Journal Reading

The Effect of Preoperative Short Course of Oral Steroids followed

by Postoperative Topical Nasal Steroids Sprays on Nasal Polyp
Recurrence after Endoscopic Nasal Polypectomy






Tutors:
dr. Tris Sudyartono, Sp. THT-KL
dr. Santo Pranowo, Sp. THT-KL
dr. Agus Sudarwi, Sp. THT-KL

Presented by:
Caroline (11-2013-083)
Lidya B.E Saptenno (11-2013-151)
Luqman Hakim MJ (11-2013-170)

Departement of Ear Nose and Thorat-Head and Neck
Faculty of Medicine Krida Wacana Christian University
Period 31 Maret 2014-3 Mei 2014
Mardi Rahayu Hospital Kudus








J. Dhaka National Med. Coll. Hos. 2011; 17 (02): 40-43

Original Article

The Effect of Preoperative Short Course of Oral Steroids followed by
Postoperative Topical Nasal Steroids Sprays on Nasal Polyp Recurrence after
Endoscopic Nasal Polypectomy


Dr. Khaled Mahmud
1
, Prof.M.N.Faruque
2
, Dr. K. A. Faisal
3


1
Assistant Professor, ENT, Dhaka National Medical College Hospital,
2
Professor ENT, Dhaka National Medical College Hospital.
3
Registrat
ENT, Dhaka National Medical College Hospital.


Abstract:
Objective: To evaluate the effect of preoperative short course of oral steroids followed
by postoperative topical nasal steroids sprays on nasal polyp recurrence after
endoscopic nasal polypectomy.
Methods: Forty eight patients of both genders with symptoms and signs of nasal polyps
were included in this prospective study between January 2006 and December 2009.
Their ages ranged between 18 and 60 years. The sample was divided into two groups.
Group I constituted 24 patients treated by endoscopic nasal polypectomy without oral
and local steroid therapy. Group II consisted of 24 patients also treated by endoscopic
nasal polypectomy but received preoperatively 60mg prednisolone tablets daily for one
week and postoperatively topical nasal steroid spray (Mometasone furoate suspension)
for three months. All patients were followed up for at least one year. Recurrence of nasal
polyps was assessed endoscopically at three, six and 12 months after surgery. Any
evidence of nasal polyps-formation of whatever size was considered as recurrence.
Results: Forty eight patients (32 males and 16 females) with sinonasal polyposis were
included in this study. Male to female ratio was 2:1. Patients age ranged from 18 to 60
years; median age was 42 years. Recurrence rates at three, six and 12 months after
surgery for the first group of patients were 8.33% (2 patients), 25% (6 patients) and
41.6% (10 patients) accordingly, while the recurrence rates for the second group were
4.1% (1 patient), 8.3% (2 patients) and 12.5% (3 patients) accordingly.
Conclusions: Preoperative short course of oral steroid followed by postoperative nasal
steroid spray show significant reduction in the recurrence rate of nasal polyps after
endoscopic nasal polypectomy.
Key words: Endoscopic nasal polypectomy, Local steroids, Nasal polyps, Oral steroid

Introduction
Nasal polyps are oedematous soft tissue outgrowths of the
nasal mucosa and paranasal sinuses.
(1)
They are characterized
macroscopically by a smooth, shiny, pink or grey surface, and
microscopically by an oedematous stroma covered by
respiratory or metaplastic squamous celepithelium
.(2)

Sinonasal polyposis is a chronic disorder with major effects on
the quality of life of the affected individuals. The management
options for sinonasal polyposis are medical treatment, surgery
or combined medical and surgical treatment. It is a common
practice to use systemic or topical corticosteroids as the first

therapeutic choice,followed by surgery for resistant or
recurrent cases.
(3)
The prevalence of nasal polyposis in the
general population varies from 1% to 5%.
(4)
Nasal polyps are
usually manifested after the age of 20 years. Male to female
ratio is 2 : 1
.(5)
Seventy-one percent of patients with nasal
polyps have bronchial asthma,
(6)
although the mechanisms of
nasal polyp formation and growth are still unclear and the role
of allergy is controversial.
(7)
Nasal polyposis can be
accompanied by troublesome or agonizing symptoms that
markedly impair one's quality of life; they even can cause
serious orbital and cerebral complication.
(8)
The main


J. Dhaka National Med. Coll. Hos. 2011; 17 (02): 40-43


presenting symptoms are nasal blockage, rhinorrhea, sneezing,
hyposmia, postnasal discharge and sometimes anosomia.
Hypoxia, hypercapnia, snoring, sleep disorders and an
increased risk of hypertension may develop in patients with
nasal polyposis.
(9)
Nasal polyps can cause obstruction of the
sinuses resulting in sinusitis and further polyp growth.
(5, 10)

