Comparison of Montelukast and Mometasone Furoate in the Prevention of Recurrent

Nasal Polyps
Erkan Vuralkan, MD, Cem Saka, MD, Istemihan Akin, MD, Sema Hucumenoglu, MD,
Binnur Uzmez Unal, MD, Gokhan Kuran MD, Berrak Ocal, MD
Disclosures
Ther Adv Resp Dis. 2012;6(1):5-10.

Abstract
Background: The aim of our study was to compare the effects of montelukast and
mometasone furoate nasal spray on the postoperative course of patients with nasal polyposis.
Patients and methods: Fifty patients diagnosed with nasal polyposis between March 2006
and August 2007 were included in the study. All patients underwent bilateral endoscopic
sphenoethmoidectomy and were randomized postoperatively into two groups. Group A (n =
25) received 10 mg montelukast per day and group B (n = 25) received 400 μg mometasone
furoate nasal spray twice daily. All patients were followed up for 6 months. Sino-Nasal
Outcome Test (SNOT)-22 scores, polyp grades, computerized tomography (CT) scores
(Lund–Mackay), eosinophils in peripheral blood and polyp tissue were evaluated before and
after surgery.

Results: There was a significant reduction in SNOT-22 scores in both groups throughout the
study period. There was a significant difference in the recurrence rate between both groups
with a marginal advantage of mometasone furoate nasal spray. Eosinophils in peripheral
blood were found to be effective on the recurrence rate (p < 0.05).

Conclusions: In conclusion, both drugs seem to have a complementary action and further
studies are needed to determine which patients should receive which treatment.






Introduction
Certain applications of medical therapy should have a prominent role in the treatment of nasal
polyposis and can be valuable in reducing the risk of recurrence, especially in patients who
have previously undergone surgical interventions. The goal of long-term medical treatment in
the postoperative phase is to achieve a steady decrease of relevant inflammatory mediators
and thus to prevent the formation of recurrent disease [Picado, 2001; Lamblin et al. 2000]. In
many respects, the methods employed after the operation to maintain healthy and open sinus
cavities may be as important as the initial surgery itself.
Penerapan tertentu dari terapi medis seharusnya memiliki peran penting dalam pengobatan
poliposis nasal dan bisa berarti dalam mengurangi risiko kekambuhan, terutama pada pasien
yang sebelumnya telah mengalami intervensi bedah. Tujuan dari perawatan medis jangka
panjang dalam tahap pasca operasi adalah untuk mencapai penurunan tetap dari mediator
inflamasi yang relevan dan dengan demikian untuk mencegah pembentukan penyakit
berulang [Picado, 2001; Lamblin et al. 2000]. Dalam banyak hal, metode yang digunakan
setelah operasi untuk menjaga rongga sinus yang sehat dan terbuka mungkin sama
pentingnya dengan operasi awal itu sendiri.
Intranasal corticosteroids (ICS) have a strong anti-inflammatory effect and can reduce
eosinophilia as they directly interact with several chemokines and cytokines involved in the
inflammatory process. ICS therapy has a positive effect on objective measures of nasal
patency and has been shown to reduce the size of the polyps. Furthermore, ICS are important
postoperatively, when they help to reduce the recurrence rate [Virolainen and Puhakka, 1980;
Karlsson and Rundcrantz, 1982].
Kortikosteroid intranasal (ICS) memiliki efek anti-inflamasi yang kuat dan dapat mengurangi
eosinofilia karena mereka langsung berinteraksi dengan beberapa kemokin dan sitokin yang
terlibat dalam proses inflamasi. Terapi ICS memiliki efek positif pada langkah-langkah
patensi nasal dan telah terbukti mengurangi ukuran polip. Selain itu, ICS penting pada pasca
operasi, karena mereka membantu untuk mengurangi tingkat kekambuhan [Virolainen dan
Puhakka, 1980; Karlsson dan Rundcrantz, 1982].
Although their efficiency concerning pulmonary function is inferior to that of inhaled
corticosteroids, the leukotriene antagonists are a useful add-on or even substitute in the case
of insufficient steroid compliance or effect [Keith et al. 2009]. Several studies show the
benefit of antileukotriene treatment in patients with aspirin sensitivity [Thomas et al. 2008].
However, the effects of aspirin challenge cannot be suppressed completely.
Meskipun efisiensi ICS mengenai fungsi paru lebih rendah daripada yang kortikosteroid
inhalasi, antagonis leukotrien berguna sebagai add-on (pelengkap/penambah) atau bahkan
pengganti dalam kasus efek / kerja steroid tidak cukup adekuat [Keith et al berguna. 2009].
