Original Article 35

A COMPARATIVE STUDY ON ASSOCIATION OF ALLERGY BETWEEN ETHMOIDAL AND ANTROCHOANAL POLYPS

* Lt Col AKM Asaduzzaman, MBBS, DLO, MCPS
Lt Col Md Rabiul Alam, MBBS, MCPS, FCPS Lt Col Mohammed Mosleh Uddin, MBBS, DCP, MCPS, FCPS Lt Col Md Ismail Chowdhury, MBBS, FCPS, MD Brig Gen Md Abdul Mannan, MBBS, FCPS

ABSTRACT This observational study was conducted on 30 cases of nasal polyps treated surgically in Combined Military Hospital (CMH) Chittagong. The study was carried out between the periods of January 2007 to December 2009 to compare the association of allergy between the patients of ethmoidal and antrochoanal polyps. Ethmoidal and antrochoanal polyps are the common varieties. According to literatures, allergy, one of the aetiology of nasal polyp, is documented as more associated with ethmoidal polyp than with antrochoanal polyp. Clinical history, biochemical and cytological investigations were adopted to detect the association of allergy. Ten out of 17 cases (58.82%) were distinguished as having allergy in ethmoidal polyp group and 6 out of 13 (46.15%) were identified among the patients of antrochoanal polyps. The variation was not statistically significant (p>0.05). So, it is concluded that antrochoanal polyps do not differ in their presentation specifically in association of allergy from ethmoidal polyps, except that they mainly cause unilateral nasal obstruction. There was no case found with aspirin sensitivity. INTRODUCTION Nasal polyps are hypertrophied oedematous mucosa and submucosa of the nose and paranasal sinuses resulting in the formation of pedunculated mass. It is composed of loose fibro-oedematous tissue and the surface is lined by ciliated columnar epithelium. Nasal polyps are classified into three categories: (1) Simple mucous polyps, (2) Fungal polyps and (3) Neoplastic polyps. Simple mucous polyps are the commonest variety and ordinarily by nasal polyps it is meant simple mucous polyps. These are of two types: (a) Ethmoidal polyps and (b) Antrochoanal polyps. Ethmoidal polyps are multiple, usually bilateral and come out from ethmoid cells. The patients present with bilateral persistent nasal obstruction, nasal intonation, headache, hyposmia or anosmia and associated features of allergy, sneezing and rhinorrhoea.1 Antrochoanal polyp, or the solitary nasal polyp, unilateral, arising from the maxillary antrum, was first described by Killian in 1906. Not much is known about the aetiology of antrochoanal polyps or diseases associated with it. Infection and chronic obstruction of the antral ostia have been postulated.2 Most of the past and contemporary researches have been concerned with ethmoidal polyps and in the elucidation of their aetiopathology. Allergy and its counterpart, non allergic rhinitis have long been recognised to be associated with only ethmoidal polyps.3,4 Few studies have attempted to identify the association between antrochoanal polyps and allergy. This study attempts to compare the association of allergy between ethmoidal and antrochoanal polyps.

* Principal Author : Graded Specialist in Otolaryngology, Combined Military Hospital, Chittagong Cantonment.

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A Comparative Study on Association of Allergy Between Ethmoidal and Antrochoanal Polyps

