|Year : 2022 | Volume
| Issue : 2 | Page : 73-77
Changes in the histological characteristics of patients from a Southern Saudi Population with chronic rhinosinusitis with nasal polyps over time
Nasir A Magboul1, Abdelaziz Qobty2, Ali Alzarei1, Areej Rajah3, Meshary Alshahrani3, Zubaidah Alahmari3
1 Department of ORL-HNS, Asir Central Hospital, Abha, Saudi Arabia
2 Department of ORL-HNS, King Khalid University, Abha, Saudi Arabia
3 Department of General Surgery, King Khalid University, Abha, Saudi Arabia
|Date of Submission||06-May-2022|
|Date of Decision||28-May-2022|
|Date of Acceptance||31-May-2022|
|Date of Web Publication||28-Jun-2022|
Dr. Nasir A Magboul
Department of ORL-HNS, Asir Central Hospital, Al-Rabwah Street, Abha 62312
Source of Support: None, Conflict of Interest: None
Objectives: Chronic rhinosinusitis with nasal polyps (CRSwNP) is the most common type of inflammation of the mucosa of the sinonasal cavity. Approximately 65%–90% of CRSwNP cases exhibit eosinophilic inflammation. Patients with CRSwNP respond to corticosteroids but tend to have more severe diseases with higher recurrence rates. We aimed to determine the histopathological types of CRSwNP in patients who underwent surgery at Asir Central Hospital in Asir Region, Saudi Arabia, and compared patients admitted from 2013 to 2016 and 2018 to 2020 to identify changes in their histological patterns. Materials and Methods: We retrospectively examined medical records of patients who underwent surgery to remove nasal polyps during two different time periods (2013–2016 and 2018–2020). A pre-structured data collection sheet was used to extract data from medical records to ensure consistency. A histological review of nasal polyp tissue was collected during the surgery, immediately fixed in 10% formalin, and sent for histopathology. All specimens were processed in the same pathologic laboratory using the same histopathologic techniques. The average number of eosinophils, neutrophils, lymphocytes and plasma cells per high-power field (HPF) for each sample was recorded. Tissue eosinophil histopathologically defined when tissue eosinophil was >10/HPF. Results: Among the patients with CRSwNP admitted for surgical intervention, 162 and 92 patients were admitted from 2013 to 2016 (Group A) and 2018 to 2020 (Group B), respectively. Neutrophilic polyps were present in 30.2% of Group A patients compared to 27.2% of Group B patients. There were significantly more eosinophilic polyps diagnosed in Group B than in Group A (51.9% vs. 72.8%, respectively; P = 0.001). Significantly more polyps were benign in Group B than in Group A (97.8% vs. 71.6%, respectively; P < 0.001). Conclusions: There was an increase over time in eosinophilic nasal polyps among cases of CRSwNP in the Asir region. The frequency of neutrophilic polyps decreased over 7 years.
Keywords: Chronic rhinosinusitis, histopathology, nasal polyps, rhinology, Saudi Arabia
|How to cite this article:|
Magboul NA, Qobty A, Alzarei A, Rajah A, Alshahrani M, Alahmari Z. Changes in the histological characteristics of patients from a Southern Saudi Population with chronic rhinosinusitis with nasal polyps over time. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:73-7
|How to cite this URL:|
Magboul NA, Qobty A, Alzarei A, Rajah A, Alshahrani M, Alahmari Z. Changes in the histological characteristics of patients from a Southern Saudi Population with chronic rhinosinusitis with nasal polyps over time. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2022 Oct 4];24:73-7. Available from: https://www.sjohns.org/text.asp?2022/24/2/73/348720
| Introduction|| |
Chronic rhinosinusitis (CRS) is considered to be one of the most prevalent diseases in the world. According to the summary health statistics for the United States, one in seven American adults is affected by CRS, and it is considered the second-most common chronic condition in the United States. In Europe, the prevalence reaches up to 10.9%.
CRS with nasal polyps (CRSwNP) mainly affects middle-aged adults, with an average age of 42 years. In patients over 80 years or under 20 years of age, we should consider different diagnoses or other chronic conditions, such as cystic fibrosis in children, or neoplasms in older adults. CRSwNP is more common in males than females; however, a study by Stevens et al. in 2015, found that females tend to have more severe diseases than males.
