Revisiting the Clinical Scoring System for the Prognosis of Chronic Rhinosinusitis with Nasal Polyps

PURPOSE

To evaluate the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis (JESREC) classification, a clinical scoring system, for predicting disease control status in chronic rhinosinusitis with nasal polyps (CRSwNP) and to investigate prognostic factors.

MATERIALS AND METHODS

In total, 134 CRSwNP patients who underwent functional endoscopic sinus surgery after maximal medical treatment were enrolled. These patients were categorized into four groups according to JESREC classification: 1) non-eosinophilic CRSwNP (non-ECRSwNP), 2) mild eosinophilic CRSwNP (ECRSwNP), 3) moderate ECRSwNP, and 4) severe ECRSwNP. Disease control status among the patients was evaluated at 1 year after surgery, and the patients were divided into two groups (disease-controlled and disease-uncontrolled groups) for the investigation of prognostic factors.

RESULTS

There was no significant difference in disease control status between non-ECRSwNP and ECRSwNP groups (p=0.970). Age, Lund-Mackay CT scores, global osteitis scores, tissue neutrophil count, and tissue eosinophil count were associated with disease control status. In subgroup analysis of the non-ECRSwNP group, only high tissue neutrophil count was related with disease control status, whereas for the ECRSwNP group, young age, high Lund-Mackay CT scores, high global osteitis scores, and high tissue and blood eosinophil counts were associated with disease control status.

CONCLUSION

No difference in disease control status was identified between non-ECRSwNP and ECRSwNP cases. Tissue neutrophilia, however, appeared to be associated with disease control status in non-ECRSwNP cases, whereas tissue and blood eosinophilia was associated with ECRSwNP cases.

Interleukin-4 C-590T Polymorphism is associated with Protection against Nasal Polyps in a Korean Population

Background

Although many studies have implicated interleukin (IL)-4 promoter polymorphisms as potential determinants of disease susceptibility, there are no reports on the association between IL-4 promoter polymorphisms and nasal polyps. The aim of this study was to investigate the relationship between an IL-4 promoter polymorphism and nasal polyps.

Methods

The C-590T promoter polymorphism of the IL-4 gene was genotyped by polymerase chain reaction-restriction fragment length polymorphism analysis in 106 Korean chronic rhinosinusitis patients with or without nasal polyps and 70 healthy Korean subjects.

Results

The frequency of the T allele at position -590 of the IL-4 gene in a Korean population was 0.85, which was significantly higher than those of other ethnic groups, and the T/T allele at position -590 of IL-4 was associated with protection against nasal polyps if compared with the C/C allele (relative risk, 0.529; 95% confidence interval, 0.307–0.912; p = 0.028).

Conclusion

T-590, which is dominant at position -590 of the IL-4 promoter, appears to be associated with a protective mechanism against nasal polyps in Korean populations.

Comparative study of outcome of the endoscopic sinus surgery and conventional surgery for nasal polyposis

This is a cross-sectional study done in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka Medical College & Hospital (DMCH) & Bangladesh Institute of Research and Rehabilitation of Diabetic Endocrine and Metabolic Disorder (BIRDEM), Dhaka during the period of January 2009 to August 2010. This study included 60 cases of nasal polyposis, among them in 30 cases Functional Endoscopic Sinus Surgery (FESS) was done and in 30 cases conventional surgical procedure was done as treatment procedure. Here mean age of patient in FESS was 45.43 years and in conventional surgery was 45.13 years and male female ratio was 3.3:1. In this study postoperative complication of FESS were found in 07(23.33%) cases whereas in conventional surgery it were in 16 (53.33%) cases (p = <0.01, df = 1, Chi-squire = 7.65). In case of outcome, complete relief of symptoms occur in 22(73.33%) cases by FESS and 14(46.66%) cases by conventional procedure (p = <0.05 df = 2, Chi-squire = 9.29). In FESS 22(73.33%) cases and in conventional technique 14(46.67%) cases discharged within 24-48 hours (p = <0.05, df = 1, Chi-squire = 4.44). Recurrence after FESS was 6.67% cases and conventional surgery was 30% cases. The results of this series reveled that FESS had the combined advantages of precise removal of the disease with minimal complication.