Beberapa penelitian menunjukkan manfaat dari pengobatan antileukotriene pada pasien
dengan sensitivitas aspirin [Thomas et al. 2008]. Namun, efek dari aspirin tidak bisa ditekan
sepenuhnya.
The aim of our study was to compare the effects of montelukast and mometasone furoate
nasal spray on the postoperative course of patients with nasal polyposis.
Tujuan dari penelitian ini adalah untuk membandingkan efek montelukast dan furoate
mometasone semprot nasal pada perjalanan pasien pasca operasi dengan poliposis nasal.


Patients and Methods
Study Design
The study protocols were approved by the Institutional Review Board. Fifty patients
undergoing functional endoscopic sinus surgery (FESS) as described in the Messerklinger
technique [Stammberger and Posawetz, 1990] for nasal polyposis between March 2006 and
August 2007 were followed prospectively. Patients were randomized postoperatively into two
groups. Group A (n = 25) received 10 mg montelukast per day and group B (n = 25) received
400 μg mometasone furoate nasal spray twice daily. Nasal irrigation with saline solution was
used by all patients. All patients were followed up for 6 months. Patients with systemic
diseases (diabetes mellitus, etc.), immunological diseases, liver or kidney diseases,
pregnancy, or phenylketonuria were excluded from the evaluation. A uniform history was
documented for each patient, including the location of facial pain and pressure; whether nasal
drainage was anterior or posterior, thick or thin, milky or purulent; the presence of allergic
symptoms such as itchy eyes, watery eyes, itchy nose, seasonality, asthma or aspirin
sensitivity; the presence of nasal obstruction, congestion, anosmia; and previous medical
treatment.
Protokol penelitian telah disetujui oleh Institutional Review Board. Lima puluh pasien yang
menjalani bedah sinus endoskopi fungsional (FESS) seperti yang dijelaskan dalam teknik
Messerklinger [Stammberger dan Posawetz, 1990] untuk poliposis nasal antara Maret 2006
dan Agustus 2007 telah diikuti secara prospektif. Pasien pasca operasi secara acak dibagi
menjadi dua kelompok. Kelompok A (n = 25) menerima 10 mg per hari dan montelukast dan
kelompok B (n = 25) menerima 400 mg furoate mometasone nasal spray dua kali sehari.
Irigasi nasal dengan larutan garam digunakan oleh semua pasien. Semua pasien kemudian
ditindaklanjuti selama 6 bulan. Pasien dengan penyakit sistemik (diabetes mellitus, dll),
penyakit imunologi, penyakit hati atau ginjal, kehamilan, atau fenilketonuria ekslusi. Riwayat
penyakit didokumentasikan untuk setiap pasien, termasuk lokasi nyeri wajah dan tekanan;
apakah drainase hidung di anterior atau posterior, tebal atau tipis, seperti susu atau purulen;
adanya gejala alergi seperti mata gatal, mata berair, gatal hidung, asma atau sensitivitas
aspirin; adanya sumbatan hidung, kongesti, anosmia; dan perawatan medis sebelumnya.

Outcome Measures
The sinus symptoms were analyzed using objective and subjective measures. Each patient
was examined with a nasal speculum and head mirror. The anterior and posterior rhinoscopic
examination was performed again by a 4 mm 0° telescope. Information was recorded on the
presence of findings. Nasal polyps were graded using a staging system [Rasp et al. 2000].
The preoperative and postoperative Lund–Mackay scores were determined objectively by
evaluating the sinus computed tomography (CT) scans. Postoperative CT scans were
performed at the sixth month of the treatment and compared with preoperative scans. A score
from 0 to 24 was calculated as described by Lund–Mackay [Lund and Mackay, 1993]. The
Sino-Nasal Outcome Test (SNOT) 22, a disease-specific questionnaire on rhinosinusitis
symptoms, was performed to compare the treatment efficacy of both groups. Patients rated on
22 different symptoms related to both nasal and general health on a score of 0 (no problem)
to 5 (problem as bad as it can be). SNOT-22 is a modified version of SNOT-20 and the 31-
item Rhinosinusitis Outcome Measure (RSOM-31). In SNOT-22, two items have been added
to the 20-item version: one item on nasal blockage and one item on sense of taste and smell.
SNOT covers a broad range of health and health-related quality of life (QoL) problems
including physical problems, functional limitations, and emotional consequences, as
described by Browne and colleagues [Browne et al. 2007]. In the present study, SNOT-22
was evaluated as a single construct, even if it obviously covers more than one construct. The
first 12 items cover physical symptoms (items 1–12) and the last 10 items (items 13–22)
cover aspects of health-related QoL.
