Original Article

DOI: 10.21276/APALM.1173

A study on Histomorphological Spectrum of Nasal Polyp

K Pushpalatha*, Sreedevi CH, Soujanya R

Department of Pathology, Maheshwara Medical College, Sangareddy, India

ABSTRACT
Background: Nasal Polyp is commonly encountered in clinical practice and important from clinical and pathological perspectives as they
have varieties of histological patterns. The Polypoidal masses in nasal cavity form a complex group of lesions with wide spectrum of
histopathological features, mainly grouped under allergic and inflammatory. Histopathological examination shows a spectrum of lesions
ranging from the non-neoplastic ones to neoplastic tumors.
Methods: Present study included 153 polypoidal lesions of the nasal cavity during a period of one year. All the tissues were fixed in 10%
buffered formalin, processed, stained with H & E and studied for various histopathological patterns. Periodic acid Schiff’s and reticulin
stains were used wherever necessary.
Results: classifying the sinonasal lesions according to histo-pathological features into various types helps us to know the clinical
presentation, treatment, clinical outcome and prognosis of the disease. Although most of nasal polyps sent for histopathology are
inflammatory, secondary to infection or allergy, various benign and malignant lesions of nose may present as polypoidal masses,
Conclusion: The study recommends, all polyps need histo-pathological examination.

Keywords: Nasal Polyps, Sinonasal Lesions, Histo-Pathology.

Airway Inflammation in Chronic Rhinosinusitis

with Nasal Polyps and Asthma: The United
Airways Concept Further Supported
Abstract
Background

It has been established that patients with chronic rhinosinusitis with nasal polyps (CRSwNP) often have
co-existing asthma.

Objective

We aimed to test two hypotheses: (i) upper and lower airway inflammation in CRSwNP is uniform in
agreement with the united airways concept; and (ii) bronchial inflammation exists in all CRSwNP
patients irrespective of clinical asthma status.

Methods

We collected biopsies from nasal polyps, inferior turbinates and bronchi of 27 CRSwNP patients and 6
controls. All participants were evaluated for lower airway disease according to international guidelines.
Inflammatory cytokines were investigated using a Th1/Th2 assay including 14 chemokines and
cytokines; tissue concentrations were normalized according to tissue weight and total protein
concentration. Individual cytokines and multivariate inflammatory profiles were compared between
biopsy sites and between patients and controls.

Results

We found significantly higher concentrations of Th2 cytokines in nasal polyps compared to inferior
turbinate and bronchial biopsies. In addition, we showed that the inflammatory profile of nasal polyps
and bronchial biopsies correlated significantly (p<0.01). From the Th2 cytokines measured, IL-13 was
significantly increased in bronchial biopsies from CRSwNP patients with, but not without asthma.

Conclusion

Our findings support the united airways concept; however, we did not find evidence for subclinical
bronchial inflammation in CRSwNP patients without asthma. Finally, this study indicates for the first
time that nasal polyps potentially play an important role in the airway inflammation rather than being a
secondary phenomenon.

The Development of Nasal Polyp Disease

Involves Early Nasal Mucosal Inflammation and
Remodelling

Abstract

Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by both a chronic inflammation and
tissue remodelling; as indicated by extracellular matrix protein deposition, basement membrane
thickening, goblet cell hyperplasia and subepithelial edema, with reduced vessels and glands. Although
remodelling is generally considered to be consequence of persistent inflammation, the chronological
order and relationship between inflammation and remodelling in polyp development is still not clear.
The aim of our study was therefore to investigate the pathological features prevalent in the development
of nasal polyps and to elucidate the chronological order and relationship between inflammation and
remodelling, by comparing specific markers of inflammation and remodelling in early stage nasal polyps
confined to the middle turbinate (refer to as middle turbinate CRSwNP) obtained from 5 CRSwNP
patients with bilateral polyposis, mature ethmoidal polyps from 6 CRSwNP patients, and normal nasal
mucosal tissue from 6 control subjects. Middle turbinate CRSwNP demonstrated significantly more
severe epithelial loss compared to mature ethmoidal polyps and normal nasal mucosa. The epithelial cell
junction molecules E-cadherin, ZO-1 and occludin were also expressed in significantly lower amounts in
mature ethmoidal polyps compared to healthy mucosa. Middle turbinate CRSwNP were further
characterized by significantly increased numbers of subepithelial eosinophils and M2 type macrophages,
with a distinct lack of collagen and deposition of fibronectin in polyp part. In contrast, the turbinate area
of the middle turbinate CRSwNP was characterized by an increase in TGF-β activated myofibroblasts
expressing α-SMA and vimentin, an increase in the number of pSmad2 positive cells, as well as
increased deposition of collagen. These findings suggest a complex network of processes in the
formation of CRSwNP; including gross epithelial damage and repair reactions, eosinophil and
macrophage cell infiltration, and tissue remodelling. Furthermore, remodelling appears to occur in
parallel, rather than subsequent to inflammation.
Immune Imbalance in Nasal Polyps of
Caucasian Chronic Rhinosinusitis Patients Is
Associated with a Downregulation of E-
Selectin
Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) in Caucasians is a chronic Th2 inflammatory disease of
the nasal and paranasal mucosa and the recruitment of leukocytes to the site of inflammation is poorly
understood. We studied mRNA and protein expression profiles of adhesion molecules in nasal polyp and
associated inferior turbinate tissues using molecular, biochemical, and immunohistological methods.
Analysis showed a strongly decreased E-selectin expression in nasal polyps with a significant difference
between eosinophil and neutrophil counts in nasal polyps and balanced counts in inferior turbinates. E-
selectin expression is known to be downregulated in a Th2 milieu and has an essential role in
immunosurveillance by locally activating neutrophil arrest and migratory function. A downregulation of E-
selectin may come along with an immune imbalance in Caucasian nasal polyps due to a significant
inhibition of neutrophil recruitment. Therefore, we suggest that an upregulation of E-selectin and the
associated influx of neutrophils may play a significant role in the resolution of inflammation as well as for
the pathophysiology of nasal polyps of Caucasian chronic rhinosinusitis patients.