Corticosteroids reduce inflammation by decreasing the
infiltration of inflammatory cells, especially mast cells and
eosinophills. They also diminish the hyper-reactivity and
vascular permeability of the nasal mucosa, and they might
decrease the reactive mediators from the mast cells.
(10, 11)
A
short course of preoperative oral steroids greatly facilitates
functional endoscopic sinus surgery by reduction of polyp
size.
(12,13)
Recurrence of nasal polyps after endoscopic sinus
surgery may be the result of severe inflammatory reactions
during the mucosal healing period.
(14)
Therefore,
postoperative topical nasal steroid sprays are used to suppress
these reactions and allow the reestablishment of the normal
epithelial architecture and local defenses.
(15,16)
They are also
frequently used to manage persistent sinonasal symptoms after
surgery
(17)
and to decrease the recovery rate of bacteria from
sinus cavity following functional endoscopic sinus surgery
(FESS) surgery.
(16)
Nowadays, FESS is one of the most
common procedures performed by rhinologists.
(18)
The
incidence of serious complications of FESS has been reported
to be 0.5% or less.
(19)
The most common complications
include bleeding, infection, orbital injury, cerebrospinal fluid
leak, naso-lacrimal duct injury and carotid injury. The purpose
of this study is to evaluate the benefit of a preoperative short
course of oral steroids followed by postoperative topical nasal
steroid sprays on decreasing the recurrence of nasal polyps
after endoscopic nasal polypectomy.

Methods
This prospective study was conducted at the Ear, Nose, Throat
(ENT) Department at Dhaka national medical college &
hospital from Jan 2006 to Dec-2009 .48 patients of both
genders with symptoms and signs of nasal polyps were
included in this study. The age of the patients ranged from 18
to 60 years (median age 42 years). Patients were divided into
two groups:
1. Group I comprised 24 patients treated by endoscopic nasal
polypectomy without
preoperative oral and postoperative local steroid therapy.
2. Group II comprised 24 patients treated by endoscopic nasal
polypectomy who received preoperatively 60 mg prednisolone
tablets daily in three equal divided doses (20 mg 3) for one
week and postoperatively by topicalnasal steroid spray



(Mometasone furoatesuspension) of two 50 micrograms
metered doses in each nostril twice daily (total daily dose 400
mcg) for one month then reduced to two metered doses in each
nostril once daily (total daily dose 200mcg) for two months.
All patients were followed up for at least one year. Recurrence
of nasal polyps was assessed endoscopically at three, six and
12 months after surgery. Any evidence of nasal polyp
formation of any size was considered as a recurrence. All
patients underwent full medical examination including upper
airway endoscopy, chest X-ray,pulmonary function tests,
coronal and axial CTscans for sinuses. Patients with history of
previous nasal polypectomy, hypertension, gastric problems,
diabetes mellitus, cystic fibrosis, allergic fungal sinusitis,
aspirin intolerance, herpes keratitis, glaucoma, psychiatric
disorders, advanced osteoporoses and tuberculosis were
excluded from this study. Endoscopic nasal polypectomy was
performed under general anesthesia in a standard anterior to
posterior approach. Anterior nasal packing was removed on the
next day and all patients were discharged on oral antibiotics of
one week course..

Results
48 patients (32 males and 16 females) with sinonasal polyposis
were included in this study.
Table I. Symptoms of nasal polyps at presentation (N=48)
Patients %
Patients %
Nasal obstruction 40 83.3
Rhinorrhea 36 75
Recurrent URTI 32 66.6
Sneezing 30 62.5
Postnasal discharge 28 58.33
Headache 26 54.16
Hyposmia 18 37.5
Facial pain 10 20.8
Table II. Percentage of recurrence in both groups
3 months 6 months 12 months
Patients % Patients % Patients %
3 Months 6 months 12 months

Patients % Patients % Patients %

Group 1

2 8.33

6

25 10 41.6

Group 2

1 4.1

2

8.3 3 12.5

Male to female ratio was 2 : 1. The patients age ranged from
18 to 60 years and median age was 42 years. Nasal obstruction
was the most common symptom present in 40 patients
(83.3%), followed by rhinorrhea in 36 patients (75%),
recurrent attacks of upper respiratory tract infection in 32
patients (66.6%), sneezing in 30 patients (62.5%), postnasal


