Eur Arch Otorhinolaryngol (2010) 267:721–724
DOI 10.1007/s00405-009-1146-x
RHINOLOGY
Osteitis in chronic rhinosinusitis with nasal polyps: a comparative
study between primary and recurrent cases
Laila Mohammed Telmesani · Mohamed Al-Shawarby
Received: 26 July 2009 / Accepted: 22 October 2009 / Published online: 6 November 2009
© Springer-Verlag 2009
Abstract Reports in rhinology suggest that operated
cases of chronic hypertrophic rhinitis with nasal polyps are
more prone to further recurrence. This study was designed
to Wnd out if recurrence rate after surgery is related to a
possible increase in the incidence and degree of osteitis.
A prospective study of 82 patients with nasal polyps was
carried out. They were divided into two groups: group A 50
patients, undergoing FESS for the Wrst time, group B 32
patients, undergoing revision surgery. Histopathological
examination was performed for specimens taken from the
bony septa of the ethmoid with the overlying mucosa. Bony
changes were seen in only 30% of the patients in group A,
compared to 87.5% in group B; this diVerence was statisti-
cally highly signiWcant (p = 0.001). Failure was seen in Wve
patients (10%) in group A, 26.6% had osteitis. In contrast,
failure was seen in 53% of group B, and constituted 60.7%
of patients with osteitis in this group. Surgery plays a major
role in increasing the incidence of osteitis in patients with
nasal polyps. The increase recurrence rate in revision cases
is not only related to osteitis. There are other factors than
osteitis which needs further studies.
Keywords Nasal polyps · Osteitis · Recurrent nasal
polyps
L. M. Telmesani (&) · M. Al-Shawarby
King Fahad University Hospital,
King Faisal University, Al-Khobar, Saudi Arabia
e-mail: telmesanilaila@hotmail.com
Introduction
Kennedy [1] stated that, evidence suggests that the underly-
ing bone in the ostiomeatal complex is actively involved in
chronic rhinosinusitis. Despite the aggressive treatment of
the overlying sinus mucosa, chronic inXammation can often
remain within the underlying bone leading to recurrence of
the disease. Clinical experience has shown that, in post
operative patients, localized persistent mucosal inXamma-
tion may remain until the underlying bone is removed [2].
Several previous reports suggest that osteitis in cases of
chronic rhinosinusitis is directly related to the failure rate
[3, 4].
Revision patients are more prone to further failures; this
is observed in patients with nasal polyps where the
increased number of surgeries results in increased rate of
recurrence and shortening of the disease-free periods [5].
The main problem in the treatment of nasal polyps is the
recurrence of the disease [6]. The aim of this study was to
estimate the incidence and degree of osteitis in primary and
revision cases, and to Wnd out if there is a direct correlation
between osteitis and recurrence.
Patients and methodology
This prospective study was carried in King Fahd Hospital
of the University in Al-Khobar, Kingdom of Saudi Arabia
from January 2006 through December 2007.
Eighty-two patients diagnosed as having chronic rhinos-
inusitis with nasal polyps were included. Children below
18 years of age and patients who were pregnant or had
metabolic bone disease, immotile cilia syndrome, mucoce-
les, tumors, fungal sinusitis or were immunocompromised
were excluded from the study.
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Patients were classiWed into two groups: group A, 50
patients with virgin noses, subjected to FESS for the Wrst
time, group B, 32 patients were subjected to FESS as revi-
sion surgery for a second or third time.
Histopathological examination
Bony samples were collected from the bony ethmoid septa
with their covering mucosa for histopathological examina-
tion. Mucosal and bony changes were reported.
Pathological changes occurring in the mucosa were
graded using the Milbrath et al. [7], grading system. Muco-
sal changes were categorized according to the intensity of
chronic inXammatory cellular inWltration and the presence
or absence of squamous metaplasia, edema and Wbrosis into
three grades; mild, moderate and severe mucosal reaction.
Degrees of bony changes were graded according to
Biedlingmaier et al. [8]. This classiWcation depends on the
presence or absence of periostial thickening, increased
osteoblastic or osteoclastic activity and bone resorption.
Accordingly, bony changes were categorized into no oste-
itic changes, mild, moderate and severe bone reaction.
changes were observed in 12 patients (14.6%) (Table 1).
The number of patients according to the degree of mucosal
changes in each group is also shown in Table 1.
Variable degrees of histopathological bony changes
were detected in 43 out of 82 cases (52.4%) with a diagno-
sis of nasal polyps. Detected osteitic changes are shown in
Table 2.
There was a correlation between the incidence of oste-
itis, and the degree of mucosal pathology. InXammatory
process in the ethmoid bone and the overlying sinus
mucosa showed a highly signiWcant positive correlation
with p value = 0.005 (Kendall Tau_b test) (Table 3).
Osteitic changes were seen in 28 (87.5%) patients in
group B, compared to only 15 (30%) in group A. This
diVerence was highly statistically signiWcant with p
value = 0.001. The incidence of bony changes in revision
cases is thus much higher.
As shown in Table 4 in group A, 35 patients (70%) had
no bony aVection. While 11 (22%) had mild, and 4 (8%)
moderate osteitis. In contrast, in group B, only 4 patients
(12.5%) had no osteitic changes but 9 (28.1%) had mild, 17
(53.2%) moderate and 2 (6.2%) severe osteitis.

