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Mashhad University of Medical Sciences

(MUMS) Reviews in Clinical Medicine Clinical Research Development Center


Ghaem Hospital

Recurrent sinonasal polyposis after the endoscopic sinus surgery


Fereshteh Esmatinia (MD)*, Mahdi Bakhshaei (MD)
Sinus and Surgical Endoscopic Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical
Sciences, Mashhad, Iran

ARTICLE INFO ABSTRACT


Article type Nasal polyposis is one of the chronic airway diseases, which affects the
Review article patient’s quality of life in different ways. There are various complications
along with nasal polyposis, which might be cured by drug administration.
Article history Due to failure of pharmacotherapy effects, various surgical approaches
Received: 2 Mar 2014
Revised: 10 Mar 2014
might be useful to resect the polyps with the possibility of polyposis re-
Accepted: 12 Mar 2014 currence after the surgery. In this study, we aimed to review different stud-
ies about the etiology and prevalence of recurrent nasal polyposis and the
Keywords efficacy of endoscopic sinus surgery in reducing the incidence of recur-
Endoscopic sinus surgery rent nasal polyposis. We searched the PubMed and google scholar for the
Eosinophil relevant articles. Based on the studied articles, there are various factors
Nasal polyposi
including the history of inflammatory diseases, the severity of polyposis,
Paranasal sinus
Sinonasal polyps etc., which affect the long-term efficacy of surgical intervention.

Please cite this paper as:


Esmatinia F, Bakhshaei M. Recurrent sinonasal polyposis after the endoscopic sinus surgery. Rev Clin Med.
2014;1(2):86-92.

Introduction
Nasal polyposis (NP) is one of the chronic transparent, the hallmark cells in sinonasal
severe airway diseases. It is known as a polyposis. Infiltrated eosinophils in nasal
non-neoplastic inflammatory process of polyp tissue syntheses the transforming
nasal mucosa that eventually leads to the growth factor beta (TGF-β), which leads to
outgrowth of abnormal masses inside the the specific grape like clusters and without
mucosa of nasal cavity and paranasal sinuses. bleeding (1). They contain loose connective
The polyps are most frequently detected in tissue, edema and pro-inflammatory cells,
middle meatus and ethmoid region. They which are mostly eosinophils (almost in
are usually bilateral and multiplex with soft, 85% of NP). Due to high rate of eosinophils

*Corresponding author: Fereshteh Esmatinia. This is an Open Access article distributed under the
Sinus and Surgical Endoscopic Research terms of the Creative Commons Attribution License
Center, School of Medicine, Mashhad (http://creativecommons.org/licenses/by/3.0),
University of Medical Sciences, Mashhad, Iran which permits unrestricted use, distribution, and
E-mail: F.esmatinia@yahoo.com reproduction in any medium, provided the original
Tel: 051-38012689 work is properly cited.

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Esmatinia F et al.

in nasal polyp’s tissue, they are proposed different methods. Applying corticosteroids
as structural changes of nasal polyps such are the most significant medical treatment
as fibrosis of stromal and thickening of among wide range of pharmacotherapy
membrane. TGF-β and interleukin 5 (IL- method, which have been applied pre- or
5) produced by eosinophils contributes postsinonasal surgical interventions for
in the pathogenesis of NP (2,3). Different obtaining more success. The mechanism
disease conditions such as asthma, chronic of corticosteroids is mainly through
sinusitis, and aspirin sensitivity are related decreasing the infiltration of eosinophils
to the higher risk of NP occurrence. and production of IgE by increasing the
NP is a chronic health complication, expression of anti-inflammatory genes, or
which affects the patient’s quality of life enhancing the apoptosis of inflammatory
more that other chronic diseases (4). cells (7,8).
Nasal obstruction is the major symptom of In different conditions, applying
sinonasal polyposis, which shows various medication would not be sufficient for NP
intensity based on the polypsis and location. treatment, which leads to use of sinonasal
Nasal congestion, anosmia, rhinorrhea, surgeries. Polypectomy and endoscopic
postnasal drip, headache, hyposmia/ sinus surgery (ESS) are surgical options,
anosmia, loss of smell and coughing are which have shown considerable efficacy
other common presentations of NP. In one in treating inflammatory diseases of
study, it is demonstrated that small size paranasal sinuses. Although there might be
polyps lead to lower level of sinonasal various side effects along with performing
complications (5). surgical interventions, considerable levels
of reduction in NP complications and
Diagnosis and treatment methods improvement in patient’s quality of life
Conventional radiography is not sensitive have been observed (9).
enough to use for NP investigations. This Although the prevalence of NP is still a
method can only illustrate the opacification controversial issue, the general prevalence
of the involved sinuses. Performing nasal of NP has been estimated to be low in
endoscopy and computed tomography be- general population (range from 1-4%), with
fore any intervention usually provides con- higher frequency in adults compared with
siderable data about the initial diagnosis of children under 10 (10).
bilateral and symmetric NP. Nasal endosco- The incidence rate of the NP is dependent
py is known as the gold standard method for on the studied population. According to the
NP diagnosis. For the unilateral NP, more investigations, elderly and patients with
diagnostic procedures are required (6). cystic fibrosis, Churg-Strauss syndrome,
Different medical treatments have been used sarcoidosis and asthma are at higher risk for
for reducing the NP irritating presentations NP (11,12).
(e.g., nasal obstruction, congestion and
sinus inflammation) in patients. The main The etiology of NP
purpose of pharmacotherapy or even Although there are multiple predisposing
sinonasal surgery is providing a sinonasal factors in the development and pathogenesis
environment without any stimuli for polyp of NP, but the exact causes are under
development. Topical and oral steroids, debate. NP occurs almost due to unknown
macrolide antibiotics, diuretic nasal washes or idiopathic causes and has high relapse
and intrapolyp steroid injection are among tendency, which leads to complex treatment

