Abstract
Nasal polyps are benign inflammatory growth of sinonasal mucosa, often associated with chronic rhinosinusitis. This condition prevalent among adults, significantly impacts the quality of life. Eosinophil plays a crucial role in the pathogenesis of nasal polyposis. Hence, this study was carried out to compare the relationship between tissue eosinophilia and radiological findings in nasal polyposis. This observational study was conducted at a tertiary care centre, involving 30 patients with nasal polyposis underwent endoscopic sinus surgery. All patients underwent pre operative CT scan and Lund MacKay score were calculated. Excised polyp tissues were examined, and eosinophil count was calculated per high power field (400 X). Eosinophil count was categorized as low (≤ 10 E/HPF) and high (> 10 E/HPF). The study population had a mean age of 41.65 ± 11.43 years, with a male predominance (80%). Hypertension was the most common comorbidity (26.67%). The mean Lund MacKay score was 18.03 ± 4.3 with the majority of patients (60%) had Lund-Mackay scores between 17–24, indicating significant sinus involvement. Patients with higher eosinophil counts (> 10 E/HPF) showed more severe disease, reflected by higher Lund-Mackay scores (p < 0.0001). A moderate positive correlation (r = 0.005) was observed between tissue eosinophil count and Lund-Mackay scores. This study found moderate positive correlation between the Lund Mackay score and tissue eosinophil count. The correlation between tissue eosinophil count and disease severity underscores its potential as a prognostic marker in nasal polyposis.
Keywords: Nasal polyposis, Eosinophils, Lund-mackay score, Chronic rhinosinusitis with nasal polyposis
Introduction
Nasal polyps are benign, inflammatory, and hyperplastic protrusion of sinonasal mucosa. The prevalence of nasal polyposis among Indian population is 1–4% and males are more frequently affected than females [1]. Nasal polyposis represents terminal manifestation of uncontrolled hypersensitivity which is frequently associated with chronic rhinosinusitis. Nasal polyposis may also be linked to conditions like cystic fibrosis, aspirin-exacerbated respiratory disease (AERD), and systemic vasculitis. These conditions may present with substantial nasal obstruction, nasal congestion, anosmia and rhinorrhoea or may even be asymptomatic at times [2]. Despite the fact that numerous studies have been conducted to determine the etiopathogenesis of nasal polyposis, the precise cause remains unknown. Nasal polyposis often results from eosinophilia driven by T-helper 2 (Th2) cells, IgE inflammation, and IL-5. These conditions are frequently triggered by exposure to seasonal and environmental allergens [3]. On histopathological examination nasal polyps are usually infiltrated with inflammatory cells, predominantly eosinophil infiltration along with myxoid stroma and with or without squamous metaplasia [4]. The Lund-Mackay scoring system is a widely used and highly regarded tool for assessing the severity of CRSwNP. It is based on radiological findings from CT scans and provides a quantitative measure of the extent of sinus involvement. The Lund-Mackay system offers a standardized approach to evaluate the extent of sinus disease, which is crucial for both diagnostic and prognostic purposes [5]. Various studies have examined the relationship between tissue and peripheral eosinophilia and correlation of radiological findings with severity of disease. Only limited studies have explored the correction between the disease severity in CT scan and eosinophil infiltration in polyp tissue. The present study aimed to explore the relationships between radiological findings (CT) and tissue eosinophil count in nasal polyposis patients.
Materials and Methods
The study involved 30 patients who underwent endoscopic sinus surgery at a tertiary care centre in western Maharashtra. The study included patients over 18 years old with nasal polyposis who had undergone surgery following adequate conservative management. Patients with allergic fungal rhinosinusitis or sinonasal malignancy were excluded from the study.
Preoperative computed tomography (CT) scan was conducted, and the Lund-Mackay score was determined. The Lund MacKay score of participants was categorized into three categories (0–8, 9–16 and 17–24). Nasal polyp tissues were examined microscopically, with eosinophil counts calculated per high power field (400X). Eosinophil counts were categorized as high [> 10 eosinophils per high power field, (HPF)] or low (≤ 10 eosinophils per HPF). The results were then tabulated and analysed using appropriate statistical methods.
Data were entered in Microsoft Excel and analyzed using statistical software SPSS version 26 (SPSS Inc., Chicago, IL, USA). The continuous variables were evaluated by mean (standard deviation) or range value when required. The dichotomous variables were presented in number/frequency and were analyzed using the Chi-square test. A p-value of < 0.05 or 0.001 was regarded as significant.
Results
In our study, the mean age of patients was 41.65 ± 11.43 years, with the majority being male (24 patients, or 80%). Comorbidities were present in 53.33% of the patients (n = 16), with hypertension (HTN) being the most common, affecting 8 patients (26.67%). The mean preoperative Lund-Mackay score from CT scans was 18.03 ± 4.3. Most patients (18, or 60%) had Lund-Mackay scores in the higher range (17–24), while 11 patients (36.67%) had scores in the range of 9–16. (Table 1, Fig. 1).