J. Dhaka National Med. Coll. Hos. 2011; 17 (02): 40-43

drip in 28 patients (58.33%), headache in 26 patients (54.16%),
hyposmia in 18 patients (37.5%) and facial pain in 10 patients
(20.8%) as shown in Table I. Out of 24 patients in Group I
who were treated by endoscopic nasal polypectomy without
pre- and postoperative steroids, recurrence was observed in 2
patients (8.33%) after three months of surgery compared with
only one patient (4.1%) in the second group of patients who
were given preoperative oral prednisolone and postoperative
topical nasal steroid spray (mometasone furoate suspension)
twice daily. After six months of surgery the total recurrence
was detected in 6 patients (25%) in the first group and in 2
patents (8.3%) in the second group of patients. After one year
of follow-up the total number of recurrences in the first group
was 10 patients (41.6%) compared with only 3 patients
(12.5%) in the second group of patients. (Table II demonstrate
the follow-up results up to one year). These results show a
statically significant reduction in the number of recurrences of
nasal polyps after one year in the second group in comparison
with the first group. Even in patients with recurrence, there
were important differences between the two groups. The
polyps size, number and speed of growth were smaller in
Group II patients which resulted in better nasal airways and
more satisfaction from operation in comparison with patients
with recurrence in Group I. It has been noted, also, that
preoperative steroids decrease the edema of nasal mucosa and
shrink the size of nasal polyps which greatly facilitates the
access and makes the operation easier without increasing the
risk of postoperative bleeding as expected (two patients in each
group). No major complications were reported in both groups
of patients. Minor complications included periorbital fat
exposure (four patients in the first group and three patients in
the second group) and postoperative bleeding (two patients in
each group) without significant differences between the two
groups. There was no increase of the usual side effects of
prolonged use of intranasal steroid sprays such as headache,
epistaxis, pharyngitis, nasal irritation and dryness more than it
is stated in the drugs leaflet and were managed accordingly.

Discussion
This study emphasizes the role of preoperative short course of
oral steroids followed by postoperative topical nasal steroid
sprays on decreasing the recurrence of nasal polyps after
endoscopic nasal polypectomy. It is well known that both
medical and traditional surgical treatment methods of nasal
polyps have high rates of recurrence, so many patients with
nasal polyps require multiple surgical procedures. Based on
many articles reviewed, intranasal corticosteroids appear to be
safe and the benefits of their use outweigh their potential risks in
appropriate patients
.(20,21)
Many studies have been conducted
to assess the effect of oral steroid and intranasal steroid in the



treatment of sinonasal polyposis. For example, Lildholdt et al.
studied the efficacy of topical corticosteroid powder
(budesonide) for nasal polyps in 129 patients and showed
success in 82% of actively treated patients as opposed to about
43% in the placebo group
.(22)
Bross-Soriano et al. in their study
on 162 patients concluded that the use of topical intranasal
steroid (fluticasone propionate) after endoscopic resection of
sinonasal polyps is not only effective in reducing recurrence
(14% compared to 44.4% in control group), but also it is a safe
and reliable and does not increase the prevalence of
infection.
(1)
Kang et al. reported that high-dose topical
corticosteroid therapy is more effective than lowdose topical
therapy in preventing recurrent nasal polyps (7.1% opposed to
44%).
(10)
Gulati et al. found that only patients who stopped
using postoperative nasal sprays (10%) developed recurrence
three months after surgery.
(23)
The results of the previous
studies strongly support the results of our study and emphasize
the importance of corticosteroid use to decrease the incidence
of recurrent nasal polyps.

Conclusions
Administration of preoperative short course of oral steroids
followed by postoperative topical nasal steroid sprays is safe
and reliable for preventing recurrence of nasal polyps after
endoscopic nasal polypectomy.

References
1. Bross-Soriano D, Arrieta-Gomez J, Prado- Calleros H.
Infections after endoscopic polypectomy using nasal steroids.
Otolaryngol Head Neck Surg 2004; 130: 319-322.

2. Diamantopoulos I, Jones N, Lowe L. All nasal polyps need
histological examination: an audit based appraisal of clinical
practice. The Journal of Laryngology and Otology 2000; 114:
755-759.

3. Hissaria P, Smith W, Wormalled P, Taylor J, et al. Short
course of systemic corticosteroids in sinonasal polyposis: A
double-blind, randomized, placebo-controlled trial with
evaluation of outcome measures. J Allergy Clin Immunol 2006;
118: 128- 133.

4. Settipane GA. Epidemiology of nasal polyps. Allergy Asthma
Proc 1996; 17: 231-236.

5. Assanasen P, Naclerio R. Medical and surgical management o
f nasal polyps. Current Opinion in Otolaryngology & Head
and Neck Surgery 2001; 9:27-36.

6. Settipane GA, Chafee FH. Nasal polyps in asthma and
rhinitis: a review of 6,037 patients. J Allergy Clin Immunol
1977; 59:17-21.

7. Alatas N, Baba F, San I, Kurcer Z. Nasal polyp diseases in
allergic and non-allergic patients and steroid therapy.
Otolaryngology-Head and Neck Surgery 2006; 135: 236-42.

J. Dhaka National Med. Coll. Hos. 2011; 17 (02): 40-43


8. Alobid I, Benitez P, Pujols L, et al. Sever nasal polyposis and
its impact on quality of life. The effect of a short course of
nasal steroids followed by long-term intranasal steroid
treatment. Rhinology 2006; 44: 8-13.

9. Ozdemir R, Yorulmaz A, Kutlu R, et al. Loss of nocturnal
decline of blood pressure in patients with nasal polyposis.
Blood Pressure 1999; 8:165-171.

