Chronic Rhinosinusitis Patient with Nasal Polyp Characteristics at Otorhinolaryngology-Head and Neck Surgery Outpatient Clinic, Dr

Original Article

Chronic Rhinosinusitis Patient with Nasal Polyp Characteristics at Otorhinolaryngology-Head and Neck Surgery Outpatient Clinic, Dr. Hasan Sadikin General Hospital, Bandung Dina Riana, Arif Dermawan, Wijana, Ongka Muhammad Saifuddin

Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital

Abstract Objective: To evaluate chronic rhinosinusitis (CRS) with nasal polyp (NP) characteristics in patients with routine visits to the Otolaryngology-Head and Neck Surgery outpatient clinic of Dr. Hasan Sadikin General Hospital, Bandung.

Methods: This descriptive retrospective cross-sectional study was conducted at the Rhinology-Allergy Outpatient Clinic, Departement of Otolaryngology- Head and Neck Surgery, Dr. Hasan Sadikin General Hospital, Bandung, in the period of January 2014 to December 2014. Data were obtained from medical records and the sampling method used was total sampling. A total of 100 CRS with NP patients were evaluated. Nasal endoscopy examinations were

performed. Patients were classified based on age into 10–20 years, 21–31 years,Results: 32–42 Chronic years, rhinosinusitis 43–53 years, andwith >54 NP yearsincidences groups. were mostly found in male patients compared to females. There were several CRS cases with NP risk factors, including smoking and allergy.

Conclusions: In the study, CRS with NP patients may possibly have one or Received: more risk factors. Smoking is the major risk factor from CRS with NP after January 26, 2016 allergy.

Revised: Nasal polyp, nasal endoscopy, rhinosinusitis, risk factor [ June 10, 2016 Keywords: IJIHS. 2016;4(2):62–6] Accepted: August 3, 2016 pISSN: 2302-1381; eISSN: 2338-4506; http://dx.doi.org/10.15850/ijihs.v4n2.834

Introduction Chronic rhinosinusitis (CRS) with nasal polyp andNasal paranasal polyps sinus are mucosal defined membrane as a chronic which inflammatoryis accompanied disorder by edema found symptom in nasal as mucosa well as paranasal sinus mucosal membrane of nasal 1,2 (NP)mucosa is which an inflamatory symptoms disorder lasted more that than attacks 12 into the nasal cavity. Chronic NP causes weeks.1,2 Chronic rhinosinusitis is a common nasalinflammation congestion, of the mucous, nasal mucosaolfactory that disorder, swells heterogenous multifactorial disorder affecting headache, and decreased quality of life. children and adults.3 There are only a small Nasal polyps affect around four percents of number of studies that investigated CRS the population and are known to be associated epidemiological studies of CRS, the symptom- and aspirin sensitivity. The study also stated inflammations.based diagnosis In primaryis common, care asyet well limited, as in withthat allergy,NP presents asthma, with infection,5,6 nasal cystic obstruction, fibrosis, because endoscopic and radiological signs are anosmia, rhinorrhoea, post nasal drip, as well not considered.4 as, less commonly, facial pain. Recently, the terminology of rhinosinusitis Correspondence: is prefereably used than sinusitis. A study Dina Riana, Department of Otorhinolaryngology-Head stated that sinusitis begins with rhinitis and and Neck Surgery, Faculty of Medicine, Universitas 7 Padjadjaran, Dr. Hasan Sadikin General Hospital Jl. Pasteur No. 38, Bandung, Indonesia Chronic rhinosinusitis with NP becomes a e-mail: [email protected] rarelydisease occurs with increasingwithout nasal incidences inflammation. as well as