MATERIALS AND METHODS This observational study was carried out on a total of 30 cases with nasal polyps who received operative treatment in CMH Chittagong during the period of January 2007 to December 2009 to compare the association of allergy between the patients of ethmoidal and antrochoanal polyps. The patients were from both sexes with the age range of 15-67 years. All the cases were screened with the complaints, clinical examinations and diagnosed as cases of either ethmoidal or antrochoanal polyps and were confirmed by radiology/endoscopy. Seventeen patients were cases of ethmoidal polyps (Group-A) and 13 were diagnosed as cases of antrochoanal polyps (Group-B). All the cases were evaluated for the presence of allergy by detailed questionnaire administered to the patient enquiring about relevant aspects of the history like allergen exposure, symptoms and past history of allergy/ asthma/aspirin intolerance and family history of allergy. Serum total IgE was estimated from the peripheral venous blood. The fluid contained in the polyp was aspirated and sent for IgE level. Nasal exfoliative cytology smears were studied for allergy. Cotton wool swabs were used to scrape secretions from the middle of the inferior turbinate, separate swab was used for each nostril and then the fluid was smeared on a clean glass slide by gentle rotation, so that the material became visible by naked eye after smearing. The smears from each nostril, a total of 6 slides, were marked and numbered and fixed in 100% methanol. Then these were stained with Hematoxylin and Eosin, Papanicoloau and Toulidine blue. The cytogram was then counted for the number of inflammatory cells and the numbers of different types of cells in 10 consecutive high power fields. The findings were compared between the two groups of patients: Group-A: Ethmoidal polyps and GroupB: Antrochoanal polyps. The results were analysed by the Z test for variance and the Chisquare test. Allergy was diagnosed by the following criteria5:
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Allergy Increased eosinophils (1-4+)* Increased basophil /mast cells (1-4+) Non-allergic rhinitis with eosinophilia Increased eosinophils (1-4+)* Increased basophil /mast cells (1-4+) Infection- increased neutrophil (2-4+)* * Mean of cell per 10 high power fields * A normal nasal smear does not contain eosinophils or basophilis and has only ciliated epithelial and goblet cells. RESULTS Thirty cases with nasal polyps were included in this study. Demographic status of two groups of patients is shown in Table-I. Among 17 cases of ethmoidal polyp mean age was 34.3 and out of 13 patients of antrochoanal polyp the mean age was 32.7 years. No significant demographical variations were found among the patients of both the groups. TABLE-I: Distribution of demography of the patients in two groups.
Group Type of polyps Ethmoidal polyp Total number Age in years Male: of (mean/range) Female patients (n) ratio 17 13 34.3 (23-65) 32.7 (15-67) 8:5 10 : 7 P-value

Group-A

>0.05

Group-B Antrochoanal polyp

The complaints, relevant history and clinical findings are summarised in Figure-1. The comparisons of symptoms related with allergy in the patients of both groups are shown in TableII. The percentages of incidences of history of allergy, asthma, sneezing, runny nose and positive family history among the population in both the groups had no statistical significance. Only preponderance of unilateral nasal obstruction was found statistically significant (p<0.001) and it was high in Group-B (92.30%) than that of Group-A (17.64%). In all other respects, antrochoanal polyps were similar to ethmoidal polyps, there being no statistical significance in the distribution of symptoms, between the two groups.
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20
No of patients

15 10 5 0
ory is t ly h y mi e rg Fa all in n pir sio As clu lo nta De TI rR e rs we Lo o rd dis ep Sle dia me i tis Ot it is us a Sin thm As H/O erg y ure All os O xp H/ ne rge Alle g z in ee k Sn lo c g lb h in sa ck Itc na blo r al al a te as Bil ln e ra e ilat s Un no in g nn Ru

Group-A: Ethmoidal polyps

Group-B: Antrochoanal polyps

Fig-1 : Clinical features among the patients of both groups. TABLE-II : Incidence of salient features of allergy among the patients.
Group H/O Allergy (%) H/O Asthma Sneezing (%) (%) Running nose (%) Unilateral Family Statistical nasal block history significance (%)** (%)

Correlation between different allergic parameters have been summarised in Table-IV. When the elevated levels of both serum IgE and polyp IgE were compared, 52.94% were found allergic in the cases of ethmoidal polyps and 53.84% in patients of antrochoanal polyps. Again, when the combination of IgE levels and nasal smear cytology was analysed, 70.58% of patient with ethmoidal polyps showed allergy compared to 69.23% of patient with antrochoanal polyps. However, the differences between the two groups were not statistically significant for any single or in combination of parameters. When any 2 criteria of the 3 parameters (nasal smear, serum IgE and polyp fluid IgE) were positive for allergy, we found allergy in 58.82% of the cases (10/17) with ethmoidal polyps and 46.15% (6/13) in patients of antrochoanal polyps. TABLE-IV : Correlation between the different cytological and biochemical parameters of allergy.
Parameters Allergic nasal smear Elevated polyp fluid IgE Elevated serum IgE IgE & nasal smears positive for Allergy Elevated both serum and polyp IgE Any two criteria positive
Group-A Ethmoidal polyps Group-B Antrochoanal P-values polyps

Group-A 41.17 Group-B 38.46

29.41 23.07

64.70 69.23

94.11 84.61

17.64 92.30

47.05 46.15

ns*

Note: ns* = not significant (p>0.05); Chi-square test was done. ** All the symptoms in both the groups were found ns except the unilateral nasal block which revealed statistically significant (p<0.001)