Table 1 Frequency and degree of mucosal changes in group A and B

Follow up
Mucosal Group A Group B Total
changes
All patients were followed-up for 1 year and the appearance n % n % n %
of recurrence was documented and related to the mucosal
Mild 17 34 13 40.6 30 36.6
and bony changes.
Moderate 24 48 16 50 40 48
Severe 9 18 3 9.4 12 14.6
Total 50 100 32 10 82 100
Statistical methods

Statistical analysis was performed using the software SPSS Table 2 Degree of bony changes in all patients
for windows version 10 (SPSS Inc., IL, USA).
Degree of osteitis No. of patients %
The incidence of mucosal, osteitic changes and recur-
rence in both groups was analyzed using
2 test. Correlation No bony changes 39 48.6
between the degree of mucosal changes and the presence of Mild osteitis 18 22
osteitis, and between the degree of osteitis and recurrence Moderate osteitis 23 28
were performed using the non-parametric Kendall Tau test. Severe osteitis (osteomyelitis) 2 2.4
Total 82 100

Results
Table 3 Percentage of patients with osteitis in each degree of mucosal
The mean age of those in group A was 39.8 years with a change in 82 patients
range of 27–61 years. There were 33 males and 17 females. No. of No. of patients %
The mean age of those in group B was 38.3 years with a patients with osteitis
range of 29–58 years. There were 21 males and 11 females.
Mild mucosal change 30 7 23.3
Both groups were comparable.
Moderate 40 25 62.5
DiVerent degrees of mucosal changes were detected in
Severe 12 11 91.6
all 82 patients. Thirty patients (36.6%) showed mild muco-
Total 82 43 52.4
sal changes, 40 (48.8%) had moderate changes and severe

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Table 4 Number and percentage of recurrence in each degree of In this study, we tried to verify if there is a diVerence in
osteitis in both groups the incidence or degree of osteitis between primary and
Degree of Number of Number of failures revision cases, and whether there is a relation between the
osteitis patients degree of osteitis and the rate of recurrence. Two groups of
Group A Group B Group A % Group B %
patients were selected, group A primary cases, and group B
revision cases. All patients showed variable degrees of
No osteitis 35 4 1 2.8 0 0 mucosal aVection and there were no signiWcant diVerences
Mild osteitis 11 9 2 18.2 3 33.3 in the two groups. Mild mucosal changes were seen in 34%
Moderate 4 17 2 50 12 70.5 of patients in group A, and 40.6% in group B; moderate
osteitis mucosal changes were in 48 and 50% in group A and B,
Severe osteitis 0 2 0 0 2 100 respectively. Severe mucosal aVection was seen in 18% of
patients in group A, and 9.4% of patients in group B.
Relating the incidence of osteitis to the degree of muco- Mucosal aVection can thus be excluded as a cause for the
sal changes and comparing both groups, it was evident that diVerence in the incidence or degree of osteitis between the
there is increased incidence of osteitis with an increase in two groups.
the degree of mucosal change. But what is more important Lee et al. [10] determined the osteitic changes in surgical
is that the incidence of osteitis is signiWcantly higher in specimens of patients with chronic rhinosinusitis who
group B compared to group A (p = 0.001), where 0% of underwent FESS. Although they did not mention whether
patients with mild mucosal changes in group A showed their patients included those with nasal polyps or not, 53%
osteitis, while 69% of patients with mild mucosal changes of their cases were found to exhibit reactive bony changes
showed osteitis in group B. by light microscopy. This is very similar to our results
37.5 and 66.6% of patients with moderate and severe where incidence of bony changes was observed in 52.4% of
mucosal changes, respectively, showed osteitis in group A, cases.
in contrast all patients (100%) with moderate or severe On the other hand, Catalano et al. [11], tried to correlate
mucosal changes showed osteitis in group B. bone SPECT scintigraphy with histopathological examina-
The overall recurrence was 5 (10%) patients in group A, tion; they found that the histopathological incidence of
and 17 (53%) in group B. This diVerence was highly statis- bone changes was around 86%. This is very similar to 87%
tically signiWcant p < 0.0005. In group B, 17 patients with incidence observed in our revision cases.
recurrence were all among the 28 patients with osteitis We found that, there is a statistical signiWcant relation
(60.7%). While in group A, four out of the Wve (26.6%) had between the incidence of osteitis and the degree of overly-
osteitis. Statistically, this showed high signiWcant positive ing mucosal pathology (p value = 0.005). The incidence of
correlation between the score of bone aVection and the inci- osteitis was 23.3% in patients with mild mucosal aVection,
dence of recurrence after FESS with p value <0.0005 62.5% in patients with moderate mucosal aVection and
(Kendall Tau_b test). 91.6% in those with severe mucosal aVection. The number
The number and percentage of patients with recurrence of patients with bony changes therefore increases with the
in both groups according to the degree of osteitis is shown advance of the grade of mucosal aVection. However,
in Table 4. the grade of mucosal aVection does not correlate with the
Comparing the incidence of failure in mild and moderate degree of bony change.
degree of osteitis in both groups, it was found statistically The overall incidence of osteitis was 30% in group A,
signiWcant p < 0.05. and 87% in group B.
In group A, 70% had no osteitic changes, 22% had mild
changes, 8% had moderate changes and no (0%) patients
Discussion had severe osteitic changes. In contrast in group B, only 13
showed no bony changes, 25 had mild, 57 moderate and 6%
The phenomenon of bone remodeling in chronic rhinosi- severe osteitis. This was statistically signiWcant (p < 0.05).
nusitis is now considered to be one of the most important Thus, the incidence and degree of osteitis in group B is
causes of persistence and recurrence of the disease [9]. To higher than in group A. These Wndings suggest that surgery
our knowledge, no work has been done to compare osteitis may play a role in increasing the incidence of osteitis.
in primary and recurrent cases of nasal polyps. Cho et al. [12], assessed bone remodeling of the ethmoid
Kennedy et al. [5] stated that revision patients are more sinuses after surgery by the presence of new bone forma-
vulnerable to further failures. They stress the role of bone tion and measurements of bone density and they concluded
involvement in the propagation of mucosal inXammatory that, in revision cases soft tissue and bone remodeling may
disease. be greater than primary cases. These results are supported