10. Bachert C, Hormann K, Mosges R, et al. An update on the
diagnosis and treatment of sinusitis and nasal polyposis.
Allergy 2003; 58:176-191.

11. Jacquelynne P, Steven M, Bernard A. Nasal congestion: a
review of its etiology, evaluation, and treatment. ENT-Ear,
Nose & Throat Journal 2000; 79(9):690-702.

12. More D. Overview of nasal polyps. About.com [internet];
[cited 2008 June 27]. Available from:
http://www.nap.edu/books/0309074029/html/.

13. Alobid I, Benitez P, Bernal- Sprekelsen M, et al. Nasal
polyposis and its impact on quality of life: comparison between
the effects of medical and surgical treatments. Allergy 2005;
60:452-458.

14. Larsen L, Tos M. Origin and structure of nasal polyps in nasal
polyposis: an inflammatory disease and its treatment.
Copenhagen: Munksgaad 1997; 17-30.

15. Meltzer O, Orgel A, BackhausW, et al. Intranasal flunisolide
sprays as an adjunct to oral antibiotic therapy for sinusitis. J
Allergy Clin Immunol 1993; 92: 812-823.

16. Desrosiers M, Hussain A, Frenkiel S, et al. Intranasal
corticosteroid use is associated with lower rates of bacteria
recovery in chronic rhinosinusitis. Otolaryngol Head Neck
Surg 2007; 136: 605-609.



17. Kang G, Yoon B, Jung J, et al. The effect of highdose topical
corticosteroid therapy on prevention of JOURNAL OF THE

ROYAL MEDICAL SERVICES Vol. 17 No. 4 December
2010 60 recurrent nasal polyps after revision endoscopic sinus
surgery. Am J Rhinol 2008; 22:497- 501.

18. Lin P, Lin H, Chang H, et al. Effects of Functional
Endoscopic Sinus Surgery on Intraocular Pressure. Arch
Otolaryngol Head Neck Surg 2007; 133:865-869.

19. Cumberworth L, Sudderick M, Mackay S. Major
complications of functional endoscopic surgery. Clin
Otolaryngol Allied Sc 1994; 19(3): 248-253.
20. Penttila M, Poulsen P, Hollingworth K, Holmstrom M.

Dose-related efficacy and tolerability of fluticasone propionate
nasal drops 400 g once daily and twice daily in the treatment
of bilateral nasal polyposis : a placebo-controlled randomized
study in adult patients. Clinical and Experimental Allergy
2000; 30: 94-102.

21. Sheth K. Evaluating the safety of intranasal steroids in the
treatment of allergic rhinitis. Allergy, Asthma, and Clinical
Immunology 2008; 4 (3): 125-129.

22. Lildholdt T, Rundcrantz H, Lindqvist N. Efficacy of topical
corticosteroid powder for nasal polyps: a double-blind,
placebo-controlled study of budesonide. Clinical
Otolaryngology 2007; 20: 26- 30.

23. Gulati P, Raman W, Antariksh D. Efficacy of Functional
Endoscopic Sinus Surgery in the treatment of Ethmoidal
polyps. Internet Journal of Otorhinolaryngology 2007; 7(1):
150-157
6

Journal Reading
Efek Pemberian Steroid Peroral Jangka Pendek Sebelum Operasi
Diikuti dengan Pemberian Steroid Topikal Semprot pada Polip
Nasi Kambuhan Setelah Endoskopi Polipektomi





Tutor:
dr. Tris Sudyartono, Sp. THT-KL
dr. Santo Pranowo, Sp. THT-KL
dr. Agus Sudarwi, Sp. THT-KL
Disusun oleh:
Caroline (11-2013-083)
Lidya B.E Saptenno (11-2013-151)
Luqman Hakim MJ (11-2013-170)


Kepaniteraan Klinik Ilmu Penyakit Telinga Hidung Tenggorok
Fakultas Kedokteran Universitas Kristen Krida Wacana
Periode 09 Juni 2014 - 12 Juli 2014
Rumah Sakit Mardi Rahayu Kudus
7