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Esmatinia F et al.

and management processes. Several factors are important inflammatory mediators


have been proposed historically as the which are produced in eosinophil cells
predisposing elements to NP occurrence. from arachidonic acid and contribute in NP
The chronic inflammation inside nasal formation by increasing the contraction of
sinuses or the nasal cavity, which leads smooth muscles and promoting vascular
to the formation of nasal polyps, can be infiltration of airways (19).
the result of different stimuli that activate
the inflammatory cascades including Nasal polyposis recurrent
mechanical trauma after surgery, bacteria, There are various evidences regarding
viruses, fungi, and environmental allergens. the prevalence of the recurrent NP in
The eosinophilic inflammatory mechanisms patients who had been under endoscopic
are the superior reason for the formation of sinus surgery due to unilateral or bilateral
NP in almost 80% of patients, which may polyposis. It has been estimated that the
be along with diseases including asthma recurrence rate of sinonasal polyposis
and aspirin sensitivity (13). varied from 15% to 25% (20).
Based on one study on chronic According to the study of Wynn et al.
rhinosinusitis, the bacterial infections do the history of patient’s inflammatory
not interfere in the pathogenesis of nasal disease is an influential factor, which
polyps (14). The possible association of increases the recurrence rate of NP and
fungi with the incidence of NP was studied also the requirement for revision sinonasal
through microscopic and polymerase chain surgeries. In this study, 80% of patients
reaction (PCR) techniques in 2007 by Aydil with asthma who had been under the ESS
et al. which showed that the occurrence of revealed the sinonasal polyposis recurrence
fungi colonies are most common in patients in comparison with 40% of patients without
with nasal polyps (15). ashtma. It is also observed in this study that
Unusual situations such as lymphangio- 73% of patients with the history of allergy,
genesis deficiencies, low levels of nitric which experienced the ESS, developed the
oxide, increased expression of metallopro- recurrent sinonasal polyposis (21). Based
teinase could lead to the formation of nasal on results from different studies, lower
polyps (1,16). achievements of ESS method in decreasing
There is little data regarding the pro- the recurrent NP, not only would be due to
inflammatory cells, which contribute in patients history of inflammatory diseases
the development of NP through activation but also can be the consequent of the severity
of inflammatory cascades. According to of the primarily sinonasal polyposis (21). It
recent studies, cytokines are the major has been also indicated that patients with
elements involved in the pathogenesis of various previous surgical intervention are
NP. Using immunohistochemistry staining, most prone to the revision operations and
the increased level of interleukin (IL)-3, recurrence of the polyposis in comparison
IL-5, granulocyte-macrophage colony- with patient who have not experienced any
stimulation factor (GM-CSF), tumor necrosis surgical intervention. The trauma resulted
factor and interferon have been detected in from the surgery can affect the incidence of
NP compared with control samples (17,18). polyposis.
These mediators are pro-inflammatory cells, Recent studies have proposed various
which induce the eosinophil activation and novel tools for removing the polyps
NP development. Leukotrienes (LCT4) in patients with NP such as KTP laser,

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Esmatinia F et al.

