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Journal ReadingDEPARTMENT OF OTORHINOPHARYNGOLOGY-HEAD and NECK

SWADANA KUDUS HOSPITAL

MEDICAL MANAGEMENT OF NASAL POLYPOSIS :

A STUDY IN A SERIES OF 152 PATIENTS

Tarumanagara Faculty of Medicine

2012


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The management of nasal polyps is undoubtedlya controversial subject.

The aim of this study is focused on the evaluation of

a dual modality on a series of 152 subjects treated

according to

A standardized protocol combining : A short-term administration of prednisolone

and

The daily intranasal spraying of

beclomethasone.


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Nasal polyposis occurs as a result of a multifocal

edematous degeneration, which originates from an

inflammatory mucosal reaction of the paranasal

sinuses .(Larsen and Tos, 1997)

Its starting point is chiefly located in the ethmoid

cells, particularly in their anterior portion.


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Various severesymptoms

attached to thiscondition testify to

the seriousalteration of the

naso-sinusal

function

Airwayobstruction

Anteriorrhinorrhea

Posteriorrhinorrhea

Facial pain

Loss of thesense of

smell


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This study aimed at assessing the efficacy

of a standardized drug administration

protocol in a series of 152 consecutive

patients Short-term oral steroid

Daily and long-term administration of

steroid spray


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152 new consecutive patients suffering from

nasal polyposis followed up for a one-year

period September 1998 September 1999

Patients having already benefited either from

ethmoidal surgery or from a previous medical

treatment were not included


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The diagnosis of nasal polyposis was basedfor all patients on the two following criteria:

Bilateral polyps in the nasal cavities on

endoscopic examination (Stammberger, 1997)

The existence of bilateral opaque

ethmoidal sinuses (anterior or posterior) CT-scan without contrast


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The population having entered the study included

85 males and 67 females ( 48 years)

49 patients (32%) asthma

19 patients bronchial abnormal reactivity tomethacholine (Bramann et al., 19987)

21 patients hypersensitivity reactions to aspirin

or to NSAIDs by an allergy detection test("Phadiatop") (Paganelli et al., 1998)


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The same physician examined each patientevery time at baseline, three months (M3), six

months (M6), and twelve months (M12)

At each visit, the nasal function was checked

on the basis of five criteria.


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Absence of any symptom

Sense of smell normal function

Grade 0

Symptom being revealed by specificquestioning

Sense of smell hyposmiaGrade 1

Symptom was either the reason forconsulting or else spontaneouslymentioned by the patient

Sense of smell anosmia

Grade 2


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Symptopms steroid spray

administration was lowered

Condition fall off to some worsening of

his/her physical state systemic steroid

administration

> 3 systemic courses of prednisolone

surgical option


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At each visit (baseline, M3, M6 and M12) a clinical

global severity index and polyp grade was derived

Comparison of the mean drug consumption betweenthe two categories of patients was based on the

classical calculation of the t-Test applied to the

difference of two means .

The selected level of statistical significance was

achieved (p


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The two most disabling

symptoms were found to beAnosmia

Nasal obstruction

Analysis of baselinedata


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Clinical data

Figure 1 shows clearly the change of the mean

of clinical global severity index at baseline, M6

and end point.

Baseline : 0.85

M6: 0.25

End point: 0.22


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There is a significant difference between the baseline and

the M6

There is no significant difference between the M6 and the


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The reduction of symptoms (baseline-M6):Airway obstruction and anterior rhinorrhea (>

80%).

Facial pain and smell loss (60%-70%).

Posterior rhinorrhea (35%).

M6-M12

no significant difference was derived fromseverity mean of each symptom, except

posterior rhinorrhea.


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The polyps baseline and M6 volume grades

underwent a statistically different change in strictly

medical patients.

No significant difference between the M6 and the

M12


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The oral administration of prednisolone only given topatients who were spontaneously complaining about their

nasal condition.

At baseline-M6, and M6-M12 a systemic steroid therapy wasused to a higher degree by the surgical patients (Table 3).

All the patients benefited from a beclomethasone spray

administration. During the 1st 6 months, the mean quantities

were identical in both groups.

In the other hand, during M6-M12, with regard to topically

administered beclomethasone, no difference whatsoever

could be traced between the two groups.


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This series includes 152 consecutive subjects.