Cathepsin D activity in nasal polyps

OBJECTIVES

The aim of the study was to assess the activity of cathepsin D in polyps removed during first-time FESS surgery and in recurrent polyps removed during successive FESS surgeries.

DESIGN AND METHODS

The study examined 24 polyps: 11 polyps were removed during first-time surgical procedures (termed primary polyps in the study), and 13 recurrent polyps were removed in successive FESS surgeries (termed polyps after re-polypectomy in the study). The activity of cathepsin D was determined by measuring the tyrosine released from denatured hemoglobin.

RESULT

The average cathepsin D activity in polyps after re-polypectomy was 74% higher than the average activity in primary polyps, whereas the difference between the maximum and the minimum cathepsin D activities in polyps after re-polypectomy was twofold greater than the respective difference in primary polyps.

CONCLUSION

Differences in cathepsin activity and the protein content, likely to be significant in the process of polyp recurrence, were observed in both groups of polyps.

[Experience with treatment of chronic polypoid rhinosinusitis using low doses of clarithromycin in the postoperative period]

A total of 37 patients at the age from 25 to 65 years presenting with chronic polipoid rhinosinusitis (CPRS) were available for the observation. They were allocated to two groups based on the results of endoscopic polyposinusotomy. The patients in group 1 (n=18) were instructed at discharge from the clinic to take 250 mg of clarithromycin daily for 3 months in combination with the local application of a topical corticosteroid. The patients in group 2 (n=19) were prescribed topical corticosteroids alone. It was shown that clarithromycin at low doses caused significant stabilization of CPRS remission and prevented the development of relapses in the majority of the patients (66%). Therapy of CPRS with low doses of clarithromycin was associated with a significant decrease of the frequency of acute retroviral infections (ARVI). The intake of clarithromycin had no effect on the development and/or aggravation of intestinal dysbacteriosis nor did it provoke deviation of blood biochemical characteristics from the normal values both at the onset of therapy and after a follow-up period of 3 months.

[Revision endoscopic sinus surgery and combined therapy for recurrent sinusitis]

OBJECTIVE

To investigate the efficacy of revision endoscopic sinus surgery and combined therapy on recurrent sinusitis and polyps.

METHOD

Revision endoscopic sinus surgery was performed in 72 patients, of which endoscopic nasal lateral wall dissection was used in 3 cases, the endoscopic frontal sinus surgery (Draf I-II) was used in 16 cases, and all patients received combined therapy including peri-operation conservative management and nasal endoscopy examination during the follow-up period.

RESULT

All patients were followed up for more than one year. Of 72 patients, 52 patients were successfully cured, 10 patients showed improvement, but there was no change in other 13 patients. The total efficacy rate was 91.67% (66/72). No serious complication occurred.

CONCLUSION

The treatment efficacy can be greatly improved by enough preoperative preparation, fine operation, combined pre-operation conservative therapy and postoperative follow-up.

Chronic rhinonsinusitis and nasal polyposis: the etiopathogenesis revealed?