Efek Pemberian Steroid Peroral Jangka Pendek Sebelum Operasi
Diikuti dengan Pemberian Steroid Topikal Semprot pada Polip
Nasi Kambuhan Setelah Endoskopi Polipektomi
Dr. Khaled Mahmud
1
, Prof.M.N.Faruque
2
, Dr.K.A
3
1
Assistant Professor, ENT, Dhaka National Medical College Hospital,
2
Professor ENT, Dhaka National Medical
College Hospital.
3
Registrat ENT, Dhaka National Medical College Hospital
Abstrak:
Objektif: Mengevaluasi efek pemberian steroid peroral jangka pendek sebelum operasi diikuti
dengan pemberian steroid topikal semprot pada polip nasi berulang setelah endoskopi
polipektomi.
Metode: Empat puluh delapan pasien dari kedua gender dengan gejala-gejala dan tanda-tanda
dari polip nasi yang termasuk dalam studi prospektif antara bulan Januari 2006 sampai
Desember 2009. Umur mereka antara 18-60 tahun. Sampel terbagi menjadi dua grup. Grup I
terdiri dari 24 pasien diterapi dengan endoskopi polipektomi tanpa terapi steroid peroral dan
lokal. Grup 2 terdiri dari 24 pasien yang juga diterapi dengan endoskopi polipektomi tetapi
sebelum operasi diberikan 60 mg prednisolon tablet perhari selama seminggu dan setelah
operasi mendapat steroid topikal (Mometasone Furoate suspensi) selama 3 bulan. Semua
pasien dipantau selama satu tahun. Kambuhnya polip nasi dinilai secara endoskopi pada
bulan ke-3, ke-6, dan ke-12 setelah operasi. Setiap terbentuknya polip nasi ukuran apapun
dianggap sebagai kekambuhan.
Hasil: 48 pasien (32 pria dan 16 wanita) dengan polip sinus nasi termasuk dalam studi ini.
Rasio pria dan wanita adalah 2:1. Umur pasien antara 18-60 tahun dengan nilai tengah umur
42 tahun. Tingkat kekambuhan pada bulan ke-3, ke-6, ke-12 setelah operasi untuk grup I
adalah 8,33% (2 pasien), 25% (6 pasien), dan 41,6 % (10 pasien), sementara tingkat
kekambuhan untuk Grup II 4,1% (1 pasien), 8,3% 2 pasien, dan 12,5% 3 pasien.
Kesimpulan: Pemberian steroid peroral jangka pendek sebelum operasi dengan diikuti
pemberian sterioid topikal semprot setelah operasi memberikan pengurangan yang signifikan
terhadap tingkat kekambuhan dari polip nasi setelah endoskopi polipektomi.
Kata kunci: Endoskopi polipektomi, Steroid lokal, Polip Nasi, Steroid Oral.
8

Pendahuluan
Polip nasi adalah pembengkakan jaringan lunak yang tumbuh di luar mukosa hidung dan
sinus paranasal.
(1)
Mereka memiliki karakter makroskopik halus, berkilau, permukaan merah
mudah atau keabu-abuan, dan secara mikroskopik terdiri dari stroma yang membengkak
ditutupi oleh sel epitel pernapasan dan metaplasia skuamosa.
(2)
Polip sinonasal merupakan
kelainan kronik dengan efek yang besar terhadap individu yang bersangkutan. Pilihan
penanganan polip sinonasal adalah terapi medis, bedah, atau kombinasi terapi medis dan
terapi bedah. Ini menjadi praktek umum untuk menggunakan kortikosteriod secara sistemik
dan topikal sebagai terapi pilihan pertama, diikuti dengan tindakan bedah untuk kasus
resisten dan berulang.
(3)
Prevalensi polip nasi pada populasi umum dari 1% sampai 5%.
(4)

Polip nasi biasanya bermanifestasi setelah usia 20 tahun. Rasio pria dan wanita adalah 2:1.
(5)

Tujuh puluh satu persen pasien dengan polip nasi menderita asma bronkial
(6)
, meskipun
mekanisme pembentukan polip nasi dan pertumbuhannya masih belum jelas dan peran alergi
masih kontroversial.
(7)
Polip nasi dapat disertai dengan gejala penyulit yang ditandai oleh
gangguan kualitas hidup, polip nasi juga dapat menyebabkan komplikasi orbital dan serebral
yang serius.
(8)
Gejala utama adalah hidung tersumbat, rhinorrhea, pilek, bersin, hiposmia,
post nasal drip dan kadang-kadang anosmia. Hypoxia, hiperkapnia, mengorok, gangguan
tidur dan suatu risiko hipertensi yang bertambah bisa terjadi pada pasien dengan poliposis
nasal.
(9)
Nasal polip dapat menyebabkan obstruksi sinus yang mengakibatkan sinusitis dan
perkembangan polip lebih lanjut.
(5,10)
Kortikosteroid mengurangi inflamasi dengan cara
mengurangi infiltrasi dari sel-sel inflamasi, terutama sel mast dan eosinofil. Kortikostreoid
mengurangi hiperaktivitas dan permeabilitas vaskuler pada mukosa hidung, dan
kortikosteroid juga bisa mengurangi pengaktifan kembali mediator dari sel mast.
(10)
Pemakaian jangka pendek steroid oral pada sebelum operasi sangat memudahkan
pembedahan endoskopi sinus dengan cara mengurangi ukuran polip
(12,13)
Kambuhnya polip
hidung setelah pembedahan endoskopi sinus merupakan hasil dari reaksi inflamasi yang
hebat sewaktu periode penyembuhan mukosa.
(14)
Oleh karena itu, pemakaian steroid topikal
semprot setelah operasi diperuntukkan untuk menekan reaksi ini dan memungkinkan untuk
membangun struktur epitel normal dan pertahanan lokal.
(15,16)
Itu semua juga sering
digunakan untuk mengatasi gejala persisten sinonasal setelah operasi.
(17)
dan untuk
mengurangi pertumbuhan dari bakteri di rongga sinus setelah FESS (Functional Endoscopic
Sinus Surgery).
(16)
Sekarang FESS adalah salah satu prosedur yang sering dilakukan oleh
rhinologists.
(18)
Insiden serius komplikasi dari FESS telah dilaporkan 0,5% atau kurang.
(19)