CRSwNP presents as inflammation of the mucosal surface of the nose and the paranasal sinuses and is characterised by two or more symptoms of nasal obstruction, nasal discharge (either anterior or postnasal drip), facial pain or pressure, or a reduction or loss of a smell for more than 12 weeks. Nasal polyps mostly develop in the nasal mucosa because of chronic inflammation. Nasal polyps are sac-like, movable and nontender, but facial pain may occasionally be experienced. Polyps typically develop in both nostrils in affected cases. Complications may include sinusitis-induced sleep disturbance, daytime fatigue and sleepiness and broadening of the nose. There are two main types of nasal polyps: ethmoidal and antrochoanal. Ethmoidal polyps are inflammatory processes involving all sinuses. Antrochoanal polyps mainly arise in the maxillary sinus and extend into the nasopharynx, and can sometimes be seen through an oral examination. Antrochoanal polyps represent only 4%–6% of all nasal polyps; however, they are more common among children.
Endotyping of CRSwNP is a new way to understand the inflammatory process and focus management on certain phases of inflammation. Some diseases share the same mechanism of inflammation and can be managed with targeted therapy., CRSwNP can be further divided into eosinophilic CRSwNP (ECRSwNP) and non-ECRSwNP, according to the presence of eosinophils in nasal polyp histology., ECRSwNP is more sensitive to corticosteroids and is more severe, with a higher risk of comorbid asthma and a higher recurrence rate., This makes identification of the most prevalent subtype vital in mapping a treatment strategy and predicting the prognosis. Recently, CRS been classified into primary and secondary CRS.
Primary CRS is classified anatomically into localised and diffuse which each of them can be divided furthermore according to the endotype into Type 2 and Non-Type 2 inflammation.
The secondary type of chronic rhinosinusitis caused by an established systemic disease or local pathological disease lije odontogenic or neoplasm, that is less common. The current study aimed to assess the shift in subtypes of nasal polyps among cases with CRS in the Asir region of Saudi Arabia during two different periods: 2013–2016 and 2018–2020.
| Materials and Methods|| |
A retrospective record-based approach was applied in the current study. Medical records of patients who underwent surgery to remove nasal polyps between 2013–2016 and 2018–2020 at a tertiary hospital, and whose diagnosis was confirmed by histopathological examination, were reviewed.
A histological review of nasal polyp tissue was collected during the surgery, immediately fixed in 10% formalin, and sent for histopathology. All specimens were processed in the same pathologic laboratory using the same histopathologic techniques.
The average number of eosinophils, neutrophils, lymphocytes and plasma cells per HPF for each sample was recorded.
Tissue eosinophil histopathologically defined when tissue eosinophil was >10/HPF.
Patients with an immune disease, fungal infection, ciliary disease, or a benign or malignant tumour were excluded from the study. A pre-structured data collection sheet was designed by the researchers to extract data from the medical records to avoid errors in data extraction. This included patients' personal data (i.e., sex and age) and disease-related data (i.e., histopathology, nature and type of surgery).
Ethical approval was obtained from the Institutional Review Board and Ethical Committee on April 15, 2020. Informed consent for patient information to be published in this article was not obtained because the ethics committee waived the requirement for informed consent because of the retrospective study design. This study was conducted in accordance with the Declaration of Helsinki.
Data analysis was performed using SPSS version 22 (IBM, Armonk, NY). Two-tailed tests were used, and a P ≤ 0.05 was considered statistically significant. The Chi-squared test, Monte Carlo exact test and Fisher's exact test were used to test all variables.
| Results|| |
Patients with CRSwNP admitted for surgical intervention from 2013 to 2016 were assigned to Group A (n = 162), and those admitted from 2018 to 2020 were assigned to Group B (n = 92). With regards to age, 27.8% of Group A and 33.7% of Group B patients were under 30 years of age, while 21% and 7.6% of patients, respectively, were 50 years old or more. The proportion of male subjects was 60.5% in Group A and 50% in Group B, with no significant difference (P > 0.05) [Table 1].
[Table 2] and [Figure 1] demonstrate that 30.2% of Group A patients and 27.2% of Group B patients had neutrophilic polyps. Eosinophilic polyps were diagnosed in 51.9% of Group A patients and 72.8% of Group B patients, with a statistically significant difference (P = 0.001). Of the diagnosed polyps, 71.6% and 97.8% of Group A and Group B polyps, respectively, were benign (P < 0.001). This was the first surgery for 80.9% of Group A patients and 95.7% of Group B patients (P < 0.001). For patients who have second surgery what was the histopathology findings in the first surgery? (for those with second surgery most of them has the same histological diagnosis as the first surgery).
|Figure 1: Changes in histopathology, nature and management of nasal polyps by study phase|
Click here to view
| Discussion|| |
CRS is a heterogeneous group of sinus inflammatory diseases, and estimates of the global prevalence of CRS vary significantly. In the United States, it ranges from 2% to 16% of the population (based on the National Health Interview Survey), and from 7% to 27% in the European population. CRS can be classified according to the absence or presence of nasal polyps, each with distinct inflammatory and remodelling characteristics.