Nasal polyps represent a severe eosinophilic inflammation of the upper airways which is characterized by poor impact of therapeutic intervention and frequent recurrences. Based on distinct cytokine, mediator and cell profiles, chronic sinonasal disease in Caucasians can be differentiated into several subgroups such as chronic rhinosinusitis without nasal polyps, chronic rhinosinusitis with nasal polyps, and nasal polyps in cystic fibrosis patients,. In Caucasians, nasal polyps showed a Th2 polarisation with high IL-5 concentrations, while chronic rhinosinusitis without polyps was characterized by a Thl polarisation with high levels of IFN-gamma. In the Caucasian nasal polyps we found that significantly more nasal polyp patients are colonized with S. aureus and that colonization increased in patients with concomitant asthma and aspirin sensitivity. Although there was no major difference in the presence of enterotoxin genes in S. aureus strains derived from nasal polyp or control patients, we found an increased immune response to S. aureus enterotoxins in nasal polyps, which resulted in a more pronounced eosinophilic inflammation and higher total IgE production in those polyps affected. We suggest that S. aureus superantigens amplify the inflammation in about 50% of nasal polyps, resulting in a strong Th2 polarisation, eosinophil activation, and an overproduction of IgG4 and IgE. These findings imply new therapeutic approaches apart from the currently used topical and systemic steroid therapy for nasal polyposis. In three double blind placebo controlled studies it was shown that firstly, oral corticosteroids only led to a short term reduction of polyp size. Secondly that a low dose of doxycycline treatment for 20 days had a sustained clinically relevant effect on polyp size for more than 3 months and thirdly we also showed a significant effect on polyp size by selective antagonizing IL-5 with a monoclonal antibody.

The effect of topical corticosteroid on basic fibroblast growth factor in nasal polyp tissue

BACKGROUND

The etiology of nasal polyposis and pathophysiological mechanisms of polyp formation is still poorly understood. Experimental models have suggested that nasal polyp growth requires extracellular matrix formation and is associated with fibroblast proliferation. Intranasal corticosteroids appear to be useful in reducing nasal polypoid lesions and the likelihood of polyp recurrence after surgery. Basic fibroblast growth factor (bFGF) is a potent angiogenesis factor and is mitogenic for a wide range of cell types. We investigated the alteration of bFGF levels in nasal polyp tissue after administration of topical corticosteroid.

METHODS

Nasal polyp tissues were obtained from 36 patients with diffuse nasal polyposis before and after topical nasal steroid treatment. As a topical nasal steroid mometasone furoate was given for 4 weeks in a dosage of 200 microg/day. The bFGF levels were measured by competitive enzyme immunoassay method.

RESULTS

The mean levels of tissue bFGF, before and after topical nasal steroid treatment, were 1485 +/- 826 ng/mg protein (range, 416-3434 ng/mg) and 1340 +/- 749 ng/mg protein (range, 330-3288 ng/mg), respectively. The levels of bFGF in nasal polyps were significantly lower than those before treatment after administration of topical nasal steroid (p = 0.011).

CONCLUSION

Administration of topical nasal steroid decreases bFGF levels of nasal polyp. It may be suggested that one of the effects in diminishing the size of nasal polyps is by decreasing the bFGF.

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.

[Anti-recurrence treatment of patients with polyposis rhinosinusitis in initial vagotonic type of the vegetative tonus]

Transcranial electrostimulation (Transair-2) in patients with polypous rhinosinusitis having initial vagotonic type at optimal therapeutic doses 2.6-2.8 mA potentiates immunocorrective action of leukinferon. This effect was achieved due to impact on sympathetic autonomic nervous system and correction of vegetative imbalance. A persistent antirecurrence clinical effect was obtained in 22 of 23 patients with polypous rhinosinusitis accompanied with affection of the upper respiratory tract. Early recurrences of nasal polyps reduced to 4.3% in follow-up 1.5-3 years.

Efficacy of inhalation form of furosemide to prevent postsurgical relapses of rhinosinusal polyposis

The aim of the work is to demonstrate the efficacy of furosemide to prevent relapses of rhinosinusal polyps after surgical treatment. Two groups of people with rhinosinusal polyposis were enrolled: the study group consisted of 64 patients and the control group of 40 subjects. After surgical treatment, the study group started the therapy with topical furosemide; the control group had no treatment administered after the operation. Six years after the operation only 4 cases of relapse were noticed in the study group (10%), while there were 12 relapses, 4 slight (6.4%) and 8 severe (20%), in the control group. In conclusion, furosemide could represent a valid therapeutic aid in the prevention of nasosinusal polyps.