Gejala sinus dianalisis dengan menggunakan langkah-langkah yang obyektif dan subyektif.
Setiap pasien diperiksa dengan spekulum nasal dan cermin. Pemeriksaan rhinoscopic
anterior dan posterior dilakukan lagi oleh teleskop 4 mm 0 °. Informasi dicatat pada setiap
temuan yang didapatkan. Polip nasal dinilai menggunakan sistem staging [Rasp et al. 2000].
Skor Lund-Mackay untuk pra operasi dan pasca operasi ditentukan secara obyektif dengan
mengevaluasi sinus dengan menggunakan CT scan. CT scan pascaoperasi dilakukan pada
bulan keenam dari pengobatan dan dibandingkan dengan CT scan pra operasi. Skor 0-24
dihitung seperti yang dijelaskan oleh Lund-Mackay [Lund dan Mackay, 1993]. The Sino-
Nasal Outcome Test (SNOT) 22, sebuah kuesioner penyakit tertentu pada gejala rinosinusitis,
dilakukan untuk membandingkan efektivitas pengobatan pada kedua kelompok. Pasien
dinilai pada 22 gejala yang berbeda terkait dengan kedua hidung dan kesehatan umum pada
skor 0 (tidak ada masalah) sampai 5 (seburukapapun yang dapat terjadi). SNOT-22 adalah
versi modifikasi dari SNOT-20 dan 31-item Rhinosinusitis Outcome Measure (RSOM-31).
Dalam SNOT-22, dua item telah ditambahkan ke versi 20-item: satu item pada hidung
tersumbat dan satu item pada indera perasa dan penciuman. SNOT mencakup berbagai
kesehatan dan kualitas hidup terkait kesehatan (kualitas hidup) termasuk masalah fisik,
keterbatasan fungsional, dan konsekuensi emosional, seperti yang dijelaskan oleh Browne
dan r ekan [Browne et al. 2007]. Dalam penelitian ini, SNOT-22 dievaluasi sebagai konstruk
tunggal, bahkan jika itu jelas mencakup lebih dari satu konstruk. 12 item pertama meliputi
gejala fisik (item 1-12) dan 10 item terakhir (item 13-22) mencakup aspek kualitas hidup
yang berhubungan dengan kesehatan
A complete blood count with a differential was performed. The percentage of eosinophils and
the total eosinophil count were calculated by automatic analysis. Biopsy of nasal polyps was
performed before surgery and at the sixth month of treatment. Histologic analysis was
performed on specimens of polyps in all patients by a pathologist blinded to the outcome. All
specimens were examined microscopically and the number of eosinophils was counted per
high-power field (HPF, ×40). Counts were performed for five separate HPFs per specimen.
These five counts were then averaged to calculate the average number of polyp eosinophils
per HPF. Preoperative and postoperative biopsy and peripheral eosinophil results were
compared.
Hitung darah lengkap dengan diferensial telah dilakukan. Persentase eosinofil dan total
jumlah eosinofil dihitung dengan analisis otomatis. Biopsi dari polip nasal dilakukan sebelum
operasi dan pada bulan keenam pengobatan. Analisis histologi dilakukan pada spesimen
polip pada semua pasien oleh ahli patologi untuk hasilnya. Semua spesimen diperiksa secara
mikroskopis dan jumlah eosinofil dihitung per lapang dengan daya tinggi (HPF, × 40).
Hitungan dilakukan pada lima HPFS secara terpisah per spesimen. Kelima hitungan
kemudian di rata-rata untuk menghitung rata-rata jumlah eosinofil polip per HPF. Biopsi dan
eosinofil perifer hasil pra operasi dan pasca operasi kemudian dibandingkan

Statistical Analyses
Data were analyzed using Statistical Package for Social Sciences (SPSS) software (version
11.0). All differences associated with a chance probability of 0.05 or less were considered
statistically significant. Mean differences between preoperative and postoperative scores were
evaluated for statistical significance using within-subjects t-tests for Lund–Mackay scores,
polyp grades, symptom scores, eosinophil results of the biopsy and blood. Mean differences
between two groups were evaluated for significance using independent-samples t-test.
Data dianalisis menggunakan statistik Package for Social Sciences (SPSS) software (versi
11.0). Semua perbedaan yang berhubungan dengan probabilitas peluang 0,05 atau kurang,
dianggap signifikan secara statistik. Perbedaan rata-rata antara pra operasi dan pasca operasi
skor dievaluasi untuk signifikansi statistik dengan menggunakan subyek t-tes untuk skor
Lund-Mackay, nilai polip, skor gejala, hasil eosinofil dari biopsi dan darah. Perbedaan rata-
rata antara dua kelompok dievaluasi untuk signifikansi menggunakan independent-sample t-
test.
