Comparison of Eosinophil Profile and Lund Kennedy Score in Patients with Nasal Polyps

Abstract

Nasal polyps are epithelial and stromal non-neoplastic proliferations of nasal cavity and paranasal sinuses. Nasal polyps are a consequence of damage in the epithelium of the nasal mucosa. Since eosinophils are the main inflammatory cells in the substantial proportion of nasal polyp tissues, they are considered potentially responsible for the etiopathogenesis and prognosis of the disease. This cross-sectional observational study was conducted in the department of ENT, H&NS, Government Medical College, Srinagar. A total of 62 patients were included in the study. The recorded data was compiled and entered in a spreadsheet (Microsoft Excel) and then exported to data editor of SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA). A total of 62 patients participated in the study. Majority of subjects were in the age group of 60–69 and the least number in 20–29. 47 patients had a mean lund kennedyscore of 13.34 ± 1.178 with peripheral eosinophil count of ≥ 500 and 15 patients had a score of 7.00 ± 0.632 with peripheral eosinophil count of < 500. 50 patients had a mean lund kennedy score of 13.04 ± 1.359 with tissue eosinophil count of ≥ 10/HPF and 12 patients had a score of 7.16 ± 0.669 with atissue eosinophil count of < 10/HPF. The conducted study indicates that the levels of tissue and peripheral osinophils are positively related to severity of nasal polyps as indicated by Lund Kennedy scores. Also, our study concluded that the disease has male preponderance.

Introduction

Nasal polyps are epithelial and stromal non-neoplastic proliferations of nasal cavity and paranasal sinuses. Morphologically nasal polyps are edematousgrapelike protrusions most often originating in the upper part of the nose around the osteomeatal complex on the lateral wall. The surface epithelium tends to be smooth and consists of pale translucent tissue which distinguishes them from the more vascular mucosa of the nasal cavity. Polyps can vary widely in size and should be considered a bilateral condition [1]. Nasal polyps are a consequence of damage in the epithelium of the nasal mucosa. Injuries of the epithelium may be caused by infections due to bacteria, fungus or viruses, as well as prolonged inhalation of irritating substances. Polyps arise in the presence of inflammation that may be initiated by a number of factors, resulting in dysregulated interaction between the sinus epithelium and the lymphoid system. In the last decade, research has revealed unique cytokine and cellular inflammatory profiles that may contribute to the formation of nasal polyps [5]. Histologically, nasal polyps have myxoid and edematous stroma covered by respiratory epithelium exhibiting hyperplasia or squamous metaplasia and infiltrated pre-dominantly by eosinophils [2]. Since eosinophils are the main inflammatory cells in the substantial proportion of nasal polyp tissues, they are considered potentially responsible for the etiopathogenesis and prognosis of the disease [3]. Eosinophils contain leukotrienes, eosinophilic cationic protein, major basic proteins, platelet activating factor, eosinophilic peroxidase and other vasoactive substances that causes mucosal damage. These play a critical role in the development of nasal polyps [3]. Eosinophils have been positively and negatively correlated with clinical severity of nasal polyps. It has also been seen patients having higher mucosal eosinophil count have higher recurrence rate [4]. In addition to that there is a controversy whether mucosal eosinophilia need to be examined or not [5]. The incidence of nasal polyp is between 1 and 20 per thousand of population. This incidence decreases after age of 60 years. Nasal polyps are more common in males (2-4:1) [6] Nasal polyp are associated with allergy and other conditions such as asthma, cystic fibrosis, kartargener's syndrome, young's syndrome [1]. Nasal polyps are best thought as chronic rhinosinusitis with nasal polyps and clinically defined as inflammation of the nose and paranasal sinuses associated with two or more symptoms, one of which should be nasal blockage/obstruction/congestion or nasal discharge with facial pain or pressure or reduction or loss of smell. Patients with eosinophilic chronic rhionosinusitis have variable clinical presentations depending upon the extent of disease .Small polyps are usually asymptomatic, whilst larger polyps present with various symptoms progressing from mild nasal congestion with a watery rhinorrhea to a persistent nasal obstruction associated with hyposmia or anosmia as well as a thicker post nasal discharge and very occasionally headache Nasal polyps are usually diagnosed clinically with the help of diagnostic nasal endoscope. Polyps are graded by using a grading score known as lund- kennedy score. This system gives a score of 0-2 depending upon presence or absence of polyps, oedema, discharge, scarring and crusting. A maximum score of 20 can be achieved by this method [2].

Objective

To identify any association of tissue and peripheral eosinophil levels with severity of nasal polyp.

