Smell Decline as a good Predictor of Sinonasal Polyposis Recurrence after Endoscopic Surgery

Original Article Iranian Journal of Otorhinolaryngology, Vol.28(2), Serial No.85, Mar 2016 Smell Decline as a good Predictor of Sinonasal Polyposis Recurrence after Endoscopic Surgery Mahdi Bakhshaee1,*Mohammad Reza Sharifian1, Amir Hossain Ghazizadeh2, Kianoosh Nahid1, Karim Jalaeian Samani3 Abstract Introduction: To evaluate the most sensitive symptom to predict early recurrence of nasal polyposis. Prospective longitudinal cohort study. Tertiary university referral center with accredited otorhinolaryngology residency programs. Materials and Methods: In this prospective study, we evaluated 62 patients with diffuse nasal polyposis. All patients underwent functional endoscopic sinus surgery. The author-devised questionnaire relating to the four major symptoms of chronic rhinosinusitis were answered by patients at the pre-operative visit and at 1, 3, 6, 12, and 24 months after surgery. Patients were followed up with serial endoscopic examinations, and a computed tomography (CT) scan was performed if indicated. Results: All 62 patients (37 male, 25 female) completed the study. The mean age was 41.24 ± 12.47 years. All major symptoms showed significant improvement after surgery (P=0.000); however, the severity of symptoms gradually increased in patients with a recurrence of polyposis, but at different points in time (P= 0.008). Sense of smell was the first symptom to deteriorate in patients with relapse (mean, 6 months) followed by nasal secretion (12 months), obstruction and pain (24 months). Patients with asthma, Samter’s triad, allergic fungal rhinosinusitis (AFRS) and allergic rhinitis showed symptoms of recurrence sooner than other patients (P<0.05). Conclusion: The most sensitive symptom for the early detection of recurrence of nasal polyposis is a decrease in the sense of smell. Nasal obstruction and facial pain were observed in the late stage of relapse when frank polyposis formation was established. Keywords: Asthma, Allergic rhinitis, Endoscopic sinus surgery, Nasal secretion, Nasal obstruction, Recurrence, Sinonasal polyposis, Smell. Received date: 13 Jun 2015 Accepted date: 13 Aug 2015 1 Sinus and Surgical Endoscopic Research Center, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. 2 Department of Otorhinolaryngology Head and Neck Surgery, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3 Department of Otorhinolaryngology Head and Neck Surgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. * Corresponding Author: Department of Otorhinolaryngology, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Tel/Fax: +98 513 859 40 82, E-mail: 125 Bakhshaee M, et al Introduction Sinonasal polyposis (SNP) is a chronic inflammatory disorder of the nasal cavity and paranasal sinus mucosal membranes that typically affects patients bilaterally in the form of a benign edematous mass known as a polyps, extending from the paranasal sinuses towards the nasal cavity (1). The etiology of SNP remains uncertain and the precise prevalence is not well known; however prevalence has been reported through medical records as varying between 0.2–5.6% (2-7). An increase in prevalence of SNP with patient age and male gender has been observed (8). Factors or associated conditions include smoking, allergy, asthma, fungal sensitivity, nonsteroidal antiinflammatory drug (NSAID) intolerance and genetic factors (8,9), although the relationship between SNP and allergy and the genetic-hereditary factors has yet to be clarified (8). No association between SNP and smoking has yet been demonstrated. Diagnosis of SNP is based on the presence of major symptoms (nasal obstruction, altered smell, anterior and/or posterior rhinorrhea, and pain or facial pressure) and minor symptoms (sore throat, dysphonia, cough, malaise, fever, dental pain, halitosis or pain/discomfort in the ears); then polyposis is confirmed through endoscopic evaluation and imaging (10). Management of SNP requires adequate medical treatment that may be supplemented with surgery. Corticosteroids are the first-line treatment for chronic rhinosinusitis (CRS) with polyposis, according to the most recent European and North American consensus documents (11–13). The impact of surgical treatment is difficult to establish with precision, since surgery is performed on those patients who are intractable to medical management, while recent endoscopic surgery is associated with better results than conventional simple polypectomies (8,14). Approximately 10% of all patients undergoing endoscopic surgery show a poor response to surgical treatment and concomitant medical therapy (8). Furthermore, recurrence of polyps is a major concern, and can be classified according to the type of surgery, definition of recurrence, follow-up duration, disease extension, and background disorders (15-21). The purpose of this study was to assess the short-time outcome of endoscopic sinus surgery based on subjective clinical presentation of the four main symptoms of SNP including nasal obstruction, rhinorrhea, facial pain and olfactory disturbance over 2 years’ follow-up among patients with highgrade sinonasal polyposis. Materials and Methods This prospective longitudinal cohort study included CRS patients followed up for at least 2 years after endoscopic sinus surgery. Between April 2008 and February 2011, 148 adult CRS patients with and without polyposis were followed from private practice and the institution clinic. Diagnosis of CRS with nasal polyps was based on the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2012 criteria (11), as the indication for surgery. Patients with low-grade polyposis (Grade 1,2 according to the Lildholdt classification system), no chronic polypoid sinusitis, or who did not complete 2-year follow-up were excluded from the study. Sixty-two of the 148 original patients were finally included in the study. CT scan as the imaging technique was performed in all patients preoperatively and during follow-up, according to indication. The sensitivity and specificity of CT has been evaluated using the LundMackay scoring system (22). Nasal endoscopic evaluation of SNP was performed according to the Lildholdt classification (23), and only those with advanced grade (Grade II or III) were selected. Patients were asked to complete the questionnaire relating to the four main symptoms of severity prior to surgery 126 Iranian Journal of Otorhinolaryngology, Vol.28(2), Serial No.85, Mar 2016 Smell Decline as a good Predictor of Sinonasal Polyposis Recurrence (preop) and 1,3,6,12 and 24 months after surgery (PO1, PO3, PO6, PO12, and PO24 m; respectively) (Table.1). Table 1: Symptoms scoring system. Score 1 Score 2 Score 3 Nasal Obstruction Absent Occasionally Partial Always Partial Facial Pain Absent Occasionally Vague Always Vague Rhinorrhea Absent Olfactory Disturbance A (...truncated)