Results
Fifty surgical procedures were performed for a previously untreated nasal polyposis from
March 2006 to August 2007 (23 female, 27 male; age range 30–66 years, median 48.50 ±
9.16). The mean age of patients in group A and group B was 49.44 ± 7.20 years and 47.56 ±
10.85 years, respectively. Five patients in group A were diagnosed with asthma and three of
them were aspirin-sensitive patients. Four patients in group B were diagnosed with asthma
and two of them were aspirin-sensitive patients.
Lima puluh prosedur bedah dilakukan untuk poliposis nasal yang sebelumnya tidak diobati
dari Maret 2006 sampai Agustus 2007 (23 perempuan, 27 laki-laki, rentang usia 30-66 tahun,
rata-rata 48.50 ± 9.16). Usia rata-rata pasien dalam kelompok A dan kelompok B adalah
49.44 ± 7.20 tahun dan 47,56 ± 10,85 tahun, masing-masing. Lima pasien dalam kelompok
A didiagnosis dengan asma dan tiga dari mereka adalah pasien dengan sensitif aspirin. Empat
pasien dalam kelompok B didiagnosis dengan asma dan dua di antaranya adalah pasien
dengan sensitif aspirin
Figures 1 and 2 show preoperative and postoperative stages of the polyps in group A and
group B, respectively. The mean preoperative CT scan score in this study was 16.32 ± 5.78
(5–24) in group A and 16.96 ± 5.27 (6–24) in group B. The preoperative Lund–Mackay
scores were not statistically different (p > 0.05). The mean postoperative CT scan score was
7.48 ± 3.36 (4–15) in group A and 8.52 ± 5.67 (2–22) in group B. r Wrong, It should be
with Table 1 shows the preoperative and postoperative SNOT-22 scores of group A and
group B. There was no significant difference between two treatment groups in terms of
SNOT-22 scores in either the preoperative or postoperative period (p = 0.245 and 0.361,
respectively). For group A (the montelukast group), the mean SNOT-22 sum score was 32.44
± 14.46 preoperatively and 7.13 ± 4.90 in the postoperative period. For group B (mometasone
furoate), the mean SNOT-22 sum score was 34.04 ± 11.58 preoperatively and 6.67 ± 5.16 in
the postoperative period.
Grafik1 dan 2 menunjukkan pra operasi dan pasca operasi tahap polip dalam kelompok A
dan kelompok B , masing-masing. Rerata skor CT scan pra operasi dalam penelitian ini
adalah 16.32 ± 5.78 ( 5-24 ) pada kelompok A dan 16,96 ± 5.27 ( 6-24 ) pada kelompok B.
pra operasi skor Lund - Mackay tidak berbeda secara statistik ( p > 0,05 ) . Rerata
pascaoperasi skor CT scan adalah 7.48 ± 3.36 ( 4-15 ) pada kelompok A dan 8,52 ± 5,67 ( 2-
22 ) pada kelompok B. r .Wrong , itu harus dengan Tabel 1 menunjukkan pra operasi dan
pasca operasi SNOT - 22 skor grup A dan grup B. Tidak ada perbedaan yang signifikan
antara dua kelompok perlakuan dalam hal SNOT - 22 skor baik dalam pra operasi atau
periode pasca operasi ( p = 0.245 dan 0.361 , masing-masing) . Untuk kelompok A (
kelompok montelukast ) , rata-rata jumlah skor SNOT - 22 adalah 32,44 ± 14,46 sebelum
operasi dan 7.13 ± 4,90 pada periode pasca operasi . Untuk kelompok B ( furoate
mometasone ) , rata-rata jumlah skor SNOT - 22 adalah 34,04 ± 11,58 sebelum operasi dan
6.67 ± 5.16 pada periode pasca operasi .


(Enlarge Image)
Figure 1.
Preoperative and postoperative stages of the polyps in group A.

(Enlarge Image)

Figure 2.
Preoperative and postoperative stages of the polyps in group B.
The mean number of preoperative and postoperative peripheral eosinophils for group A was
0.31 ± 0.04 × 103/μl and 0.28 ± 0.16 × 103/μl, respectively. There was no significant
difference between the number of these peripheral eosinophils (p > 0.05). The mean number
of preoperative and postoperative peripheral eosinophils for group B was 0.32 ± 0.21 ×
103/μl and 0.31 ± 0.20 × 103l/μl, respectively. The difference between the number of these
peripheral eosinophils was not significant (p > 0.05).