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by our observations of osteitis in 30% of primary, and 87%
in revision cases.
Comparing the incidence of bony changes in each degree
of mucosal aVection between the two groups, there was
high statistically signiWcant diVerence (p = 0.001), as in
group A no patients with mild mucosal reaction showed
osteitis, 37.5% of patients with moderate mucosal reaction
showed osteitis and 69% of patients with severe mucosal
reaction had osteitis, while in group B 69% of patients with
mild mucosal reaction showed bony changes and all
patients (100%) with moderate and severe mucosal reaction
showed some degree of bony change. This may reXect the
eVect of surgery which opens virgin bone to infection and
hence increased incidence of osteitis.
Recurrence was seen in 5 (10%) patients in group A and
17 (53%) patients in group B. This diVerence in failure was
highly statistically signiWcant with p value <0.0005. This
result supports the statement of Kennedy et al. [9] that revi-
sion patients are more vulnerable to further failures.
There was a statistically signiWcant diVerence in the rate of
failure in patients with osteitis in both groups (p < 0.0005).
This may reXect a positive correlation between previous
surgery and recurrence, as incidence of failure in patients
with osteitis in group A was 26.6% (4 patients out of 15),
compared to 60.7% (17 patients out of 28) in group B.
This Wnding allows us to compare the percentage of fail-
ures in each degree of bone aVection in both groups. In
patients with mild osteitis, failure rate was 18% in group A
compared to 33.3% in group B. In patients with moderate
osteitis, failure was 50% in group A, and 70.5% in group B.
This was statistically signiWcant (p < 0.05). This suggests
that in addition to osteitis, there should be another factor,
which contributes to the rate of failures in both groups.
The prevalence of osteitis in the underlying bone should
discourage the universal application of the minimally inva-
sive sinus technique. Leaving behind osteitic ethmoids
bony partitions provides a source of inXammation that often
results in persistent mucosal edema. Endoscopic sinus sur-
gery with the complete removal of bony partitions within
the diseased area is a better procedure to eradicate a persis-
tent source of inXammation [2]. Our results support this and
should be applied especially in recurrent cases.
Due to the fact that 95.4% of failed cases were patients
showing some degree of osteitis, we could conclude that
osteitis might have an important role in recurrence.
Surgery may play a role in increasing the incidence of
osteitis as the percentage of osteitis in group B was 87%
and in group A was 30%. However, the increased recur-
rence rate in revision cases is not only related to the
increased incidence of osteitis, because if this is true then it
should be expected that recurrence rate would be similar in
each degree of bony change whether in primary or revision
cases. There should therefore be another factor which leads
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Eur Arch Otorhinolaryngol (2010) 267:721–724
to increased rate of recurrence with the increased number of
interventions in addition to the bony changes.
Conclusion
Osteitis in cases of chronic hypertrophic rhinosinusitis with
nasal polyps is most probably one factor among those caus-
ing recurrence of the disease.
Recurrent cases showed increased incidence of osteitis
leading to further recurrence. However, osteitis is not the
only cause of increase recurrence in revision cases as equal
degrees of osteitis in primary and recurrent cases resulted in
a signiWcant diVerence in the incidence of recurrence.
Nasal polyps are better treated medically if possible, and
if surgery is performed complete removal of bone within
the diseased area may be a better procedure than minimally
invasive sinus techniques.
ConXict of interest statement We have no conXict of interest nor
relationship with any organization concerning this work.
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