the epithelium. The tissue density of CD14+ cells

Nasal polyp (monocyte/macrophage) and of tryptase+ cells (mast

cells) was the same in the two groups. These findings
demonstrate tissue effects of topical corticosteroid

inflammation.
treatment which may point to the mechanisms of
therapeutic benefit. In addition, these observations
illustrate the value of markers that indicate cell functional
activity rather than just cell numbers.

Effect of topical
nasal steroid.
Topical nasal corticosteroid therapy produces clinical
improvement in patients with nasal polyposis. To
examine the mechanisms of steroid effect, we quantified
the number of inflammatory cell types as well as the
expression of relevant cell markers in nasal polyps from
steroid treated patients (n = 11) and polyps from
untreated patients (n = 10) judged to require
polypectomy for symptomatic relief. We found that the
majority of eosinophils in these tissues were in the
stromal layers, and that the proportion of activated
eosinophils (EG2+ versus total eosinophil count) was
significantly lower in polyps from patients treated with
the topical nasal steroid budesonide, 200 to 400
micrograms/d for 1 mo, than in polyps from untreated
patients. We also found that in polyps from treated
patients, the superficial stromal layer (SSL) and deep
stromal layer (DSL) both contained a significantly lower
tissue density of lymphocytes of CD3, CD4, and CD8
subsets. Treatment was also associated with a lower,
albeit nonsignificant, expression of ICAM-1 and HLA-DR in