Polyp tissues were examined in all patients. The mean number of preoperative and
postoperative tissue eosinophils for group A was 23.55 ± 22.88 and 33.38 ± 28.90,
respectively. There was a significant difference between the number of these tissue
eosinophils in recurrence (p < 0.05). The mean number of preoperative and postoperative
tissue eosinophils for group B was 23.85 ± 19.56 and 26.99 ± 21.12, respectively.
CT scans, the number of tissue and peripheral eosinophils, and sinonasal symptoms were
evaluated by Student's t-test in group A and group B. The difference between preoperative
and postoperative results in group A was significant (p < 0.05). There was a significant
difference between preoperative and postoperative results in group B except for the sense of
smell scores (p < 0.05). CT scans and sinonasal symptoms of group A and group B were
compared by independent samples t-test. The difference between the two groups was
observed to be significant with regard to the sense of smell (p < 0.05).
There were 12 (48%) recurrences in group A and 5 (20%) recurrences in group B at the sixth
month of the treatment.

Discussion
The management of patients with nasal polyps constitutes a significant part of the workload
of otorhinolaryngologists. Nasal polyps cause morbidity including nasal obstruction,
rhinorrhea and anosmia. The incidence of nasal polyps rises in the second and third decades.
There is a consensus on male predominance (2–4/1) [Bernstein et al. 1995]. The mean age
was determined to be 48.50 ± 9.16 in our study, which included 27 male and 23 female
patients.
Pengelolaan pasien dengan polip nasal merupakan bagian penting dari kerja
otorhinolaryngologists. Polip nasal menyebabkan morbiditas termasuk obstruksi hidung,
rhinorrhea dan anosmia. Insiden polip nasal meningkat pada dekade kedua dan ketiga. Ada
konsensus tentang dominasi laki-laki (2-4/1) [Bernstein et al. 1995]. Usia rata-rata 48.50 ±
9.16 dalam penelitian kami, yang meliputi 27 laki-laki dan 23 pasien perempuan.
The pathophysiological significance of cellular immunity in nasal polyps is well known [Tan,
1998]. Intense eosinophilia is a feature of nasal polyps and 80–90% of nasal polyps are
eosinophilic [Meco and Oberascher, 2004]. The histological appearance and ultrastructure of
various types of nasal polyps have been studied [Davidsson and Hellquist, 1993; Tos et al.
1990]. The characteristic features include large quantities of extracellular edema and an
inflammatory cell infiltrate consisting of mast cells, eosinophils, lymphocytes and plasma
cells, and eosinophils is often observed to be dominant. There is an uneven distribution of
goblet cells [Tos and Mogensen, 1977] and submucosal glands [Baraniuk, 1997] in the
epithelium with smaller quantities of both compared with nasal mucosa. In our histological
examinations, 94% of polyps were eosinophilic. The ratio of the chronic inflammatory polyps
was 6%.
Signifikansi patofisiologi imunitas seluler pada polip nasal telah diketahui [Tan, 1998].
Eosinofilia intens adalah fitur dari polip nasal dan 80-90% dari polip nasal adalah eosinofilik
[Meco dan Oberascher 2004]. Gambaran histologis dan ultrastruktur dari berbagai jenis polip
nasal telah dipelajari [Davidsson dan Hellquist, 1993; Tos et al. 1990]. Ciri-cirinya antara lain
jumlah besar edema ekstraseluler dan infiltrasi sel radang yang terdiri dari sel-sel mast,
eosinofil, limfosit dan sel plasma, dan eosinofil sering dominan. Ada distribusi yang tidak
merata dari sel goblet [Tos dan Mogensen, 1977] dan kelenjar submukosa [Baraniuk, 1997]
dalam epitel dengan jumlah yang lebih kecil dari kedua dibandingkan dengan mukosa
hidung. Dalam pemeriksaan histologis kami, 94% dari polip yang eosinofilik. Rasio polip
inflamasi kronis adalah 6%.
The role of eosinophils in asthma and other allergic diseases has been investigated, and this
may be relevant to polyp pathogenesis. Stimulation of such an effector capability by
structural cell-derived cytokines would undoubtedly represent a major amplification pathway
of the inflammatory response in nasal polyps [Bernstein et al. 1995]. Leukotrienes, derivates
of arachidonic acid, are generated during allergic and inflammatory respiratory diseases
[Baraniuk, 1997; Wardlaw et al. 1989]. Leukotrienes have a wide range of actions such as
inducing bronchoconstriction, vasodilation, vascular permeability, chemotaxis and mucus
secretion. Nasal polyps have higher levels of leukotriene C
4
and B
4
than normal mucosa
[Jung et al. 1987].
