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Nasal Polyposis, Eosinophil Dominated Inflammation, and Allergy

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Nasal Polyposis, Eosinophil Dominated Inflammation, and Allergy Thorax 2000;55 (Suppl 2):S79–S83 S79 Nasal polyposis, eosinophil dominated Thorax: first published as 10.1136/thorax.55.suppl_2.S79 on 1 October 2000. Downloaded from inflammation, and allergy Niels Mygind, Ronald Dahl, Claus Bachert A polyp is an oedematous mucous membrane computed tomographic (CT) scanning). The which forms a pedunculating process with a overall prevalence rate is probably about slim or broad stalk or base. Nasal polyps origi- 2–4%5–7 which increases with age of the study nate in the upper part of the nose around the population. Nasal polyposis occurs with a high openings to the ethmoidal sinuses. The polyps frequency in groups of patients with specified extend into the nasal cavity from the middle airway diseases (table 1). meatus, resulting in nasal blockage and re- Although symptomatic nasal polyposis is stricted airflow to the olfactory region. The rare in the general population, much higher polyp stroma is highly oedematous with a vary- figures for the occurrence of isolated nasal ing density of inflammatory cells. Nasal polyps have been obtained from necropsy polyposis, consisting of recurrent, multiple studies. A thorough endoscopic examination of polyps, is part of an inflammatory reaction removed nasoethmoidal blocks and endoscopic involving the mucous membrane of the nose, examination of unselected necropsy specimens paranasal sinuses, and often the lower airways. have shown polyps in as many as 25–40% of The polyps are easily accessible for immuno- specimens.89 logical and histological studies and an increas- Allergic rhinitis has a high prevalence rate of ing number of publications have appeared in about 15–20%.10 Most cases in the western recent years, including two monographs.12 world are caused by pollen allergy, having a Nasal polyps have long been associated with seasonal occurrence. In striking contrast to rhinitis and asthma. However, the role of nasal polyposis, which is a disease of middle allergy in the aetiology and pathogenesis of aged people, allergic rhinitis occurs with its nasal polyps is a controversial issue. It has been highest prevalence in children and young peo- postulated that allergy is an aetiological factor ple and the clinical significance of the diseases for nasal polyposis. If this is so, then it can be decreases with age. expected that allergic patients will have polyps more often than a control population and that Occurrence of nasal polyps in allergic patients with polyps have an increased occur- patients rence of positive allergy testing. Caplin and coworkers11 examined 3000 con- In this paper we will describe the possible secutive atopic patients and found that only connection between nasal polyposis and al- 0.5% had polyps. Bunnag and coworkers12 http://thorax.bmj.com/ lergy, based on an analysis of (1) the occur- reported a 4.5% incidence of nasal polyps in rence of polyps and of allergy, (2) the anatomy 300 patients with allergic rhinitis. Settipane and histology of nasal polyps, (3) the inflam- and ChaVe13 found that only 0.1% of paediatric mation in nasal polyps, (4) the occurrence of patients attending an allergy clinic had nasal positive allergy tests in patients with polyps, (5) polyps. Thus, the prevalence of nasal polyps in the eVect of allergen exposure on nasal allergic patients is low, usually under 5%, symptoms in patients with polyps, and (6) the which is similar to that of the general response to treatment. population. on October 3, 2021 by guest. Protected copyright. Nasal polyposis with known aetiology While the aetiology of nasal polyposis is Anatomy and histology of nasal polyposis unknown in many patients, in a few cases it is SITE OF POLYP FORMATION Nasal endoscopic examination of a large well defined. Polyps occur in most patients with number of patients with nasal polyposis14 15 and allergic fungal sinusitis. In this disease the a detailed anatomical examination of necropsy tissue inflammation is typically eosinophil specimens89 have shown that nasal polyps are dominated.3 Department of Nasal polyps frequently occur in patients Respiratory Diseases, Table 1 Prevalence of nasal polyposis in diVerent University Hospital of with cystic fibrosis and in those with primary population subgroups Aarhus, DK-8000 ciliary dyskinesia (Kartagener’s syndrome). Aarhus, Denmark The polyps associated with these diseases are Aspirin intolerance 36–72% N Mygind Adult asthma 7% not characterised by tissue eosinophilia but by IgE mediated 5% R Dahl lymphocytes in the tissue and neutrophil Non-IgE mediated 13% leucocytes in the secretions.4 Chronic sinusitis in adults 2% Department of IgE mediated 1% Otorhinolaryngology, Non-IgE mediated 5% University Hospital, Occurrence