9

Komplikasi yang paling sering termasuk pendarahan, infeksi, cedera orbital, kebocoran
cerebrospinal, cedera duktus nasolakrimal, dan cedera karotis. Tujuan dari studi ini untuk
mengevaluasi keuntungan pemakaian oral steroid jangka pendek diikuti dengan steroid
topikal semprot hidung untuk menurunkan kekambuhan dari polip hidung setelah endoskopi
polipektomi hidung,
Metode
Studi prospektif ini telah dilakukan pada Ear, Nose, Throat (ENT) Department di Dhaka
national medical college & hospital dari Januari 2006 sampai Desember 2009. Empat puluh
delapan pasien semua gender dengan gejala dan tanda dari polip hidung telah masuk pada
studi ini. Range umur pasien dari 18-60 tahun (umur rata-rata 42 tahun). Pasien dibagi
menjadi dua kelompok:
Grup I terdiri dari 24 pasien dilakukan dengan polipektomi endokopi hidung tanpa steroid
oral sebelum operasi dan steroid lokal sehabis operasi.
Grup II terdiri dari 24 pasien dilakukan dengan polipektomi endoskopi hidung yang
mendapat tablet 60 mg prednisolon perhari sebelum operasi, dibagi menjadi 3 dosis (20mg x
3) untuk satu minggu dan steroid topikal semprot hidung (suspense Momethasone furoate)
setelah operasi dengan dosis 2x50 mcg pada setiap lubang hidung dua kali sehari (total dosis
sehari 400mcg) untuk 1 bulan. Lalu dikurangi menjadi 2x50 mcg pada setiap lubang 1x
sehari (total dosis harian 200mcg) untuk 2 bulan. Semua pasien telah dipantau minimal 1
tahun. Kekambuhan dari polip nasal dinilai secara endoskopi pada bulan ke 3,6 dan 12
setelah operasi. Jika ada bukti pembentukan polip hidung dengan berbagai ukuran
diperhitungkan sebagai kekambuhan. Semua pasien melewati pemeriksaan medis secara
menyeluruh termasuk endoskopi saluran pernapasan atas, X-ray dada, tes fungsi paru, CT
scan sinus coronal dan axial. Pasien dengan riwayat dari polip nasal, hipertensi, gangguan
lambung, diabetes melitus, kistik fibrosis, sinusistis alergi jamur, intoleransi aspirin, keratitis
herpes, glaukoma, gangguan psikiatri, osteoporosis lanjut dan tuberkulosis sebelumnya tidak
termasuk pada studi ini. Polipektomi endoskopi hidung telah dilakukan dengan anestesi
general dengan pendekatan standart anterior dan posterior. Balutan anterior hidung dilepas
pada hari berikutnya dan semua pasien dipulangkan dan diberi obat antibiotik oral selama 1
minggu.

10

Hasil
48 pasien (32 pria dan 16 wanita) dengan polyposis sinonasal dilibatkan pada studi ini.
Tabel I. Gejala dari polip nasal dalam persentase (N=48)
Jumlah Pasien %
Sumbatan hidung 40 83.3
Rhinorrhea 36 75
ISPA berulang 32 66.6
Bersin-bersin 30 62.5
Postnasal discharge 28 58.33
Sakit kepala 26 54.16
Hyposmia 18 37.5
Nyeri wajah 10 20.8

Tabel II. Persentase kekambuhan pada kedua kelompok
3 bulan 6 bulan 12 bulan
Pasien % Pasien % Pasien %
Kelompok 1 2 8.33 6 25 10 41.6
Kelompok 2 1 4.1 2 8.3 3 12.5