Peran eosinofil pada asma dan penyakit alergi lainnya telah diteliti, dan ini mungkin relevan
dengan patogenesis polip. Stimulasi seperti kemampuan efektor oleh sitokin sel yang
diturunkan secara struktural pasti akan mewakili jalur amplifikasi utama dari respon
inflamasi dalam polip nasal [Bernstein et al. 1995]. Leukotrien, turunan dari asam arakidonat,
yang dihasilkan selama penyakit pernafasan alergi dan inflamasi [Baraniuk, 1997; Wardlaw
et al. 1989]. Leukotrien memiliki berbagai tindakan seperti menginduksi bronkokonstriksi,
vasodilatasi, permeabilitas vaskuler, kemotaksis dan sekresi lendir. Polip hidung memiliki
tingkat leukotriene C4 dan B4 dari mukosa normal [Jung et al. 1987].
In this study, we considered the effect of leukotrienes in the formation of nasal polyps. One
group of patients received leukotrienes receptor antagonist and the other group were
administered intranasal steroid spray. Our data also showed that patients with recurrence of
nasal polyps had higher levels of tissue eosinophil counts compared to patients without
recurrence. We did not detect significantly higher levels of peripheral eosinophilia in any of
the groups. The finding of high levels of tissue eosinophils shows the effect of eosinophils in
the formation of nasal polyps.
Dalam penelitian ini, kami mempertimbangkan efek leukotrien dalam pembentukan polip
nasal. Satu kelompok pasien menerima antagonis reseptor leukotrien dan kelompok lainnya
diberikan spray intranasal steroid. Data kami juga menunjukkan bahwa pasien dengan
kekambuhan polip nasal memiliki kadar jumlah eosinofil jaringan dibandingkan dengan
pasien tanpa kekambuhan. Kami tidak mendeteksi tingkat lebih tinggi dari eosinofilia perifer
di salah satu kelompok. Temuan tingkat tinggi eosinofil jaringan menunjukkan efek eosinofil
dalam pembentukan polip nasal.
The management options for nasal polyposis include observation, medical treatment, and
surgery alone or in combination with medical treatment. Surgical procedures alone are
insufficient to treat the underlying inflammation of the nasal mucosa. Supplementary medical
treatment is always necessary to prevent recurrence [Holmberg and Karlsson, 1996]. The
most important drugs for the treatment of nasal polyposis are corticosteroids. They can be
used systemically or topically [Kutting et al. 2000; Parnes and Chuma, 2000]. Corticosteroids
are generally very effective in asthma and rhinitis. Clinical experience shows that nasal
polyps and chronic sinusitis respond less to corticosteroids than bronchial asthma and rhinitis
[Picado, 2001]. Few studies have demonstrated the effectiveness of corticosteroids in chronic
sinusitis and nasal polyposis [Lund et al. 1998]. ICSs improve nasal obstruction but only
partially reduce the size of polyps and have an insignificant effect on the sense of smell
[Kuran et al. 2002]. As reported in one study, the use of ICSs had an eligible effect on the
inflammation of paranasal sinuses [Lund et al. 1998]. Poor efficacy of ICSs in nasal polyps is
associated with two factors. The first factor is the relative corticosteroid resistance induced by
the very active inflammatory process. Corticosteroids have more effectiveness on eosinophils
in normal mucosa than on eosinophils in nasal polyps. The second factor is the difference
observed in topically applied ICSs in reaching the polyps [Mullul et al. 1995]. Steroids can
be used systemically; however, systemic steroids should be used only for short-term
treatment due to the risk of systemic side effects. In our study, recurrence of nasal polyps was
determined in 20% of the patients who were treated with intranasal steroid. We evaluated the
paranasal sinus CT scans before treatment and at the end of the sixth month. The statistical
relation of these results was found to be significant (p < 0.05). Patients who used ICSs
reported a postoperative reduction in the symptoms except for the sense of smell.
Pilihan manajemen untuk poliposis nasal meliputi observasi, perawatan medis, dan operasi
sendiri atau dalam kombinasi dengan pengobatan medis. Prosedur bedah saja tidak cukup
untuk mengobati peradangan yang mendasari mukosa hidung. Perawatan medis tambahan
selalu diperlukan untuk mencegah terulangnya [Holmberg dan Karlsson, 1996]. Obat-obatan
yang paling penting untuk pengobatan poliposis nasal adalah kortikosteroid. Kortikosteroid
dapat digunakan secara sistemik atau topikal [Kutting et al. 2000; Parnes dan Chuma 2000].
Kortikosteroid umumnya sangat efektif dalam asma dan rhinitis. Pengalaman klinis
menunjukkan bahwa polip nasal dan sinusitis kronis kurang sensitif terhadap kortikosteroid
dibandingkan pada penyakit asma dan rhinitis [Picado 2001]. Beberapa penelitian telah
menunjukkan efektivitas kortikosteroid pada sinusitis kronis dan polip nasal [Lund et al.
