Comparative analysis of local and systemic corticosteroid therapy in post-operative patient of allergic rhinitis with nasal polyps

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Yerevan State Medical University, Yerevan, Armenia

Comparative analysis of local and systemic corticosteroid therapy in post-operative patient of allergic rhinitis with nasal polyps

Nazanyan A.Kh.

Shukrian A.J.

Shukuryan A.K.

Allergic rhinitis with nasal polyps is a clinical entity of great importance that is yet to be fully understood. It is the chronic inflammation of the nose and paranasal sinuses and is characterized with the formation and recurrent growth of polyps that are mostly infiltrated with neutrophils and eosinophils. Originating from the ethmoid sinus, nasal polyps are defined as inflammatory lesions that project into the nasal airway and are typically bilateral [1]. This pathology is considered chronic and slow growing in nature. It considerably hinders nasal breathing and may bring about various complications [4]. A diagnosis can be made by the presence of both subjective and objective evidence of chronic sinonasal inflammation, and it's worth mentioning that asthma is frequently associated and can be seen in conjunction with this clinical entity [6]. This element of allergic rhinitis with nasal polyps is one of the reasons this disease is on the rise in all parts of the world.

Allergic rhinitis with nasal polyps has a 1-5% prevalence in the world population, comprising 5-20% of all ENT diseases. It is more common in males than females with a mean age of 42 [2]. According to statistics from the year 2012, there were 1.400 000 million people suffering from allergic rhinitis with nasal polyps in the Russian federation, meanwhile 2- 4.3% of the population in the EU had the disease. The disease manifests in different symptoms including anterior or posterior rhinorrhea, nasal congestion and hyposmia. [3]

Taking into consideration the number of worldwide cases and the high recurrence rates, allergic rhinitis with nasal polyps remains under the spotlight to be further explored by medical researchers.

Despite the fact that in the last 20-30 years this disease has been thoroughly investigated by many with abundant literature readily available, nonetheless, the exact mechanism of pathogenesis is still unclear. Numerous conservative and surgical treatment methods exist, but they are still not as efficient as desirable.

According to the most recent pathogenic mechanisms, we classify 3 different types [8]:

Infectious-Allergic

Autoimmune

Neurovascular

Viral infections can also play a role, alongside genetic predisposition, mechanical and constitutional factors [5].

Allergic Rhinitis with Nasal polyps arising from Infectious-Allergic factors is explained using the direct relationship an infection has with the secretory mucosa of the nose and paranasal sinuses, and its predisposition to polyp formation. The role microorganisms and allergens play is equally important, as the allergic process that lasts for a prolonged period of time brings about the delayed type hypersensitivity and creates favorable conditions for chronic mucosal inflammation and future polyp formation.

Certain investigators consider the infectious-allergic mechanism of the disease pathogenesis not sufficiently proven, since the morphological picture of the nasal mucosa in allergic rhinitis with nasal polyps and the disease's clinical manifestations do not correspond to the delayed type hypersensitivity reactions [7]:

Another group of investigators attribute allergic rhinitis with nasal polyps to pseudoallergic reactions, in the absence of the immunoactive stage, and signify the role of chronic inflammatory foci, presence of mechanical factors and vasomotor hyperreactivity in the pathogenensis of the disease entity [10].

A recent theory suggests that the main reason of mucosal immune inflammation is lymphocyte sensitization, that leads to cytotoxic and cytolytic effects on mucosal cells. The discovery of organ specific antigen, and the high quantity of which in tissues, speaks about the autoimmune basis of the disease.

While investigating the pathogenesis of recurrent ethmoiditis with polyps, it was revealed that the main mechanism bringing about this condition was an immunopathologic one, more specifically, injury to the immune complex. The alterations in cellular and humoral immune indices in conjunction with the changes in mucosal microcirculation stand in favor of this discovery [11].

The other equally important pathogenetic mechanism that plays a major role in the development of allergic rhinitis with nasal polyps is change in the neurohormonal system. This was demonstrated during investigations, where attention was given to the notable upsurge of adrenal mineralocorticoid function and the drop in androgen activity [12].