of nasal polyps and of allergy Childhood asthma/sinusitis 0.1% Ghent, Belgium Cystic fibrosis The exact prevalence rate of nasal polyposis in Children 10% C Bachert the general population is not known because Adults 50% there have been few epidemiological studies Allergic fungal sinusitis 66–100% Correspondence to: Primary ciliary dyskinesia 40% Dr N Mygind and their results depend upon the diagnostic [email protected] methods used (history, rhinoscopy, endoscopy, Adapted from Settipane et al.1 www.thoraxjnl.com S80 Mygind, Dahl, Bachert mainly situated in the middle meatus and Electrolyte and water transport Thorax: first published as 10.1136/thorax.55.suppl_2.S79 on 1 October 2000. Downloaded from originate from the nasal mucous membrane of The basic elements of Na+ and Cl– movement the outlets (ostia, clefts, recesses) from the in the respiratory surface epithelium may be of paranasal sinuses. This area, so critical for relevance for the understanding of nasal polyp sinus pathology, is also referred to as “the ostio- formation. In the normal nasal mucosa there is meatal complex”. a net absorption of Na+ and very little Cl– It is remarkable that polyps develop exclu- secretion.23 24 In cystic fibrosis (CF), a disease sively from a few square centimetres of airway often associated with polyp formation, there is mucous membrane which often is universally both an absence of the cyclic AMP controlled inflamed. The reason for this is unknown and Cl– channel and abnormal regulation of the one can only speculate about the nature of a Na+ channel.23 24 Increased Na+ and decreased “localisation factor”. In the upper part of the Cl– secretion in CF result in dehydration of nose, including the middle meatus, the airway mucus because of the net movement of water lumen is a narrow slit with only a few milli- into the interstitial space. metres between opposing mucous membranes. Increased Na+ absorption may also be Stammberger14 15 has observed that polyp secondary to chronic inflammation, which is formation predominantly occurs in contact the hallmark of nasal polyposis. Recent find- areas between two opposing mucous mem- ings indicate that the absorption of Na+ is branes. It is known that stimulation of altered, not only in CF polyps but also in epithelial cells induces the generation and non-CF polyps.23 24 These results suggest that release of a series of pro-inflammatory cyto- factors leading to the development of nasal kines, and one can therefore hypothesise that polyposis include pathophysiological changes mechanical stimulation of the surface epithe- in the electrolyte and water transport in the lium in contact areas contributes, or even initi- surface epithelium. ates, the inflammatory reaction in the polyps. Other “localisation factors” may be related GOBLET CELLS to the anatomy of nerve endings, blood vessels, The histopathological picture shows great vari- and mucociliary flow in the thin mucous mem- ations, not only in type of epithelium but also in brane near the border between the nose and goblet cell density in diVerent locations on a paranasal sinuses. single polyp. The density of goblet cells is lower in anterior than in posterior polyps, and much lower than in the normal nasal mucosa.16 SURFACE EPITHELIUM Most of the polyp surface is covered by a ciliated pseudostratified epithelium, but a tran- INNERVATION sitional and squamous epithelium is also The sensory nerves and the autonomic vaso- found, especially in anterior polyps, influenced motor and secretory nerves invariably found in by the inhaled air currents.16 normal and abnormal nasal mucosa cannot be identified within the stroma of polyps, either in the vicinity of the epithelial basement mem- http://thorax.bmj.com/ Epithelial defects brane or within the walls of blood vessels or There is experimental evidence that cytotoxic glands. A few nerve fibres can be seen in the proteins from eosinophil leucocytes can dam- stalk of some polyps.25 age the respiratory epithelium and induce It is therefore assumed that denervation of 17 bronchial hyperreactivity in asthma. Epithe- nasal polyps causes a decrease in secretory lial defects have apparently also been described activity of the glands and induces an abnormal 18 in nasal polyps, but when polyps are removed vascular permeability, leading to an irreversible carefully and gentle methods are used for fixa- tissue oedema. Nasal polyps develop in areas tion, dehydration and cutting, the polyp where the lining of the nasal cavity joins that of on October 3, 2021 by guest. Protected copyright. epithelium appears well preserved without the sinuses, and these marginal zones contain 19 defects on scanning electron microscopy. thin nerve fascicles25 which may be more sensi- Although gross epithelial defects do not seem tive to damage from, for example, eosinophil to appear in carefully prepared polyp speci-
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