[Antileukotrienes in the prevention of postoperative recurrence of nasal polyposis in ASA syndrome]

There is a high incidence of post-surgical recurrences of nasal polyps (NP) in patients suffering from the ASA Syndrome. The numerous theories as to the pathogenesis of the ASA Syndrome include an increase in lipoxygenase-mediated arachidonic acid metabolism, with the subsequent hyperproduction of leukotrienes (LT), and an inhibition of the cycloxygenase. Therefore, based on the information acquired on the immunobiological action mechanism of montelukast, a cysteinyl-LT receptor antagonist, it appeared worth testing the effectiveness of this substance in preventing post-surgical NP recurrences in a group of ASA Syndrome patients. After taking a case history, filling out a questionnaire scoring nasal symptoms, undergoing rhinoendoscopy and rhinomanometry, 40 patients suffering from ASA-Syndrome and NP (age range 30-72 years) were recruited for the study. They were uniformly classified according to Lund and Mackay using high resolution CT of the nose and paranasal sinuses performed after at least 1 month of nasal medical treatment. All the patients underwent microendoscopic anterior-posterior ethmoidectomy and bilateral maxillary antrostomy. After removing the nasal packing, the only treatment administered was 10 mg of montelukast/die for 6 months, with the drug suspended for 1 months after the first 3 months of treatment. The monthly follow-up included rhinoendoscopy, rhinomanometry and the questionnaire to score symptoms. After the seventh month a new CT was performed and compared with the pre-operative CT. In a control group of subjects, homogeneous with the test group, momethasone furoate nasal spray was administered at a dose of 100 mcg per nostril/die and loratadin tablets 10 mg/die. The results obtained in the patients treated with montelukast were analogous with those obtained in the second group, and during follow-up all patients showed total absence of any local recurrence, good nasal patency and no significant nasal symptom score on the questionnaire. In no case did the comparative CT, performed after the seventh month, show any signs of recurrence. The patients taking the montelukast reported a significant reduction in the use of steroids and bronchodilator inhalants during the course of the study than did the second group; indeed the number of asthmatic episodes dropped and they reported an improvement in the quality of life. Based on these results, the authors suggest that the use of montelukast in the treatment of post-surgical NP recurrences in ASA Syndrome is possible and advisable, even in synergetic association with the treatment administered to the second group. The positive results also support the hypothesis of altered arachidonic acid metabolism and call attention to the role of cysteinyl-LT in the pathogenesis of the ASA Syndrome.

[Multi-center study of recurrent nasal sinus polyposis: prognostic factors and possibility of prophylaxis]

Today, surgery is the treatment of choice for nasal sinus polyposis. Nevertheless, although meticulous surgery does "per se" reduce the percentage of recurrences, there are cases where even the most painstaking removal of the entire pathology cannot prevent recurrence. Therefore recurrences do not appear linked to the type of surgery; rather onset appears linked to intrinsic, only partially recognizable factors responsible for the primary and secondary polypogenesis. In order to identify negative prognostic factors which might be implicated in recurrences, the present study extrapolated the data from forms on 181 patients who had undergone surgery for nasal sinus polyposis and subjected it to multivariance analysis. These patients were recruited during the course of a multicenter study with the participation of 12 ENT Centers in Piemont and Liguria. The recurrence rate was 13%. In analyzing unfavorable factors prognosticating recurrence, thirteen parameters were examined. Nine of these (age, sex, severe deviation of the septum causing restriction, severe turbinate hypertrophy, surgery or repeat surgery for recurrence, type of macro-micro endoscopic surgery, allergy to seasonal inhalants, allergy to perennial inhalants, mixed allergies) did not prove to have any significance in recurrences. The presence of bilateral involvement of the sinus system presented a negative trend as regards recurrences while involvement of more than one subsite (anterior ethmoid, posterior ethmoid, maxillary sinus, sphenoid), ASA and NSAID intolerance and abundant eosinophilic infiltration in the mucous chorion proved statistically significant (p < 0.05 for all three parameters) for recurrence. Post-operative topic prophylactic treatment with steroids (beclomethasone) or anti-H1 drugs (azelastin, HCl) did not appear to affect the onset of recurrence although it did have a positive effect on subjective symptoms.

