically characterized by edema, goblet cell hyperplasia of the epithelium, thickening of the basement membrane, and of numerous leukocytes, predominantly eosinophils. The second histological type is a fibroinflammatory polyp characterized by chronic inflammation and metaplastic changes of the overlying epithelium. Another rare variant presents with pronounced hyperplasia of seromucinous glands, but otherwise shows many similarities with the edematous type of polyp. The fourth type is very rare and is a polyp with atypical stroma. This latter polyp calls for awareness and careful histological examination to avoid misdiagnosis of a neoplasm.

[Analysis of the cellular infiltrate and epithelial class I and II molecular expression in edematous type nasal polyps]

Although in the last few years histopathological, immunohistochemical and immunological studies on nasal polyps have been carried out by several Authors, the etiology of these formations still remains unknown. Nasal polyps have a very characteristic structure and have been classified in three histologic types: edematous, glandular and fibrous. In the present report, 11 nasal polyps of edematous type, representing 61% of total number of collected polyps, were studied employing immunohistochemical methods. All the examined polyps were similar in histology and positivity pattern for HLA molecule expression. The edematous core appeared infiltrated (149 cells/mm.2) mainly by eosinophils (> 90%), whereas the peripheral subepithelial connective tissue contained cellular clusters (416 cells/mm2.) made up of different subsets of hematic cells (30.8% were monocytes-macrophages and 48.6% were lymphocytes largely represented by CD4+ cells). On the contrary, mast cells were quite rare (on the average 1.7 cells/mm2.) and located near T cell clusters. The epithelial positivity for HLA-DR and HLA-A,B,C molecules showed a characteristic discontinuous pattern. In the same patient, controlateral nasal mucosa showed a histological structure very similar to that of polyps. The above data suggest that the presence of polyps is the result of an inflammatory process brought about by a complex array of cellular and humoral components.

Inverted papilloma: an analysis of 87 cases

A group of 87 patients with inverted papilloma, a locally aggressive benign sinonasal tumor, were treated over the past 15 years. Selection of therapy depends on an accurate radiographic assessment of the extent of tumor. The tumor's local aggressiveness, high rate of recurrence, associated malignancy, and multicentric tendency have led most workers to advocate radical surgical removal of the tumor by lateral rhinotomy and en bloc resection of the ethmoid labyrinth. Radiographic evaluation by computed tomography scanning and magnetic resonance imaging permits identification of a small group of patients who have limited lesions and may be candidates for conservative tumor resection by intranasal or transantral sphenoethmoidectomy. Among our ten patients treated with conservative surgery, there was recurrence in one case (10%). Seventy-five patients underwent rhinotomy and medial maxillectomy, with seven cases recurring (9%). The overall recurrence rate was 9% (8 of 87). Among the 87 cases, 5 patients had carcinoma (6%). The literature is reviewed and the principles of case selection and management are discussed.

Mesenchymal cell atypicality in inflammatory polyps

Excised nasal polyps should be examined histologically for classification as to aetiological process. Recently a 'pseudosarcomatous' change was reported in nasal polyps. We reviewed one hundred excised polyps for mesenchymal atypicality and found a wide degree of mesenchymal atypicality in the majority of nasal polyps. Nasal and choanal inflammatory polyps are the most frequent nasal masses which the otolaryngologist has to treat. Surgical excision is frequently required to alleviate the nasal symptoms of polyps unresponsive to medical therapy. Excised nasal polyps should be examined histologically for classification as to possible aetiological mechanisms and to rule out neoplastic lesions (Shea, 1947). Smith, Echevarria, and McLelland (Smith, 1974) recently described 'pseudosarcomatous changes' in nasal polyps. This stimulated us to investigate our inflammatory nasal polyps for these histological changes. Causal observations demonstrated an impressive number of inflammatory polyps with varying amounts of atypical mesenchymal stroma cells. To quantitate these alterations, we reviewed the histological slides from one hundred patients with excised inflammatory polyps and the results are the subject of this report.