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:62–6 Dina Riana, Arif Dermawan, et al. increasing prevalences.2,8,9 In the United States, Methods approximately 31 million people suffer from CRS.2,8 CRS that affects adults and children is Descriptive and prospective methods were usually associated with physical and emotional used in this study. The study was conducted morbidity which causes economic impacts for at the Otolaryngology-Head and Neck Surgery some people. clinic, Dr. Hasan Sadikin General Hospital, Epidemiology data in Indonesia regarding Bandung, in the period of January to December to CRS prevalences have not been clearly 2014. The subjects of the study were 100 studied. According to one study, Indonesian medical records of CRS with NP patients. Total Ministry of Health, in 2003, published a report sampling was applied. Ethical approval for this th study was obtained from the Health Research Ethic Commitee of Dr. Hasan Sadikin General 102,817that nasal patients diseases were and sinusitisrecorded were as suffering the 25 Hospital. offrom 50 NPserious in several diseases hospitals. in which10 In approximately addition, the The family history is primarily focused on study that was conducted at the Departement asthma, aspirin sensitivity, nasal polyposis of Otolaryngology-Head and Neck Surgery and atopy.7 In addition, The patients were of Cipto Mangunkusumo General Hospital asked several questions related to the habitual Jakarta has also described that NP generally activities, including smoking habit. The Lund-Mackay system of staging was A similar study on CRS was also performed used in this study to classify NP into 4 stages: affectsin another patients ares of aged Indonesia 30–50 inyears. 2008. A hundred stage 0, no polyp; stage 1, polyps in meatus media do not penetrate the nasal cavity when rhinitis comorbidity of rhinosinusitis were it is observed through anterior rhinoscopy andrecorded fourty at twothe Rhinology-Allergy (75%) patients with Outpatient allergic examination but occurrence can be diagnosed Clinic, Departement of Otolaryngology-Head through nasoendoscopy examination; stage and Neck Surgery, Dr. Hasan Sadikin General 2, polyps come out from the meatus media Hospital, Bandung.11 with swelling in the nasal cavity but does The developments of integrated studies, not obstruct the nasal cavity; stage 3, polyps that include pathophysiology, performance obstruct the nasal cavity.12 The Lund-Mackay diagnosis, and disorder test for sinusitis system of staging is considered a gold standard have been concisely described in two expert and mostly used in several previous studies. recommendations from the United States and European. The United States experts, through a recommendation1,5,7,8 of Rinosinusitis Table 1 Subject Characteristics based on Task Force (RSTF) in 1996 have recommended Sex, Age, and Polyp Stage that rhinosinusitis should be diagnosed based on the clinical symptoms, symptom durations, Subject Characteristics Total physical examination, nasal endoscopy, as well Sex as based on the computerized tomography Males (CT) scan. The European experts, through the Females recommendation of the European Position 56 (56%) Paper on Rinosinusitis and Nasal Polyp (EPOS), Age (years) has described the differences between NP and 44 (44%) rinosinusitis that can be diagnosed through nasoendoscopy investigation. Several studies on CRS were conducted 10–20 8 (8%) but the major causal factors have not been 21–31 25 (25%) 32–42 38 (38%) that there are several risk factors for CRS with NP i.e. sex, age, ethnic, occupation, asthma, 43–53 23 (23%) clearly identified. Previous studies reported Polyp stage allergic rhinitis, aspirin sensitivity, food >54 6 (6%) allergy, smoking habit, genetic/family history, Stage 0 fungal or virus. Stage 1 This study investigated3–8 CRS with NP risk 0 (0%) Stage 2 factors in patients who routinely visited the 15 (15%) Otolaryngology-Head and Neck Surgery clinic, Stage 3 Dr. Hasan Sadikin General Hospital, Bandung 40 (40%) based on medical history, physical test, and 45 (45%) nasoendoscopy examination.

