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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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