Rasio antara pria dan wanita adalah 2:1. Umur pasien berkisar antara 18 60 tahun dengan
rata-rata umur adalah 42 tahun. Sumbatan hidung adalah gejala yang paling umum terdapat
pada 40 pasien (83.3 %), diikuti dengan rhinorrhea pada 36 pasien (75%), serangan
berulang infeksi saluran pernafasan atas pada 32 pasien (66.6%), bersin-bersin pada 30 pasien
(62.5 %), postnasal drip pada 28 pasien (58.33 %), sakit kepala pada 26 pasien (54.16 %),
hyposmia pada 18 pasien (37.5 %) dan nyeri wajah pada 10 pasien (20.8 %) seperti yang
ditujukan pada tabel I. Dari 24 pasien pada kelompok I yang ditangani dengan endoskopi
polipektomi nasal tanpa penggunaan steroid pre dan post-operasi, kekambuhan ditemukan
pada 2 pasien (8.33%) setelah 3 bulan post-operasi dibandingkan hanya 1 pasien (4.1%) pada
kelompok kedua yang diberikan prednisolon oral pre-operasi dan steroid topikal semprot
hidung post-operasi (larutan nometasone furoate) dua kali sehari. Pasca 6 bulan pembedahan,
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kekambuhan ditemukan pada 6 pasien (25%) pada kelompok pertama dan 2 pasien (8.3%)
pada pasien kelompok kedua. Follow up setelah setahun dari jumlah total kekambuhan pada
kelompok pertama adalah 10 pasien (41.6%) dibandingkan hanya 3 pasien (12.5%) pada
pasien kelompok kedua. (Tabel II menunjukan hasil follow up selama setahun). Hasil ini
menunjukan perbedaan statistik yang signifikan dalam jumlah kekambuhan polip nasal
setelah satu tahun, pada kelompok kedua dibandingkan dengan kelompok pertama. Bahkan
pada pasien yang terjadi kekambuhan terdapat perbedaan yang penting diantara kedua
kelompok. Ukuran, jumlah, dan kecepatan pertumbuhan polip nasal lebih kecil pada pasien
kelompok kedua yang memberikan hasil aliran udara nasal yang lebih baik, dan kepuasan
dari operasi yang lebih dibandingkan dengan pasien yang mengalami kekambuhan pada
kelompok pertama. Juga didapatkan, penggunaan steroid pre-operasi menurunkan edema
mukosa hidung dan mengecilkan ukuran polip hidung dimana memberikan akses yang lebih
baik dan membuat operasi jauh lebih mudah tanpa meningkatkan risiko perdarahan post-
operatif (2 pasien pada masing-masing kelompok). Tidak ada komplikasi mayor yang
dilaporkan pada kedua kelompok pasien. Timbul komplikasi minor seperti tampak lemak
periorbital ( 4 pasien pada kelompok pertama dan 3 pasien pada kelompok kedua) dan
perdarahan post-operasi (2 pasien pada masing-masing kelompok) tanpa perbedaan signifikan
diantara kedua kelompok. Tidak terdapat peningkatan efek samping yang tidak biasa dari
penggunaan steroid semprot didalam hidung yang berkepanjangan seperti sakit kepala,
epistaksis, faringitis, iritasi hidung dan kekeringan, melebihi yang telah tercantum pada
leaflet obat dan penggunaan secara umum.

Pembahasan
Penelitian ini menekankan peran pre-operasi steroid oral jangka pendek yang diikuti dengan
steroid topikal semprot hidung post-operasi, terhadap penurunan kambuhnya polip nasi
setelah endoskopi nasal polipektomi. Hal ini juga diketahui bahwa kedua metode terapi bedah
medis dan tradisional polip nasi memiliki tingkat kekambuhan yang tinggi, begitu banyak
pasien dengan polip nasi memerlukan prosedur bedah yang berkelanjutan. Berdasarkan
banyak artikel terakhir, kortikosteroid intranasal tampaknya aman dan manfaat penggunaan
kortikosteroid lebih besar dibandingkan potensi risikonya pada pasien yang cocok. Banyak
penelitian telah dilakukan untuk menilai efek dari steroid oral dan steroid intranasal dalam
pengobatan poliposis sinonasal. Misalnya, Lildholdt et al. mempelajari khasiat bubuk
kortikosteroid topikal (budesonide) untuk polip nasi pada 129 pasien dan menunjukkan
keberhasilan pada 82 % pasien yang aktif diterapi dibandingkan dengan sekitar 43 % pada
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kelompok plasebo Bross - Soriano et al. dalam studi mereka pada 162 pasien disimpulkan
bahwa penggunaan steroid topikal intranasal (flutikason propionat) setelah reseksi
endoskopik polip sinonasal tidak hanya efektif dalam mengurangi kekambuhan (14 %
dibandingkan dengan 44,4 % pada kelompok kontrol), tetapi juga aman dan terpercaya dan
tidak meningkatkan prevalensi infeksi. Kang et al. dilaporkan bahwa dosis tinggi terapi
kortikosteroid topikal lebih efektif daripada terapi topikal dosis rendah dalam mencegah polip
nasi berulang (7,1 % dibandingkan dengan 44 %). Gulati et al. menemukan bahwa hanya
pasien yang berhenti menggunakan semprot nasal pasca operasi (10%) meningkatkan
kekambuhan tiga bulan setelah operasi. Hasil penelitian sebelumnya sangat mendukung hasil
penelitian kami dan menekankan pentingnya penggunaan kortikosteroid untuk mengurangi
kejadian polip nasi berulang.

Kesimpulan
Pelaksanaan pre-operasi steroid oral jangka pendek diikuti dengan steroid topikal semprot
hidung post-operasi adalah aman dan dapat diandalkan untuk mencegah kekambuhan polip
hidung setelah endoskopi nasal polipektomi.