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Table 2 Patient Characteristics based on There were several risk factors found in Chronic Rhinosinusitis with Nasal Polyp Risk Factors (Table 2). The risk factors found in female Total male patients, including smoking 23 (41.1%), Subject allergy 20 (35.7%), and asthma 14 (25%) Characteristics Male Female Patients Patients patients were allergy 18 (40.9%), asthma 15 Smoking habit (34.1%), and smoking habit 12 (27.3%). Iatrogenic Discussion 23 (41.1%) 12 (27.3%) Allergy 1 (1.8%) 0 (0%) In general population, the prevalence of NP in Asthma 20 (35.7%) 18 (40.9%) NP in children is lower than adults, especially Aspirin sensitivity 14 (25 %) 15 (34.1%) adults is around 1–4%.3–6 The prevalence of is higher along with the increasing age until Genetic 0 (0%) 2 (4.5%) in cystic fibrosis. However, the frequency of NP Fungus Chronic rhinosinusitis is commonly found 0 (0%) 2 (4.5%) >50 years. 1 (1.8%) 2 (4.5%) study shows a similar result to several studies inwhich adults stated aged that 32–42 CRS years occurs old in(Table people 1). agedThis The clinical diagnosis of CRS was made 8,13,14 using the guideline by the RSTF of the However, a study has American Academy of Otolaryngology, Head reported different results that CRS occurs in and Neck Surgery (AAO-HNS).8 The major 35–42 years old. criteria included asthma, allergic rhinitis, 4,9 aspirin sensitivity, allergy, smoking habit, >19years years old. old patients while another study medical history, bacteria or virus. discoveredMost CRS CRS with occurs NP inpatients people whoaged visited15–24 3–8 the Otolaryngology-Head and Neck Surgery clinic, Dr. Hasan Sadikin General Hospital, Results employees with outdoor activities who were A hundred patients diagnosed with CRS visited Bandungexposed thein 2014air pollution, were 32–42 such yearsas smoke old with and the Otolaryngology-Head and Neck Surgery vehicle emission comprised the majority of outpatient clinic of Dr. Hasan Sadikin General the patients based on their occupation. This condition leads to the risk of virus and fungal with a male to female ratio of 1.2:1. The age infection. Hospital. There were 56 males and 44 females, The study showed that the number of male withThe NP CRS affects with anyone NP occurs in any in age, males as well (56%) as rangedpatients from was 10 higher years tothan >54 females years. (Table1). 9 The data revealed that the majority of patients and females (44%). Chronic In rhinosinusitisaddition, the study also reported that NP affected men and womenin adults with aged a ratio 30–60 of 1.42:1. years. CRS with NP was rarely found in patients Chronic rhinosinusitis and NP is considered were 32–42 years old (38%) followed by a disease. The lack of data and the presence patients who were 21–31 years old(25%). Lund-Mackay system of staging, the majority of some contradictions create a challenge for conducting a study to differentiate CRS and NP. whose age was >54 years (6%). Based on the However, several studies also discovered that of patients were in stage 3 (45%) and stage 2 (40%). Table 3 Total of Chronic Rhinosinusitis with Nasal Polyp Risk Factors Total Characteristics Total Patients (n=100) Male Patients Female Patients One risk factor Two risk factors 90 (90%) 51 (91%) 39 (89 %) More than two risk factors 9 (9%) 5 ( 9%) 4 (9%) 1 (1%) 0 (0%) 1 (2%)

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NP is regarded as a subchronic rhinosinusitis disorder. A study reported that the upper airway There1,6–9 are several studies on rhinosinusitis prevalence in NP patients is 10–64%. with NP conducted for any purpose. The inhaled toxins and pathogens including studies revealed that rhinosinusitis with10–13 NP functionsenvironmental as the pollutants first line like of defensetobacco againstsmoke and microbes that can cause potential harm Th1/Th2 polarization, remodeling process and to the host.16 The study also described that symptomsedema shaping caused or immune by the inflammatoryproduct. Therefore, cells, the sinonasal epithelial cells utilize the mucociliary clearance (MCC) which relies on results that only a small number of studies an airway surface liquid (ASL) barrier and theseexamined investigations the risk factor do of not rhinosinusitis carry sufficient with proper ciliary beating to effectively transport NP. mucus and clear potentially toxic irritants. Most patients in this study were on stage 3. In this study, it was found that number of This result is similar to the result of a previous male patients is higher than female patients study that reported the majority of patients for CRS with NP. The majority of patients are subjects (n=43). It was also stated that the risk factor, such as smoking habit in males and werehigher onnasal stage polyp 15 3 whichstage led was to complications, 79.1% of the betweenallergy in 32–42females. years old and have at least a such as chronic obstructive lung disease This study has several limitations, including (COPD). The higher nasal polyp stage is caused the sample size. Further studies on CRS may by the patient unawereness of the CRS with NP need to collect data from several hospitals symptom. to be able to achieve the appropriate sample The most frequently found CRS with NP size with adequate power. Knowledge on risk factors are smoking habit and allergy for CRS characteristics is important for deciding males and females, respectively. The allergy treatment for patients.

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