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Abstract
الملخص Nasal polyposis is an inflammatory condition of unknown etiology. It results from chronic inflammation of the nasal and sinus mucous membranes which causes a reactive hyperplasia which results in the formation of polyps. The precise mechanism of polyp formation is incompletely understood. Despite the great progress that had been made in the rhinology, it can be stated that neither the causal nor the formal pathogenesis of nasal polyposis has been clarified (Larsen et al., 1992).
Most of the patients who are presenting with nasal polypi, whether unilateral or bilateral turn out to have an underlying fungal sinusitis (Handoussa, 2002). Allergic fungal rhinosinusitis is the most common form of fungal sinus disease and nasal polyposis is one of its five criteria of diagnosis (Lane and Kennedy, 2003).
Overall, the mechanisms behind polyp formation are believed to be multifactorial. Recent evidence suggests an important role for proinflammatory cytokines, chimokines, and chemotactic factors in the pathogenesis of inflammatory polyps (Lane and Kennedy, 2003), along a variety of environmental, genetic, and biochemical factors that have previously been proposed (Shin et al., 2000).
The study included 50 patients presented with nasal polyposis and admitted for surgery. The patients were divided into 2 groups (A&B) each had 25 patients. Convenient post operative medical treatment was given for the 2 groups and antifungal agents were added only to group A. For control there are additional 2 groups each include 10 patients; group C with healthy nasal mucosa and group D with chronic sinusitis but without polyposis.
Skin sensitivity prick test for fungal and non fungal antigens was done for all the patients. it was positive only in 16 patients (32 %), 6 patients were positive to fungal antigens (12 %), 5 of them were corresponding to the results of fungal culture (10 % ), 10 patients were positive to non fungal antigens (20%).
Pre operative CT scanning was done for all the patients to detect the extension of the polyps, the condition of the sinuses, and the presence of any orbital and cranial extension or complications. Scoring for the extent of the sickness was calculated for every patient depending on the CT scanning (El-Begermy scoring). The total score would be 25 points for the two sides (12.5 for each side).
Surgical findings were reported for the degree, the extent and the site of origin of the nasal polypi, associated sinusitis and any bony rarefaction. Also the presence of concha bullosa, mycetoma, mud or allergic mucin was also reported.
Fungal culture of the removed polypoidal tissue and also any mud or allergic mucin, on sabaroud agar medium to detect the presence of fungi and its type for all the patients had been done. The result was positive in 42 patients (84 %). Similar fungal cultures were done by mucosal biopsy from the inferior turbinate of the 2 control groups. The result was 3 positive in control group C (30 %) and 6 positive in control group D (60 %). By comparison there is a marked difference the studied patients and the 2 control groups.
Surgical biopsies were taken from the removed polypoid tissues for all the patients for Histopathological studies. Ten cases were diagnosed as AFS (20 %) according to the criteria.
Post operative follow up after a period between 6-18 months (mean 11.3 months) to detect any recurrence of polyps using clinical examination, endoscopy and CT scanning for all the patients. The percent of determined recurrent polyposis in the post operative follow up was calculated for both groups and the results were compared. The results were 16.7 % in group A (antifungal agents were added) and 20 % in group B. Statistically no significant difference was found between the two groups by chi square (p= 0.8). But in concern of the cases which was diagnosed as AFS the recurrence rate was 20 % in group A and 33.3 % in group B, so the use of antifungal agents may be benefit only in cases of fungal sinusitis.
The high percent of positive fungal growth among the studied cases of nasal polyposis supports the belief that there is a role of fungi in the pathogeneses of nasal polyposis, but the growth is more probably to be a result of the sickness rather than a cause. Also the two probability may be true and vicious circle can occur and exaggerate the condition.
By analyzing the results of the current study, in addition to the results of other studies in the literature, a new theory can be suggested for the cause-effect relationship between the nasal polyposis, chronic rhinosinusitis and intranasal fungal growth.
There are 3 viscous circles:
1. Between the intra nasal fungal growth and chronic rhinosinusitis.
2. Between the chronic rhinosinusitis and nasal polyposis.
3. Between the nasal polyposis and intra nasal fungal growth.
This suggestive new theory explains the recurrence of nasal polyposis in some cases; because the successful treatment has to stop the 3 vicious circles by complete removal of the polyps and improving the nasal and sinus drainage to have a healthy sinuses without stasis which causes fungal proliferation. This theory explains why the antifungal agents were ineffective in the treatment.