Daftar Pustaka
1. Bross-Soriano D, Arrieta-Gomez J, Prado- Calleros H. Infections after endoscopic
polypectomy using nasal steroids. Otolaryngol Head Neck Surg 2004; 130: 319-
322.
2. Diamantopoulos I, Jones N, Lowe L. All nasal polyps need histological examination:
an audit based appraisal of clinical practice. The Journal of Laryngology and Otology
2000; 114: 755-759.
3. Hissaria P, Smith W, Wormalled P, Taylor J, et al. Short course of systemic
corticosteroids in sinonasal polyposis: A double-blind, randomized, placebo-
controlled trial with evaluation of outcome measures. J Allergy Clin Immunol 2006;
118: 128- 133.
4. Settipane GA. Epidemiology of nasal polyps. Allergy Asthma Proc 1996; 17: 231-
236.
5. Assanasen P, Naclerio R. Medical and surgical management o f nasal polyps. Current
Opinion in Otolaryngology & Head and Neck Surgery 2001; 9:27-36.
6. Settipane GA, Chafee FH. Nasal polyps in asthma and rhinitis: a review of 6,037
patients. J Allergy Clin Immunol 1977; 59:17-21.
13

7. Alatas N, Baba F, San I, Kurcer Z. Nasal polyp diseases in allergic and non-allergic
patients and steroid therapy. Otolaryngology-Head and Neck Surgery 2006; 135: 236-
42.
8. Alobid I, Benitez P, Pujols L, et al. Sever nasal polyposis and its impact on quality of
life. The effect of a short course of nasal steroids followed by long-term intranasal
steroid treatment. Rhinology 2006; 44: 8-13.
9. Ozdemir R, Yorulmaz A, Kutlu R, et al. Loss of nocturnal decline of blood pressure in
patients with nasal polyposis. Blood Pressure 1999; 8:165-171.
10. Bachert C, Hormann K, Mosges R, et al. An update on the diagnosis and treatment of
sinusitis and nasal polyposis. Allergy 2003; 58:176-191.
11. Jacquelynne P, Steven M, Bernard A. Nasal congestion: a review of its etiology,
evaluation, and treatment. ENT-Ear, Nose & Throat Journal 2000; 79(9):690-702.
12. More D. Overview of nasal polyps. About.com [internet]; [cited 2008 June 27].
Available from: http://www.nap.edu/books/0309074029/html/.
13. Alobid I, Benitez P, Bernal- Sprekelsen M, et al. Nasal polyposis and its impact on
quality of life: comparison between the effects of medical and surgical treatments.
Allergy 2005; 60:452-458.
14. Larsen L, Tos M. Origin and structure of nasal polyps in nasal polyposis: an
inflammatory disease and its treatment. Copenhagen: Munksgaad 1997; 17-30.
15. Meltzer O, Orgel A, BackhausW, et al. Intranasal flunisolide sprays as an adjunct to
oral antibiotic therapy for sinusitis. J Allergy Clin Immunol 1993; 92: 812-823.
16. Desrosiers M, Hussain A, Frenkiel S, et al. Intranasal corticosteroid use is associated
with lower rates of bacteria recovery in chronic rhinosinusitis. Otolaryngol Head
Neck Surg 2007; 136: 605-609.
17. Kang G, Yoon B, Jung J, et al. The effect of highdose topical corticosteroid therapy
on prevention of JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. 17 No. 4
December 2010 60 recurrent nasal polyps after revision endoscopic sinus surgery. Am
J Rhinol 2008; 22:497- 501.
18. Lin P, Lin H, Chang H, et al. Effects of Functional Endoscopic Sinus Surgery on
Intraocular Pressure. Arch Otolaryngol Head Neck Surg 2007; 133:865-869.
19. Cumberworth L, Sudderick M, Mackay S. Major complications of functional
endoscopic surgery. Clin Otolaryngol Allied Sc 1994; 19(3): 248-253.
20. Penttila M, Poulsen P, Hollingworth K, Holmstrom M. Dose-related efficacy and
tolerability of fluticasone propionate nasal drops 400 g once daily and twice daily in
the treatment of bilateral nasal polyposis : a placebo-controlled randomized study in
adult patients. Clinical and Experimental Allergy 2000; 30: 94-102.
21. Sheth K. Evaluating the safety of intranasal steroids in the treatment of allergic
rhinitis. Allergy, Asthma, and Clinical Immunology 2008; 4 (3): 125-129.
14

22. Lildholdt T, Rundcrantz H, Lindqvist N. Efficacy of topical corticosteroid powder for
nasal polyps: a double-blind, placebo-controlled study of budesonide. Clinical
Otolaryngology 2007; 20: 26- 30.
23. Gulati P, Raman W, Antariksh D. Efficacy of Functional Endoscopic Sinus Surgery in
the treatment of Ethmoidal polyps. Internet Journal of Otorhinolaryngology 2007;
7(1): 150-157