Total Percentage Total Percentage

The laboratory findings of the cases are summarised in Table-III. The mean serum IgE level was 2138 IU ml-1 in Group-A and 1803 IU ml-1 in Group-B. Again, the mean polyp IgE levels were 1157 IU ml-1 and 966 IU ml -1 respectively and were revealed statistically insignificant between the groups. The findings of nasal smear cytology study are also shown in Table-III under the varieties of normal, inflammatory, allergic and non-allergic rhinitis with eosinophilia syndrome (NARES). There was no statistical significance among the percentages of different parameters between the cases of two groups. TABLE-III : Findings of laboratory investigations in cases.
Group Group-A Group-B Serum IgE IU ml -1 (mean) 2138 1803 Polyp IgE IU ml -1 (mean) 1157 966 Statistical Normal Inflammatory Allergic NARES Significance 20.54 23.07 48.04 30.76 58.82 46.15 6.04 7.69 Nasal smear cytology (%)

10 8 11 12 9 10

58.82 47.05 64.7 70.58 52.94 58.82

5 7 8 9 7 6

38.46 53.84 61.53 >0.05 69.23 53.84 46.15

Note: Chi-square test was done

TABLE-V : Previous studies on antrochoanal polyp and allergy

Year of Study 1980 1993 2001 2009 Author Schramm Cook 2 Kamath16 Our study
14

No of cases Percentage of allergy 40 33 24 13 7.5 6.7 52.38 46.15

ns p>0.05

Note : ns = not significant; paired t test was done. NARES : Non-allergic rhinitis with eosinophilia syndrome

DISCUSSION The incidence of positive history of allergy as reported in different studies is more in the patients of ethmoidal polyps than that of antrochoanal polyps.3,4 But in the present study, when we compared the cases of antrochoanal with ethmoidal polyps it was found that the variations are statistically insignificant. With the exception
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of predominance of unilateral nasal obstruction in antrochoanal polyps, there was no difference in their history, symptoms and signs from ethmoidal polyps. However, this is borne out by the fact that the difference in symptom distribution between the two groups was not statistically significant. Moreover, notable exception in this study was the absence of aspirin sensitivity in both the groups. This is contrary to previously reported studies.6 In this study, three parameters were used to assess allergy: nasal smear cytology, serum total IgE and polyp fluid IgE. No doubt the best investigation for allergy is the skin test, but its application was limited by cost and patient compliance. The cytological criterions of allergy were well documented by Meltzer et al.5 Nasal smear is an investigation which is hardly used by otolaryngologists. As the interpretation of significant level of eosinophilia is arbitrary,7 the criteria used in this study were the semiquantitative assessment, suggested by Meltzer et al.5 The limitation of the nasal smear in diagnosing allergic rhinitis lies in its variability. Eosinophil percentage can vary according to the phases of allergy, steroid therapy and concurrent infection. The maximum chance for a positive result is when the patient is manifesting an allergic response.8 The best use of the nasal smear is in diagnosing non-allergic rhinitis, than allergic rhinitis. The Non-Allergic Rhinitis with Eosinophilia Syndrome (NARES) can be diagnosed only with the help of cytology. In cases where immunology/skin tests are negative, it is likely to classify the case as vasomotor/other nonallergic rhinitis unless cytology is performed. NARES is commonly associated with nasal polyps and intrinsic asthma. It is a very steroid responsive condition. 9 Only one case each of NARES was detected in these study groups. Total IgE reflects the overall atopic status of the individual, the levels can vary widely among atopics and normal people10 although the mean
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level is higher in patients with atopy.11 The average levels of serum total IgE in the present study was high, 2138 IU ml-1 in cases of ethmoidal polyp and 1803 IU ml-1 in the antrochoanal polyp group. These levels were much higher than those found in previous studies.3, 6, 11 Previous studies11, 12 have already documented that local production of IgE by polyps, is reflective of atopy in the nose, sometimes even in the absence of systemic manifestations. 13 The elevated levels of polyp IgE estimated in this study was 8/17 (47.05%) in ethmoidal polyp group and 7/13 (53.84%) in antrochoanal polyps. Therefore, antrochoanal polyps are more associated with local allergy. When at least two parameters were positive among the cases, the study shows 58.82% allergy in ethmoidal polyp group and 46.15% in cases of antrochoanal polyp; the difference was not statistically significant. Moreover, the association of allergy with antrochoanal polyp was compared with that of previous studies shown in Table-V. It is evident that there were definite relationship between both types of polyps and allergy. The widely accepted definitive surgical treatment for antrochoanal polyps is CaldwellLuc operation. It has the implication of unequal facial development when performed in paediatric population, the age group in which this polyp commonly manifests. 14 With limited access to endoscopic sinus surgery in our country, the finding of association of allergy with antrochoanal polyps carries significance regarding treatment modalities. Seshadri et al 15 described the cases of antrochoanal polyps, those were completely treated by only steroid nasal spray. So, the authors opined that the relation between antrochoanal polyps and allergy needs to be further evaluated, so that a medical treatment for the antrochoanal polyp (as has been well documented for ethmoidal polyps) can be recommended in future. A safe and effective medical method of treatment can be recommended for the young and for poor risk cases like those with cystic fibrosis without the
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risk of injuring facial development or recurrence associated with conventional avulsion polypectomy. CONCLUSION Antrochoanal polyps are regarded as a separate entity, conventionally. This study showed that antrochoanal polyps do not differ in their presentation from ethmoidal polyps, except that they mainly cause unilateral nasal obstruction.