From baseline to endpoint, they were allexamined and followed up by the same

otolaryngologist.

The characteristics of the population are close to

those usually found in the literature : in reference to age (mean = 48 years)

sex ratio (1.25)

prevalence of associated asthma (32.6%), and

sensitivity to aspirin (13.6%)


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In the literature these characteristics

range between the following figures:

age (40-50 years)

prevalence of associated asthma(25-45%), and

sensitivity to aspirin (5-25%).


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The therapeutic efficacy was assessed

exclusively on the basis of the modification of

the most frequently encountered clinical

symptoms in nasal polyposis : nasal obstruction,

anterior and posterior rhinorrhea,

facial pain, smell disorders with special reference to

anosmia.

Each symptom carried the same weight.


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In the present results, two symptoms of nasal

polyposis towered above all the others at

baseline :

1. anosmia (1.63) and2. nasal obstruction (1.48)

The other clinical disorders (i.e., anterior andposterior rhinorrhea, and facial pain) were much

less frequent and/or less discomforting as

demonstrated by their indices ranging from 0.47

to 0.77.


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The type of treatment to apply to nasal

polyposis has been very much in debate for

several decades.

Most authors agree that polyposis

management should be based primarily on

a medical approach to be completed by

surgical procedures only in case of drug

failure.

The core of the medical management rests

on corticosteroid therapy.


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Topical therapy has a definite beneficial effect :

On the clinical disorders

To a certain degree

On the polyp size

But shows little activity on the sense of smelldysfunction.

A combined treatment :

Systemic steroid treatment + long-term sprayadministration widely used in France for many years.


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Along the same lines, Slavin (1991) asserts that the reasonableapproach to nasal polyposis should be based on :

The oral prednisoloneadministration over a 10-14 daysperiod

Course of intranasal sprayof either beclomethasone /flunisolide.

147 patients for 12 months + a one-year follow-

up.

Recently, Blomqvist et al. (2001) realized a randomized

controlled study evaluating medical treatment versussurgical treatment in addition to medical treatment of nasal

polyposis.


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The aim of this study was :

To determine whether surgical treatment in fact has an

effect additive to that of medical treatment of nasalpolyposis.

medical treatment seems to be sufficient to treat most

symptoms of nasal polyposis.

The authors concluded that :

Pretreatment with :

o Oral prednisolone for 10 days and

o Local nasal budesonide bilaterally for 1 month.

Postoperatively local nasal steroids

(budesonide).

unilateral endoscopic sinus surgery

(randomized)

32 patients


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The orally administered steroid amounts

were higher during the first quarter

then could be progressively decreased every three

months.

This dosage reduction

the clinical improvement sincethe oral route was resorted to only in case of persisting

functional impairment.

Continuation of treatment under the same protocol was

aimed at reaching the lowest possible useful dailydosage.


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The recorded mean amounts were rather on the low

side, notably in the exclusively medical group :

750 mg of prednisolone during the first six months,

i.e. the practical equivalent of two therapeutic

courses of five days of the following dosage :

o 1 mg/kg of bodyweight/ day in the instance of a

patient weighing 75 kg.


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Recourse to surgery could not be avoided in 31.5% of

the subjects. In this group, the total orally administered

steroid consumption turned out to be larger than in the

exclusively medical group.

The clinical global severity index was also found to be

higher. These findings suggest a certain degree of

resistance or at least a decreased receptivity toglucocorticoid therapy in patients having to undergo

surgery.


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Closing remarks

The maximum efficacy was achieved after a sixmonths period.

It seems reasonable to suggest that thisprobationary time is enough to decide on thecourse of therapeutic action to be taken, eithermedical or surgical, depending on the globalefficacy of the systemic and topical steroid

therapy.

A surgical procedure should be definitely proposedafter six months on the face of inadequate results.


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CONCLUSION

The study objective was the assessment of the

potentialities and limits of the strictly medical

management of nasal polyposis.

Short-term steroid systemic courses of treatment

combined with long-term steroid intranasal spray

lead to satisfactory results in 70% of the subjects.


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CONCLUSION

In these favorable cases, the symptoms

were such that the residual discomfort did

not call for recourse to surgical

procedures.

In 31.5% of the cases however, the sole

medical treatment fell short of theexpected effects, and endonasal

ethmoidectomy had to be considered


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Jurding Ycl (2)