[Corticosteroid therapy in the prevention of recurrent post-surgical nasal polyposis]

The purpose of this study was to evaluate, in a group of 30 patients, the results of a medical treatment combining an oral corticosteroid (Deflazacort) with a drug applied topically (Beclomethasone dipropionate) following a well-defined protocol, in the prevention of recurrent post-surgical nasal polyposis. In the follow-up at 6, 12 and 24 months, the possible recurrence of polyposis was evaluated as well as the nasal blockage and the olfactory function. After six months the disease recurrence was observed in 33% of the cases, always in its early stages, whereas after one year the percentage rose to 50% (15 patients, of whom only 3 displayed a severe form with considerable reduction of nasal ventilation). At 24 months recurrence was observed in 57% of the patients. However most cases did not show any sign of further progression. Throughout the entire follow-up period under observation only 6 patients (20%) had a severe recurrence which therefore required a revision surgery. The comparison with a control group not undergoing medical therapy after surgery highlighted the significance of the results obtained. Consequently the therapeutic protocol adopted proved to be reliable due to the very high tolerability in all cases and to the high percentage of good or very good short and medium term results observed. No clinical side effects of any importance were observed during the study.

[Can the recurrence of nasal polyposis be prevented? A new therapeutic approach]

Nowadays nasal polyposis must be still considered an unsolved problem as the surgical procedures are unable to treat this pathology and the recurrence is very common. For this reason several Authors starting from the pathogenesis and the histological features have chosen a medical point of view at the aim of preventing the natural course of this disease. The present study experimented the effect of the furosemide locally administered in the prevention of polyps relapsing in subjects previously operated on. The Authors pointed out that the furosemide was able to decrease the nasal reactivity to the challenge with ultrasonic nebulized distilled water. Besides this drug locally administered for 3 months (once a day) maintained the nasal mucosa of the patients affected with hyperreactivity in a good functional condition without nasal obstruction. In fact no polyps were found at the objective examinations performed during the three years follow up and the values of acoustic rhinometry measurements were within the normal range. Finally the present research gave the opportunity to hypothesize the role of sodium, potassium and calcium ions transport regulated by drugs or other physiopathological events, in the physiology of the nasal mucosa.

Intranasal treatment with lysine acetylsalicylate in patients with nasal polyposis

Forty-three patients suffering from nasal polyposis underwent intranasal treatment with increasing doses of lysine acetylsalicylate (LAS) corresponding to 20, 200, and 2000 micrograms of aspirin (ASA), until a maximal dose of 2000 micrograms weekly was reached. The patients were divided in two groups: a group of 28 patients with ASA intolerance, including 20 with ASA triad, and a group of 15 patients without ASA intolerance. The local treatment was usually started 1 month after polypectomy and was well tolerated without side effects. A control group included 191 subjects with nasal polyposis, 130 of whom had ASA intolerance. After polypectomy the controls received no further medical treatment. Patients were examined every 3 months and radiographs of the paranasal sinuses were obtained every 6 months. After 24 months 34 of 43 patients (79.1%) treated with topical LAS had suffered no relapse of polyposis. Only 45 of 191 control patients (23.6%) failed to relapse after 24 months (P less than .0001). Nine of 28 (32.1%) ASA-intolerant patients treated with LAS and 105 of the 130 (80.77%) control subjects relapsed (P less than .0001). None of the 15 ASA-tolerant patients treated with LAS relapsed, but 41 of the 61 (67.21%) nontreated control subjects relapsed (P less than .00001). These data indicate topical LAS is effective in preventing recurrence of nasal polyps after polypectomy.