Previously infection was thought to be the aetiology. On investigation, we found that they were significantly associated with an allergic diathesis. The investigations to detect allergic status in the absence of skin test were total IgE, polyp fluid IgE and nasal smear. Nasal smears were also useful to differentiate allergic from nonallergic rhinitis. It may be possible to treat allergic antrochoanal polyps safely by the use of steroids only.

REFERENCES 1. Kumar SD. Fundamentals of Ear, Nose & Throat and Head-neck Surgery. Kolkata: NBS; 2008. p. 184-89. 2. Cook PR, Davis WE, McDonald RM. Antrochoanal Polyposis: A Review of 33 cases. ENT J. 1993: 72; 401-10. 3. Busuttil A, Chandra B. Are Nasal Polyps Allergic? J of Laryngol & Otol. 1983: 101; 93-98. 4. Chaplin J, Haynes TT, Spahn J. Are Nasal polyps an Allergic phenomenon? Annals of Allergy 1971; 29: 631-34. 5. Meltzer E, Orgel HA. Jalowayski AA. Cytology. In: Mygind N, Naclerio RM, editors. Allergic and Non-Allergic Rhinitis. Philadelphia: WB Saunders; 1978. p. 66-79. 6. Choo MJ, Kim JW, Lee KW. Endoscopic sinus surgery for treatment of antrochoanal polyp. Kor J of Rhinol 1996; 3: 54-57. 7. Mullarkey MF, Hill JS, Webb DR. Allergic and Non-Allergic Rhinitis, their characterization with attention to the meaning of nasal eosinophilia. J of Allergy and Clinical Immunol 1980; 65: 12226. 8. Siegel R, Sheldon C. Rhinitis in Children. In: Mygind N, Naclerio RM, editors. Allergic and NonAllergic Rhinitis. Philadelphia: WB Saunders; 1978. p. 174-79. 9. Settipane RA, Settipane GA. Non-Allergic Rhinitis: Immunology and Allergy Clinics. North America. 1996;16: 49-64. 10. Klink M, Clini MG, Halonen M. Problems in defining normal limits for serum IgE. J of Allergy and Clinical Immunol 1990; 85: 440-44. 11. Drake AB, Barker TW. Free and cell bound IgE in nasal polyposis. J of Laryngol and Otol 1984; 98: 795-801. 12. Chandra RK, Abrol BM. Immunopathology of nasal polyps. J of Laryngol and Otol 1974; 88: 1019-24. 13. Shatkin JS, Delsupehe KG, Thisted RA. Mucosal allergy in the absence of systemic allergy in Nasal Polyposis and Rhinitis: A meta analysis. Otolaryngol Head-Neck Surg 1994; 111: 553-6. 14. Schramm VL, Effron MZ. Nasal Polyps in children. Laryngoscope 1980; 90: 1488-95. 15. Seshadri R. Antrochoanal Polyp: A case report of treatment with intranasal steroids. J of Laryngol and Otol 1995; 109: 555-58. 16. Kamath MP, Hedge MC. Antrochoanal polyps and Allergy - A comparative study. Ind J of Otolaryngol and head & neck Surg 2002; 54: 7-11.

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