1998]. ICSS meningkatkan sumbatan hidung, tetapi hanya sebagian saja yang dapat
mengurangi ukuran polip dan memiliki efek signifikan pada indera penciuman [Kuran et al.
2002]. Sebagaimana dilaporkan dalam sebuah penelitian, penggunaan ICSS memiliki efek
yang memenuhi syarat pada peradangan sinus paranasal [Lund et al. 1998].. Kemanjuran dari
ICSS di polip nasal dikaitkan dengan dua faktor. Faktor pertama adalah perlawanan
kortikosteroid relatif disebabkan oleh proses inflamasi yang sangat aktif. Kortikosteroid
lebih efektif pada eosinofil di mukosa normal daripada di eosinofil pada polip hidung. Faktor
kedua adalah perbedaan yang diamati pada ICSS topikal / oles dalam mencapai polip
[Mullul et al. 1995]. Steroid dapat digunakan secara sistemik; Namun, steroid sistemik harus
digunakan hanya untuk pengobatan jangka pendek karena risiko efek samping sistemik.
Dalam penelitian kami, kekambuhan polip nasal ditentukan dalam 20% dari pasien yang
diobati dengan steroid intranasal. Kami mengevaluasi paranasal sinus dengan CT scan
sebelum pengobatan dan pada akhir bulan keenam. Hubungan statistik hasil ini ditemukan
menjadi signifikan (p <0,05). Pasien yang menggunakan ICSS melaporkan penurunan pada
gejala kecuali untuk indera penciuman pada pasca operasi

There is limited knowledge on the possible role of antileukotrienes in the control of sinonasal
polyposis. Dahlén and colleagues showed that the 5-lipoxygenase inhibitor zileuton
diminished nasal dysfunction with remarkable return of smell, less nasal congestion and a
trend for less stuffiness and higher nasal inspiratory flow in aspirin-sensitive asthmatics
[Dahlén et al. 1998]. Kutting and colleagues evaluated the efficacy of short term oral steroid
therapy combined with montelukast in nasal polyposis [Kutting et al. 2000]. Patients were
evaluated by endoscopic examinations, symptom scores and MRI. This therapeutic procedure
proved to be beneficial in seven patients. Ragab et al. assessed the efficiency of montelukast
in nasal polyps by using nasal endoscopy, acoustic rhinometry and visual analog scale.
Clinical improvement in nasal polyposis occurred in 64% of aspirin-tolerant patients and in
50% of aspirin-sensitive patients [Ragab et al. 2001]. Jung and colleagues reported an
increase in the levels of leukotrienesin in the polyp tissues of patients with Samter's triad
[Jung et al. 1987]. In another study, patients were treated with zafirlukast and zileuton, and a
decrease was reported in the symptoms and sizes of polyps [Parnes and Chuma, 2000]. In our
study, recurrence of nasal polyps was detected in 48% of the patients who used montelukast.
We evaluated the paranasal sinus CT scans before the treatment and at the end of the sixth
month. The statistical relation of these results was found to be significant (p < 0.05). Patients
who used montelukast reported a postoperative reduction in the symptoms. No side effects of
montelukast and mometasone were observed.
Terdapat pengetahuan yang terbatas pada kemungkinan peran antileukotrienes dalam
pengendalian poliposis sinonasal. DAHLEN dan koleganya menunjukkan bahwa 5-
lipoxygenase inhibitor zileuton berkurangnya disfungsi hidung dengan return yang luar biasa
bau, berkurangnya sumbatan hidung dan berkurangnya sesak di hidung dan aliran inspirasi
yang lebih tinggi pada penderita asma dengan sensitif aspirin [DAHLEN et al. 1998].
Kutting dan rekan mengevaluasi efikasi jangka pendek terapi steroid oral yang
dikombinasikan dengan montelukast di poliposis nasal [Kutting et al. 2000]. Pasien
dievaluasi dengan pemeriksaan endoskopi, skor gejala dan MRI. Prosedur terapi ini terbukti
bermanfaat pada tujuh pasien. Ragab et al. menilai efisiensi montelukast dalam polip hidung
dengan menggunakan endoskopi hidung, rhinometry akustik dan skala analog visual.