The formation of polyps in the nose and paranasal sinuses is majorly influenced by numerous variations of intranasal architectonics, which bring about obstruction to the osteomeatal complex. These variations include acute and chronic rhinitis, deviated nasal septum, as well as various degrees of mucociliary system dysfunction [9].

The aim of this study is to collect data and present a comparative analysis on conservative treatment methods of allergic rhinitis with nasal polyps at the post-operative period based on the above mentioned etiopathogenetic factors.

The investigation took place at “Erebouni” medical center, Otorhinolaryngology department - Chair of ENT diseases at Yerevan State Medical University (YSMU).

The study included 45 patients and proceeded on the 30^th post-operative day for each participant. The patients were chosen based on the following criteria:

Established diagnosis of allergic rhinosinusitis with eosinophilic origin, confirmed by cytological examinations.

Simultaneous elevations of the following allergic markers (total IgE, Tryptase, Eosinophil Cationic Protein (ECP)) in all the patients.

Absence of pathogenic microflora based on microbiological tests from the nasal cavity.

Similar Clinical course from moment of diagnosis till 30^th post-operative day.

Identical surgical method (FESS).

18 years of age and older.

Absence of other somatic diseases.

Participants were divided into 2 groups randomly, based on the fact that all participants did not have any kind of contraindication towards all forms of steroid therapy. The first group contained 22 participants who underwent intranasal steroid therapy (mometasone furoate 400mg/day for 3 months). The second group contained 23 participants who underwent systemic steroid therapy (triamcinolone acetonide 40mg IM once). Optimally, the study would have been carried out comparing the same medication with different administration routes, but since in practice, the abovementioned 2 medications are the treatments of choice in our country for allergic rhinitis with nasal polyps, we were inclined to carry out the study using such treatment modalities.

The study carried on for 3 months during which the patients were kept under ambulatory observation. For the purpose of comparative analysis of both methods, the following objective and subjective criteria were selected.

Objective criteria:

Changes in allergic markers.

Changes in nasal breathing (based on active anterior rhinomanometry).

Evident changes on rhinoscopy.

Subjective criteria:

Changes in nasal breathing (based on the patients complains).

Changes in olfaction.

Changes in the amount of nasal mucosal secretion.

After three months, all participants were evaluated and as a result, with the first group who were administered intranasal steroid therapy, there was a total decline in IgE values in 5 patients (22.7%, P<0.01), Tryptase in 8 patients (36.3%, P<0.01) and Eosinophil Cationic Protein (ECP) in 3 patients (13.6%, P<0.01), whereas with the second group who were administered systemic steroid therapy, there was a total decline in IgE values in 16 patients (69.5%, P<0.01), Tryptase in 12 patients (52.1%, P<0.01), and Eosinophil Cationic Protein (ECP) in 17 patients (73.9%, P<0.05).

Post-treatment active anterior rhinomanometry results showed that in the first group, there was improvement in nasal breathing in 9 participants (40.9%, P<0.01), while in the second group, the improvement was evident in 18 participants (78.2%, P<0.01). Changes in the mucosal status during post-treatment rhinoscopy were unnoticed in both groups of patients.

As for the subjective criteria, the following changes were recorded:

Improvement in nasal breathing was stated by 6 participants in the first group (27.2%, P<0.01), improvement in olfaction was stated by 2 participants (9.1%, P<0.01), and decline in the amount of nasal mucosal secretion was stated by 15 participants (68.1%, P<0.01). As for the second group, improvement in nasal breathing was stated by 14 participants (60.8%, P<0.01), improvement in olfaction was stated by 19 participants (82.6%, P<0.05), while decline in the amount of nasal mucosal secretion was stated by 17 participants (73.9%, P<0.01). It is worth noting that during treatment, no side-effects were recorded in both groups.

This study gave us sufficient data to conclude that participants in the second group who were administered systemic steroid therapy, showed a significantly greater decrease in allergic markers, objective improvement in nasal breathing and olfactory restoration, in comparison with the first group who were administered intranasal steroid therapy. The abovementioned allows us to assume that systemic steroid therapy is a more efficient mode of treatment for allergic rhinitis with nasal polyps than the intranasal route.

References

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