Methods and Materials

The present study was conducted in the Post Graduate Department of Otorhinolaryngology, Head and Neck Surgery in collaboration with Department of Pathology Govt. Medical College Srinagar from Sep 2020 to Sep 2022.

Study Designs: It is a cross-sectional observational study of hospital attending patients.

Study Period: 2 years.

Inclusion Criteria

1. Patients with Eosinophilic Chronic Rhinosinusitis.

2. Patients above age of 18 years irrespective of sex with nasal polyps were included.

3. Patients on topical and systemic steroids were included by stopping the medication four weeks prior to surgery.

4. Patients on anti-histamine were included by stopping the medication four weeks prior to surgery.

Exclusion Criteria

1. Patients younger than 18 years of age.

2. Patients who are having co-morbidities that are contra-indicated for functional endoscopic sinus surgery were excluded.

Methodology

All patients who attended the hospital with symptoms of chronic rhinosinusitis with nasal polyposis like nasal congestion, rhinorrhea, nasal discharge, hyposmia or anosmia were evaluated. Pre-operative clinical evaluation was done by Anterior Rhinoscopy, Oropharyngeal Examination and Diagnostic Nasal Endoscopy (In this type of examination, we performed the staging of nasal polyps according to lund- kennedy score).

Endoscopic staging of nasal polyps
Polyp	0 = absence of polyp 1 = polyps in the middle meatus only 2 = beyond middle meatus
Oedema	0 = absent 1 = mild 2 = severe
Discharge	0 = no discharge 1 = clear, thin discharge
	2 = thick, purulent discharge
Scarring	absent 1 = mild 2 = severe
Crusting	0 = absent 1 = mild 2 = severe

Peripheral blood eosinophilia was measured. Patients were graded according to eosinophil levels into two groups < 500 and ≥ 500 eosinophils/microliter. Post- Operative Tissue eosinophilia were measured and following surgery, the tissue were collected and sent for histopathological examination to calculate the tissue eosinophils.

Statistical Methods: The recorded data was compiled and entered in a spreadsheet (Microsoft Excel) and then exported to data editor of SPSSVersion 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as Mean±SD and categorical variables were summarized as

Results

The study was conducted in the Department of Otolaryngology, Head and Neck Surgery, Government Medical College Srinagar. In this study, a total of 62 patients fulfilling the inclusion criteria were included and following observation were made. Majority of subjects were inthe age group of 60–69 and the least number were in 20–29. Mean age in years was 48.3 with a standard deviation of ±13.47.

In this study 74.2% of patients were males and 25.8% were females. Male:female ratio was 2.9:1.

On endoscopic examination, polyps were present in 91.9%, discharge in 69.4%, oedema in 85.5%, crusting in 46.8%, and scarring in 35.5% (Table 1).

Table 1.

Endoscopic findings among study patients (n = 62)

Endoscopic findings	Number	Percentage
Polyp
Present	57	91.9
Absent	5	8.1
Discharge
Present	43	69.4
Absent	19	30.6
Oedema
Present	53	85.5
Absent	9	14.5
Crusting
Present	29	46.8
Absent	33	53.2
Scarring
Present	22	35.5
Absent	40	64.5

In current study 75.8% of patients had peripheral eosinophil count ≥ 500 and 24.22% had < 500. In current study 80.6% of patients had tissue eosinophil count of ≥ 10/HPF and 19.4%had < 10/HPF. 47 patients had a mean lund kennedy score of 3.34 ± 1.178 with peripheral eosinophil count of ≥ 500 and 15 patients had a score of .00 ± 0.632 with peripheral eosinophil count of < 500 (Table 2).

Table 2.

Comparison of the patients with low and high peripheral eosinophil count interms of Lund-Kennedy endoscopic score (n = 62)

Peripheral Eosinophil Count	N	Mean Lund Kennedy Score	SD	95% CI	p value
<	15	7.00	0.63	6.5–7.9
500			2
					< 0.001
					*
≥	47	13.34	1.17	12.72-
500			8	14.1

The pearsons correlation coeffiecient (r-value) between lund kennedy score and peripheral eosinophil count was 0.948 with p < 0.001.

In current study 50 patients had a mean lund kennedy score of 13.04 ± 1.359 with tissue eosinophil count of ≥ 10/HPFand 12 patients had a score of 7.16 ± 0.669 with atissue eosinophil count of < 10/HPF (Table 3).

Table 3.