Budesonide nasal spray as prophylactic treatment after polypectomy (a double blind clinical trial)

This double-blind parallel-group study compared the effect of budesonide with placebo, in the prophylaxis of nasal polyp recurrence after evulsion. Seventy-three patients with first time or recurrent polypectomy were enrolled. At revisits 3 and 6 months after evulsion, the budesonide-treated patients had significantly lower polyp scores than the placebo-treated patients. Only patients with recurrent nasal polyposis benefited from the budesonide treatment, whereas no effect was evident in patients with first time evulsion.

Flunisolide nasal spray 0.025% in the prophylactic treatment of nasal polyposis after polypectomy. A randomized, double blind, parallel, placebo controlled study

This double blind, parallel study compared flunisolide 2 X 25 mcg in each nostril twice daily, with placebo in the prophylaxis of nasal polyposis recurrence after surgery. The treatment lasted for 12 months. The study was conducted according to the recommendations of the Declaration of Helsinki, and the patients gave verbal consent to participate. The study was reviewed by the Norwegian Medicines Control Authority. Forty-one patients with first or recurrent polypectomy were enrolled. Thirty-seven patients completed the 12 months' period. Four patients dropped out prematurely for reasons unrelated to the test drug. Flunisolide was significantly superior to placebo in preventing recurrence of polyps during 6 to 12 months' treatment, both with respect to number (p = 0.05) and size (p = 0.03) of polyps. Nasal symptoms of sneezing and stuffiness decreased significantly for flunisolide treated patients during treatment. In the placebo group, there was a significant increase in stuffiness throughout the year. For runny nose, there was no difference between the treatments. Six flunisolide patients and 10 placebo patients reported side effects during the one year treatment, transient mild itching being the most common complaint. Three cases of secretion with bloody traces were reported. No patient withdrew for drug related reasons. In this study, flunisolide was significantly more effective than placebo in preventing recurrence of nasal polyposis during one year's treatment after polypectomy.

A randomized trial of intranasal beclomethasone dipropionate after polypectomy

Beneficial effects of intranasal beclomethasone dipropionate (Bdp) in patients with nasal polyposis have been reported earlier. This study was carried out to investigate whether long-term treatment with Bdp after polypectomy could prevent formation of new polyps and reduce the number of surgical removals. Forty consecutive patients without laboratory or other clinical signs of allergy but with severe nasal polyposis were included in the study. Twenty patients were treated with intranasal Bdp and twenty patients received no treatment after polypectomy. All patients were followed for at least 2.5 years. The size of the polyps that recurred was estimated at different time-intervals by the examining doctor. After six months there was already a significant difference in favour of the group treated with intranasal Bdp. Further results of the study and the clinical implications are discussed.

Prophylactive treatment with flunisolide after polypectomy

Twenty-two patients with nasal polyps completed a double-blind study with a new topical corticosteroid, flunisolide. Treatment during three months after operation gave, in comparison with placebo, a statistically significant effect on the symptom of stuffy nose, and on the sum of scores for stuffy nose, runny nose and sneezing. There was no significant effect on rhinomanometry. Side effects were negligible. Three patients in the placebo-group required a further operation within one year but none in the flunisolide group. Prophylactic treatment with flunisolide can be recommended as a complement to other treatment after surgery of nasal polyps.

The effect of intranasal beclomethasone dipropionate on the recurrence of nasal polyps after ethmoidectomy

The purpose of this work was to examine in a double blind study the ability of beclomethasone dipropionate to prevent recurrence of nasal polyps in patients in whom radical ethmoidectomy had been performed immediately before. It analyzes the results in terms of the patients subjective symptoms, clinical status and rhinomanometry. After the follow-up period of one year 86% of the patients in the beclomethasone group and 60% in the placebo group had no subjective nasal symptoms. In clinical examination polyps were absent in 54% in the beclomethasone group and in 13% in the placebo group. Rhinomanometrically there was normal nasal patency in 68% in the beclomethasone and in 33% in the placebo group.