The Use of Omalizumab
in Thetreatment of Nasal
Polyps
PURPOSE: Allergic rhinitis and nasal polyps
are associated with elevated serum
immunoglobulin IgE levels. The allergens bind
to IgE on the surface of basophils and mast
cells, which releases histamine, leukotriens and
others, following the symptoms of allergic
rhinitis. Does the removal of free IgE by the
anti-IgE antibody, omalizumab, improve the
symptoms of allergic rhinitis and reduce nasal
polyps? The answer to that question was the aim
of this study.
METHODS: Fifty patients, 20 women and 30
men, all suffering from allergic rhinitis and
asthma with mean body weight 82 kgs
underwent rhinoscopic endoscopy, computed
tomography of the nose and the ethmoid cells
and spirometry. These tests took place twice.
First time on day 0 and second time sixteen
weeks after subcutaneous omalizumab
administration in doses depending on the body
weight and the serum levels of total IgE of each
patient with 2 or 4 week intervals. The mean
omalizumab doses were: 300mg every 2 weeks
or 450mg every 4 weeks.
RESULTS: The rhinoscopic endoscopy, on day
0, revealed nasal polyps. The computer
tomography showed extended polypodiasis to
30 out of 50 patients (60%). The other 20 had
only polyps in the ethmoid cells (40%). The
FEV1 mean value was 68.6%. Sixteen weeks
later we had an endoscopical and imaging
reduction in nasal polyps and an improvement
in the values of FEV1 in all patients (78.3%).
The patients reported reduced use of corticoid
sprays and an improvement in their quality of
life, due to reduction of nasal symptoms of
sneezing, itching, rhinorrhea and congestion.
They all reported better sense of smell.
CONCLUSIONS: Omalizumab is effective in
the symptoms of nasal congestion, anterior
rhinorrhea, loss of smell, wheezing
and dyspnea. It has been proved that
Omalizumab reduces the size of nasal polyps
and improves the quality of life. This finding
could be due to the local formation of IgE in
nose and lungs.
Factors associated with
recurrent nasal polyps: A t
ertiary care experience
Abstract
Objective:
To assess the factors associated with
recurrence of nasal polyps in operated
patients by endoscopic
surgery.
Methods:
A retrospective study was conducted on 192
patients operated for nasal polyps in a
hospital set-up
between 2001 and 2007. The median follow-
up period was 24 months (range 12 months
to 60 months). Ten
variables were analyzed to study their
association with polyp recurrence namely;
age, gender, history of purulent
nasal discharge, facial pain, anosmia, post
nasal dripping (PND), headache, nasal
allergy, asthma and computed
tomography (C.T) staging. Analysis of
recurrences was accomplished using
independent sample t-test, chi-
square and Fishers exact test. A probability
value of p < 0.05 was selected as the level of
significance.
Results:
During the study period, recurrences
developed in 36 patients, with a rate of
19%.No association of
recurrence with age, gender, purulent nasal
discharge, facial pain, anosmia, post nasal
dripping, headache,
nasal allergy, and asthma were observed.
The C.T staging was significantly higher
among the group with
recurrence as compared to the group without
recurrence. ( p < 0.001)
Conclusion:
Patients presenting with extensive disease
suggested by C.T scan staging are at higher
risk for the
development of recurrences after endonasal
surgery for nasal polyps (JPMA 60:102;
2010).
Local and systemic
eosinophilia in
patients with nasal
polyps
Abstract
Background: To determine the presence of
local and systemic eosinophilia in patients with
nasal polyps and to correlate between them.
Materials and Methods: Patients of all age
group, presented in ENT OPD during October
2004 to May 2006, with ethmoidal polyps were
studied. Patients using steroids in last one
month, antrochoanal polyps and
histopathological diagnosis other than nasal
polyps were excluded. The local eosinophils
count in nasal polyp tissue of study group and
inferior turbinate mucosa of control group were
evaluated and analyzed. Similarly absolute
blood eosinophil counts in both study and
control group were evaluated. The association
between local and systemic eosinophilia were
analysed.
Results: Out of 78 patients with nasal polyps
systemic eosinophilia was seen in 28 patients
(35.9%) and local eosinophilia was seen in 50
(64.1%) patients. Among 30 patients of control
group only 2 patients (6.7%) had systemic and
none had local eosinophilia. On analyzing the
results, the presence of systemic and local
eosinophilia in patients with polyps were
statistically significant with p value 0.005 and
0.0001 respectively. The association between
them was also significant (p<0.025).
Conclusion: There is significant local and
systemic eosinophilia in patients with nasal
polyps and also significant correlation between
them
Impact of baseline nasal
polyp size and previous
surgery
on efficacy of fluticasone
delivered with a novel
device:
A subgroup analysis
ABSTRACT
Background:
Little information exists on the impact of baseline polyp
size and previous nasal surgery on the efficacy of
intranasal steroids. This study was
designed to investigate whether baseline polyp size and
previous nasal surgery influence the efficacy of an
intranasal steroid delivered with a nove
l device.
Methods:
A
post hoc
analysis of recently published results with intranasal
administration using the OptiNose bidirectional delivery
device containing
fluticasone propionate (Opt-FP) was performed in 109
patients with mild-to-moderate bilateral polyposis.
Patients were allocated to subgroups ba
sed on
summed polyp score at baseline (2, 3, or 4) and on their
history of previous sinus surgery.
Results:
A highly significant and progressive reduction in summed
polyp size was observed for Opt-FP versus placebo in all
three polyp size subgroups
(p
0.001). A greater relative reduction in polyp size (p
0.05) and an increase in peak nasal inspiratory flow (p
0.001) were observed for Opt-FP at
12 weeks in the 28 patients with a baseline summed score
of 3 and 4 compared with the 27 with a summed score of
2. Nevertheless, in patients with small
polyps at baseline, the polyps were completely resolved
on both sides in 7 of 27 patients. Previous sinus surgery
had no impact on efficacy.
Conclusion:
The highly significant progressive treatment effect of Opt-
FP was observed regardless of baseline polyps score.
Coupled with the complete
removal of polyps in many patients with small polyps,
this suggests that improved deposition to target sites
achieved with the bidirectional deliver
y device may
translate into true clinical benefits and reduced need for
surgery.
Doxycycline or Oral
Corticosteroids for
Nasal Polyps
The study by Van Zele et al reports positive results for a
randomized, double-blind, placebo-controlled trial that
used either 20 days of doxycycline (200 mg the first day,
followed by 100 mg daily) or 20 days of a tapering
schedule of methyl prednisolone (32 mg on days 1-5, 16
mg on days 6-10, and 8 mg on days 11-20) for the
treatment of nasal polyps. The primary end point was
reduction in nasal polyp score which was graded 0 to 4
on each side, resulting in a score range of 0 to 8; the
score was determined at baseline and weeks 1, 2, 4, 8,
and 12. Entry criteria required that the patient either
have recurrent polyps after surgery or massive polyps
(grade 3 or 4); the total polyp score in each of the 3
groups averaged approximately 6. The patient population
in this study was therefore at the severe end of the
spectrum; results may not be generalizable to patients
with milder disease.