Nd:YAG laser, coblation surgery. These dipropionate, revealed the NP recurrence


methods are flexible to be performed, are which was lower than the 87% of patients
associated with lower blood loss during in placebo group that revealed recurrence
the operation, and result in progression of NP (26). In various trials, prophylactic
of hemostasis. Further investigations administration of flunisolide after the
are required to support the efficacy of surgery was suggested for obtaining more
novel surgical methods (22). Meticulous comprehensive and beneficial results
endoscopic surgery is proposed as a safe regarding the decreased rate of recurrent
method with high rate of achievement in NP and nasal symptoms such as running
reducing the recurrent NP (23). nose, stuffiness and sneezing (27,28). Based
The chronic rhinosinusitis can present on some investigations, using budesonide
with or without polyposis. Based on nasal spray in patients with the history
previous studies, in situations that NP of surgery or recurrent NP has revealed
appears in addition to rhinosinusitis, more improvements on reduction of the
patients not only show lower improvements recurrence rate in comparison with patients
after the surgery, but also are more prone with first time evulsion (29,30). In the study
to the relapse of polyposis after the FESS. of Dijkstra et al. the rate of recurrent NP
Therefore, the requirement rate for revision was evaluated using fluticasone propionate
surgery increases in patients having chronic aqueous nasal spray (FPANS) in patient
rhinosinusitis with sinonasal polyposis who has been under the FESS for 1 year
compared with those who do not have nasal follow-up. In this study, the postoperative
polyps (21). application of FPANS did not reduce the
The recurrence of NP after the sinonasal recurrence rate of NP compared with placebo
surgery is prevalent but the frequency group (31). Another study which applied
and intensity of relapse vary based on the amphotericin B as antifungal medication
medical treatment, which might be used for 6 months after the FESS, achieved the
after any surgical intervention. Although similar result with the Dijkstra and did
the FESS is an effective procedure, its long- not reveal any beneficial effect through
term efficacy is a controversial issue. Based pharmacotherapy (32). Data regarding some
on retrospective study of Cornet in 2013, articles studied the recurrence of sinonasal
the majority of children who suffered from polyposis are summarized in Table 1.
chronic rhinosinusitis with nasal polyps and According to the study of Klapan et
had experienced FESS, showed considerable al. in 1995, a follow-up duration of 18
improvement regarding the quality of life months after surgery resulted in the highest
and long-term effects of ESS (24). concentrations of leukotriene (LCT4) in
It has been proposed that patients with group of patients showed recurrent NP
asthma and aspirin sensitivity are at higher after the surgery. In this study which
risk for recurrent NP after the surgery (25). applied radioimmunoassay technique,
In the clinical trial of Virolainen in 1980, LCT4 (a lipoxygenase products of AA),
the preventive effect of beclomethasone was proposed as a prognostic parameter
dipropionate administration on recurrence of incidence of the NP recurrence. LTC4
of polyposis after the radical ethmoidectomy optimizes the sinonasal environment for
of patients was evaluated. In this study, nasal polyps formation through increasing
after a follow-up duration of 1 year, only the vascular dilatation, stromal edema
46% of patients consumed beclomethasone and infiltration (33). According to studies,

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Esmatinia F et al.

Table 1. Summarized information of different studies on recurrent nasal polyposis

Author Patients Medical intervention Follow-up duration Recurrence rate of


Year Nasal polyposis (NP)
(Reference)
Dingsør Total: 37 Flunisolide 2×25 1 year after the Reduction of NP number
1985 mcg in each nostril surgery (0.05) and size (0.03) in treat-
(27) twice daily ment group
Gulati Treatment gr:38 Budesonide nasal 9 months after Recurrent observed in 25% of
2001 Placebo gr:25 spray two puffs of the surgery treatment gr. and in 80% of
(29) Age: 18-65 50 mg twice a day placebo group
each nostril
Dijkstra Total: 162 Fluticasone propi- 1 year after FESS Recurrence rate:
2004 Men: 92 onate aqueous nasal Gr1/Gr3:1.22
(31) Female:70 spray (FPANS) (95% CI :0.70–2.13)
Age: 18-78 Group1: 400mg Gr2/Gr3:1.48
Group2:800mg (95% CI :0.86–2.66)
Group 3: placebo
Hashemi Total: 50 Amphotericine B 6 months follow- Gr1:84% of patients improved
2011 Age: 17-64 years (50 mg in 500 still up after FESS 14% unchanged
(32) Treatment water twice daily) Gr2:88% improved
(gr1):25 12% unchanged
Placebo (gr2):25 No significant relation was
observed between gr1 and gr2
Hoseini Total: 100 No medical inter- 2 years after me- Recurrence rate: 8%
2012 vention ticulous endoscop- P-value: 0.014
(23) ic surgery

applying antibiotics, local or systemic control of any slight recurrency should


corticosteroids after the surgery are be intensively evaluated. To reduce the
considered to be influential in controlling requirement for revision surgery or the
and reducing the incidence of recurrent incidence of recurrent polyposis, severe
NP and also would increase the efficacy of medical regimens are suggested pre and
polyposis surgery (34). postsurgical interventions.
In conclusion, based on the articles studied
in this review, the incidence of polyposis Acknowledgement
recurrence after the surgical intervention is We would like to thank Clinical Research
known to be common but several conditions Development Center of Ghaem Hospital for
can increase this recurrence. Although the their assistant in this manuscript. This study
surgical tools have shown considerable was supported by a grant from the Vice
success in diminishing the sinonasal Chancellor for Research of the Mashhad
polyposis, history of previous Surgeries and University of Medical Sciences for the
the severity of polyposis before the surgery, research project as a medical student thesis
the presence of diseases such as asthma, with approval number of 900733.
aspirin intolerance and etc., are factors
which increase the recurrent polyposis Conflict of Interest
rate or the requirement for revision The authors declare no conflict of interest.
surgery. Severe and accurate postoperative

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Esmatinia F et al.

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