Perbaikan klinis dalam poliposis nasal terjadi pada 64% pasien dengan toleran aspirin dan
pada 50% pasien dengan sensitive aspirin [Ragab et al. 2001]. Jung dan rekan melaporkan
peningkatan kadar leukotrienesin dalam jaringan polip pasien dengan Samter s triad [Jung et
al. 1987]. Dalam penelitian lain, pasien diobati dengan zafirlukast dan zileuton, dan
dilaporkan terdapat penurunan gejala dan ukuran polip [Parnes dan Chuma 2000]. Dalam
penelitian kami, kekambuhan polip nasal terdeteksi pada 48% dari pasien yang menggunakan
montelukast. Kami mengevaluasi sinus paranasal dengan CT scan sebelum pengobatan dan
pada akhir bulan keenam. Hubungan statistik hasil ini ditemukan menjadi signifikan (p
<0,05). Pasien yang menggunakan montelukast melaporkan terjadinya gejala pada pasca
operasi. Tidak ada efek samping dari montelukast dan mometason yang diamati
QoL is a general term integrating several aspects of life such as physical, psychological,
social, economical, emotional, cognitional, and sexual dimensions. A disturbance in any one
of these aspects will in turn affect the other domains and influence the overall QoL. The
measures of QoL have evolved as the emphasis on medical care has shifted from symptom
scores and objective test results to an assessment of the patient-centered effect of disease and
response to treatment. In general, there are two major types of QoL instruments used in
clinical trials: generic and specific. Generic measures allow comparison across different
disorders, severities of disease, and interventions, whereas disease-specific scales contain
items most relevant to the condition under study and that most likely will change with
effective therapy. In this study, the SNOT-22, a disease-specific questionnaire, was used to
evaluate the subjective outcomes. We believe that SNOT-22 may well be used on a regular
basis by the clinician to obtain information about the full range of problems associated with
rhinosinusitis. It can aid researchers in diagnosing and assessing the degree and effect of
rhinosinusitis on health status, and of treating patients with chronic rhinosinusitis (CRS). If
routinely used, it is suggested that the SNOT-22 can measure the effectiveness of treatment,
including surgery, and maybe identify patient factors that predict maximum treatment
response [Buckland et al. 2003]. According to the SNOT-22 measurements, the patients in
the two groups showed marked improvement in their subjective symptoms, which did not
differ significantly between the groups.
Kualitas hidup (Quality of Life –QoL) adalah istilah umum yang mengintegrasikan beberapa
aspek kehidupan seperti fisik, psikologis, sosial, ekonomi, emosional, cognitional, dan
dimensi seksual. Gangguan pada salah satu aspek ini pada gilirannya akan mempengaruhi
domain lain dan mempengaruhi kualitas hidup secara keseluruhan. Langkah-langkah
pencapaian kualitas hidup telah berevolusi menjadi hal yang ditekankan dalam perawatan
medis, yang mana telah bergeser dari skoring gejala dan hasil tes secara obyektif menjadi
penilaian pasien yang berpusat pada efek dari penyakit dan respon terhadap pengobatan.
Secara umum, ada dua jenis utama dari instrumen kualitas hidup yang digunakan dalam uji
klinis: generik dan spesifik. Langkah-langkah generik memungkinkan perbandingan seluruh
gangguan yang berbeda, keparahan penyakit, dan intervensi, sedangkan skala penyakit
tertentu berisi item yang paling relevan dengan kondisi yang diteliti dan yang kemungkinan
besar akan berubah dengan terapi yang efektif. Dalam penelitian ini, SNOT-22, sebuah
kuesioner penyakit tertentu, digunakan untuk mengevaluasi hasil subyektif. Kami percaya
bahwa SNOT-22 juga dapat digunakan secara rutin oleh dokter untuk memperoleh informasi
tentang berbagai masalah yang terkait dengan rinosinusitis. Hal ini dapat membantu peneliti
dalam mendiagnosis dan menilai derajat dan akibat rinosinusitis pada status kesehatan, dan
mengobati pasien dengan rinosinusitis kronis (CRS). Jika rutin digunakan, disarankan bahwa
SNOT-22 dapat mengukur efektivitas pengobatan, termasuk pembedahan, dan mungkin
mengidentifikasi faktor-faktor pasien yang memprediksi respon pengobatan maksimum
[Buckland et al. 2003]. Menurut pengukuran dengan menggunakan SNOT-22 , pasien dalam
dua kelompok menunjukkan peningkatan yang nyata dalam gejala subyektif mereka, yang
tidak berbeda secara signifikan antara kelompok.
Conclusion
We conclude that antileukotriene agents and intranasal corticosteroids seemed to have a
complementary action, yet further studies are needed to determine which patients should
receive which treatment.
Kami menyimpulkan bahwa agen antileukotriene dan kortikosteroid intranasal memiliki
peran sebagai pelengkap, namun penelitian lebih lanjut diperlukan untuk menentukan pasien
dengan kriteria seperti apa yang seharusnya menerima treatmen ini.



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