Recently, Grayson et al. proposed classification for CRS into primary and secondary CRS.
Primary CRS is defined as a primary inflammatory disorder of the airway only. Those patients who have CRS in the presence of immunodeficiencies, autoimmune conditions, genetic abnormalities, odontogenic sinusitis, or local neoplasm do not have primary CRS, as their sinonasal mucosal disease is secondary to another process.
Primary CRS is subclassified according to the anatomical distribution into localised and diffuse diseases.
The distinguish feature between localised and diffuse type is that in localised type the sinus cavities involved are anatomically discrete and almost always follow the known ostial or functional drainage pathways.
On the other hand, diffuse type describes a broader inflammatory disorder that may affect both the upper and lower airways. The involvement of the sinuses may be patchy or diffuse on radiologic assessment and does not have to have complete opacification of all sinuses but will not be limited by functional sinonasal units or spaces.
Each of the primary CRS can be divided furthermore according to the endotype into Type 2 and non-Type 2 inflammation.
The type 2 inflammatory response seen in CRS is likely associated with TH2 cells, cytotoxic T cells and innate lymphoid cells.
Type 2 immune responses are associated with upregulated production of interleukin 4 (IL-4), IL-5, IL-13, local immunoglobulin E and profound eosinophilia.
Non-type 2 inflammation is a mix of type 1 and type 3 inflammation. IL-6, IL-8 and tumour necrosis factor have been shown to stimulate the production of interferon-gamma and IL-8, which further recruit immune responses.
The secondary type of chronic rhinosinusitis caused by an established systemic disease or local pathological disease lije odontogenic or neoplasm, that is less common, simply an expression of another condition, and correction of that mechanism will result in resolution of the CRS.
Based on other studies, CRSwNP is the most commonly recorded type of CRS; 65%–90% of all nasal polyp cases have eosinophilic inflammation as a characteristic feature., Many researchers reported that eosinophilic inflammation of the nasal mucosa was a significant factor in nasal polyp pathogenesis, with poor prognosis and poor treatment outcomes.,, Different populations around the world have different inflammatory nasal polyp subtypes, for example, eosinophilia and eosinophilic inflammation are significantly more prevalent in Western and European populations, while neutrophilic inflammation is more prevalent in Asian and Eastern populations., The prevalence of histopathological types may also change in the same region over time, which may require updated assessments for planning appropriate treatment strategies. The authors should take more about the recent EPOS. The current study aimed to assess the change in histopathology of CRSwNP over a 7-year period by comparing the most prevalent subtypes from 2013 to 2016 and from 2018 to 2020. During the first period, more than half of the nasal polyps were eosinophilic, which underwent a tremendous upward trend among patients in the second period as it was diagnosed among nearly three out of four cases of nasal polyps. This means that cases of CRSwNP will tend to have a higher recurrence rate with a poorer prognosis. The incidence of benign polyps also increased by approximately 16% during the second period (2018–2020) compared to the first period. Despite the upward trend in eosinophilic polyps, revisional surgeries decreased among cases during the second phase; this may be attributed to better surgical approaches and better follow-up, reducing recurrence rates and the need for revisional surgery.
From our point of view, this shift in neutrophilic type of inflammation to eosinophilic type of inflammation attributes to decreasing incidence of infections in and increasing incidence of both autoimmune and allergic diseases.
As mentioned earlier, this was a retrospective record-based study with all the limitations accompanying its design. The study was also limited to only one hospital, with only the patients whose information was found in the new system used by the hospital. In the near future, we hope to cover all cases of CRSwNP in Saudi Arabia to have a better understanding of this disease.
| Conclusions|| |
We determined that there was an upward shift in the eosinophilic subtype of nasal polyps among cases of CRSwNP in the Asir region of Saudi Arabia; however, these were mainly benign cases with less recorded revisional surgeries. The frequency of neutrophilic polyps decreased over 7 years. Periodic follow-up of patients with ECRSwNP is required because of the remarkable increased shift in its percentage with the increased probability of recurrence and malignant transformation.
We would like to thank Editage (www.editage.com) for English language editing and journal submission support. The authors have authorised the submission of this manuscript through Editage. We would also like to thank the medical record department of ACH for their help in collecting the patient data. Finally, we would like to thank the operative room staff for their support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]