Abstract
Abstract editor
OTOLARYNGOLOGY
Ronald G. Amedee, M.D.
Chairman
Department of Otolaryngology Ochsner Health System 1514 Jefferson Hwy. New Orleans, LA 70121
Eosinophil Infiltration of Nasal Polyps in Patients with Nasal Polyposis: Role in Clinical Evolution After Medical and Surgical Treatment
Bonfils P, Badoual C, Bonfils NA, Gallast D, Malinvaud D. J Laryngol Otol, 123:509–516, 2009
This most interesting study is prospective in nature, assessing the role of eosinophilic infiltration in the associated symptoms and treatment of patients having nasal polyposis. One hundred forty-four consecutive patients (61% male, 39% female; mean age 47.4 years) with nasal polyposis were included using three inclusion criteria: (1) endoscopic evidence of bilateral nasal polyps, (2) CT scans revealing bilateral ethmoidal opacifications, and (3) preoperative systematic medical treatment including twice daily washing of the nasal cavities with sterile physiologic saline, nasal steroid spray (beclomethasone 500 μg twice daily in each nasal cavity), and oral prednisolone (1 mg/kg body weight per day) for an initial six-day period. Using the third inclusion criteria as detailed, patients were included in the study after more than three systemic courses of prednisolone per year were necessary to control nasal polyposis symptoms.
After meeting these three inclusion criteria, all patients underwent clinical evaluation at baseline and then two to four times per year postoperative. Because the presence of nasal polyposis likely represents a multifactorial disease, asthma, aspirin sensitivity, and bronchial hyper-responsiveness along with allergy were all evaluated before any treatment was prescribed. At the time of each visit nasal function was assessed regarding: nasal obstruction, anterior rhinorrhea, posterior rhinorrhea, facial pain, and loss of sense of smell. Polyp size did not represent an inclusion criteria and was rated on a 3-point scale where: 1 = mild (small polyps not extending to the lower edge of the middle turbinate); 2 = moderate (medium-sized polyps extending between the upper and lower edges of the inferior turbinate); and 3 = severe (large polyps extending below the lower edge of the inferior turbinate). Of note, this study did not use lasers or microdebriders at the time of functional endoscopic sinus surgery (FESS) to remove polypoid disease. FESS was performed in a standard fashion using traditional forceps. All patients received broad-spectrum antibiotics for 72 hours post-FESS.
After surgery, all patients received systemic therapy that typically began 4 weeks after surgery. Therapy again included saline washes of the nasal cavities, use of topical steroid spray, and oral prednisolone, if needed. In the case of topical steroid spray, beclomethasone 1,000 mg/day in each nasal cavity was initially used and dosage reductions were achieved progressively by decreasing the dose by 250 μg as nasal symptoms improved.
Nasal polyps removed at surgery were next assessed for quantification of eosinophils in both right- and left-sided nasal polyps. Using this data, patients were divided into two groups: patients with >50% eosinophilic infiltration of the nasal polyps (n = 73), and patients with ≤50% eosinophilic infiltration of their polyps (n = 71).
The combination of FESS and corticosteroid therapy was effective in the treatment of severe nasal polyposis. The three most disabling symptoms of nasal polyposis were anosmia, nasal obstruction, and posterior rhinorrhea. No significant difference was found between the two eosinophilic infiltration groups when assessing post-treatment control of nasal congestion and loss of sense of smell. However, a statistically significant difference (p = 0.01) was found between the two groups in regards to posterior rhinorrhea control with patients in the ≤50% eosinophil infiltration group having poorer control of posterior rhinorrhea.
The take home message in this study is that patients with > 50% eosinophilic infiltration treated with steroids plus FESS tended to have a higher prevalence of asthma, aspirin triad, and bronchial hyper-responsiveness. In this group of patients, improvement in symptoms associated with nasal polyps was not related to treatment with steroids. Rather, in this group FESS was most effective by decreasing the volume of diseased mucosa, thus reducing anosmia, nasal obstruction, and posterior rhinorrhea. Conversely, the group of patients in the ≤50% eosinophilic infiltration group had a lower prevalence of asthma, aspirin triad, and bronchial hyper-responsiveness. Steroids in this group were most effective in reducing eosinophil infiltration, and FESS in this group improved nasal obstruction and anosmia by decreasing the volume of diseased mucosa. However, in this group neither steroids nor FESS proved effective in controlling posterior rhinorrhea.
This manuscript is well written and loaded with more details than this brief review can accommodate. The work represents what the rhinologic community has come to expect from the senior author. I recommend this work for dedicated reading and discussion at an upcoming journal club. It represents required reading for fellows in rhinology and allergy/ immunology training programs. The themes are equally applicable to the contemporary clinician in a busy practice.
Ronald G. Amedee, MD