Comparison of the patients with low and high tissue eosinophil count in termsof Lund-Kennedy endoscopic score (n = 62)

Tissue Eosinophil Count	N	Mean	SD	95% CI	p value
< 10/HPF	12	7.16	0.669	6.32–8.02	< 0.001*
≥ 10/HPF	50	13.04	1.359	12.26–13.82

The pearsons correlation coeffiecient (r-value) between lund kennedy score and a tissue eosinophil count was 0.774 with p < 0.001.

98% patients with a peripheral eosinophil count of ≥ 500 had a tissue eosinophil count of ≥ 10/HPF and 2.1% patients with a peripheral eosinophil count of ≥ 500 had a tissue eosinophil count of < 10/HPF. Also 73.3% of patients with aperipheral eosinophil count of < 500 had a tissue eosinophil count of < 10/HPF and 26.7% of patients with a peripheral eosinophil count of < 500 had a tissue eosinophil count of ≥ 10/HPF. There was a statistically significant relationship between tissue and peripheral eosinophil count with p < 0.001.

The pearsons correlation coeffiecient (r-value) between peripheral and a tissue eosinophil count was 0.749 with p < 0.001 (Table 4).

Table 4.

Relation of peripheral eosinophil count with tissue eosinophil count in study patients (n = 62)

Tissue Eosinophil Count	Peripheral Eosinophil Count				p value
	< 500	≥ 500
	No	% age	No	% age
< 10/HPF	11	73.3	1	2.1	< 0.001*
≥ 10/HPF	4	26.7	46	98
Total	15	100	47	100

Endoscopic picture of CRS with Nasal polyoposis

Microscopic picture of Nasal Polyp showing Eosinophils

Discussion

The sinonasal polyposis is a disease of middle age with an average age of onset being 41 years and the typical age of diagnosis ranging from 40 to 60 years, Gregorias et al. [7], Fokkens et al. [8]. In the current study, maximum number of patients i.e 29% were in the age group of 62–69 years followed by 21% in the age group of 50–59 and 4–49 years. 19.4% patients in the age group of 32–39 and 9.7% in the age group of 20–9. Mean age was 48.3+-13.47. In the current study, majority of the patients i.e 74.2% were males and 25.8% were females with a male to female ratio of 2.9: 1. The distinct male dominance of nasal polyposis has been widely reported in many earlier studies as well, Tiwari et al. [9], Varshney et al. [10], Shruthi [11].

In our study, endoscopic findings among the participants revealed polyp in 91.9%, oedema 85.5% and discharge in 69.4%. Crusting was present in 46.8% and scarring was present in 35.5%. Our study findings in terms of most common endoscopic findings as polyp is similar to the study by Wang et al. [12] where polyp is found in 92.6% patients followed the discharge in 55% patients. Nathan et al. [13] also revealed polyp to be the most common endoscopic finding. Another study by Aslan et al. [2] also had similar results.

It has been found that levels of cosinophilic granule protein and its chemotactic proteins are all elevated in patients with Sino-nasal polyposis Olze et al. [14], Yao et al. [15] Derycke et al. [16]. In current study eosinophil level > 500 per microliter was found in 75.8% of the study participants. This is in accordance with the study done by Mohammad WEL anwar et al. [17] who found eosinophil levels in patients with nasal polyps > 500 per microlitre what is the similar study was done by Sree Parvathi et al. [18] found higher eosinophil count.

We checked the severity of nasal polyposis by Lund Kennedy endoscopic score. The Lund Kennedy endoscopic score consists of five terms (polyposis, discharge, oedema, scarring and crusting) guided by ordinal scale from 0 to 2 for each side. Higher score indicates worse disease [Adam s DE Conde et al 2017] [19]. In our study mean Lund Kennedy score of (13.34 ± 1.178) was found in 75.8% patients and mean Lund Kennedy score (7.00 ± 0.632) in 25.7% patients. In current study we compared the Lund Kennedy score with the peripheral tissue eosinophil count and we found statistically significant p < 0.0001 which means higher the eosinophil count higher the endoscopic score.

These findings were in accordance with a study conducted by El Anwar et al. [17], Decotso et al. [20]. There was also a positive linear correlation between Lund Kennedy score with both peripheral and tissue eosinophil count r-value − 0.948 and 0.744 respectively. The results were in accordance with a study done by Solen et al. [21], Aslan et al. [2]

Conclusion

In conclusion, eosinophils are the common constituents ofnasal polyps, and are implicated in etiopathogenesis of nasal polyps. The conducted study indicates that the levels of tissue and peripheral eosinophils are positively related to severity of nasal polyps as indicated Lund Kennedy scores. Also our study concluded that the disease has male preponderance. Moreover, our study concluded that tissue and peripheral eosinophils are positively correlated to each other.