Table 1.
Distribution of lund-mackay scores
| Lund mackay score | Number | Percentage |
|---|---|---|
| 0–8 | 1 | 3.33% |
| 9–16 | 11 | 36.67% |
| 17–24 | 18 | 60.00% |
| Mean ± SD | 18.03 ± 4.73 | |
Fig. 1.
Graphical presentation of distribution of lund-mackay scores
Based on the tissue eosinophil count, patients were categorized into high and low eosinophilia groups. The majority of patients, 21 (70%), fell into the high eosinophilia category (> 10/HPF) (Table 2, Fig. 2).
Table 2.
Tissue eosinophil count in the population
| Tissue eosinophil count | Number | Mean ± SD | Percentage |
|---|---|---|---|
| ≤ 10 E/HPF | 9 | 6.84 ± 2.68 | 30.00% |
| > 10 E/HPF | 21 | 14.84 ± 4.81 | 70.00% |
| Grand Total | 30 | 100.00% |
Fig. 2.
Graphical presentation of tissue eosinophil count wise
For individuals with a tissue eosinophil count of ≤ 10 E/HPF, the mean Lund-Mackay score was 7.18, with a standard deviation (SD) of 3.97. In contrast, those with a tissue eosinophil count > 10 E/HPF had a higher mean Lund-Mackay score of 13.65, with an SD of 5.33. Statistical analysis showed a highly significant difference between these groups, with a p-value of less than 0.0001. This indicates a strong correlation between higher tissue eosinophil count and increased severity of sinus disease, as evidenced by higher Lund-Mackay CT scores, underscoring the potential clinical importance of tissue eosinophil counts in evaluating sinus disease severity. (Table 3, Fig. 3)
Table 3.
Comparison of lund-mackay scores based on tissue eosinophil count levels
| Tissue eosinophil count levels | Lund mackay score | P-Value |
|---|---|---|
| ≤ 10 E/HPF | 7.18 ± 3.97 | p < 0.0001* |
| > 10 E/HPF | 13.65 ± 5.33 |
Fig. 3.
Graphical presentation of comparison of lund-mackay scores based on tissue eosinophil count levels
The Pearson correlation coefficient (r) of 0.46 between Lund-Mackay scores and tissue eosinophil count indicates a moderate positive correlation, suggesting that as one variable increases, the other variable tends to increase as well. The confidence interval (CI) for this correlation ranges from 0.378 to 0.458, which means there is a 95% chance that the true correlation coefficient falls within this range. The p-value of 0.005 confirms that this correlation is statistically significant. (Table 4, Fig. 4).
Table 4.
Correlation between lund-mackay scores and tissue eosinophil count
| Lund-MacKay Vs. Tissue eosinophil Count Pearson correlation | |
|---|---|
| r | 0.464 |
| 95% CI | 0.378–0.458 |
| P-value | 0.005* |
| Interpretation | Moderate correlation |
Fig. 4.
Graphical presentation of correlation between lund-mackay scores and tissue eosinophil count levels
Discussion
Nasal polyposis usually affects younger patients, in a study by Karuthedath et al., the most commonly affected age group was 31–40 years, comprising 46.7% of the participants [6]. Similarly, Ogunleye et al. conducted a 5-year study involving 63 patients with nasal polyposis, reporting a mean age of 34 years [7]. These results were in line with the results of our study.
Males are more prone to develop nasal polyposis than females. Our study found a notable male predominance, making up to 80% of the patient population. This observation is consistent with findings from several other studies [6, 8].
CRSwNP often coexists with other significant medical conditions, which can impact the severity of the disease. A large-scale retrospective study of more than 400,000 primary care patients revealed a significantly higher prevalence of allergic rhinitis, asthma, and sleep apnoea among individuals with CRSwNP [9]. In our study, hypertension was the most prevalent comorbidity, affecting 26.67% of the patients. However, a substantial portion (46.67%) of individuals had no reported comorbidities, indicating that sinus disease can manifest independently or alongside various other health conditions. In 2023, Y Zhang identified a casual correlation between the prevalence of hypertension and the occurrence of rhinitis symptoms [10]. This observation aligns with the findings of several other studies [11].
Recent studies have indicated a potential link between bronchial asthma and CRSwNP. These conditions share similar pathogenesis, characterized by mucosal sensitivity to chronic stimuli. Furthermore, eosinophilic inflammation plays a crucial role in the pathogenesis of both diseases, serving as a primary source of the persistent stimuli [12]. A recent study conducted in Finland investigated the comorbidities of patients with chronic rhinosinusitis where asthma was found to be the most common comorbidity, especially among those with CRSwNP, affecting 48.6% of patients [13]. However, in our study only 6.67% of individuals had asthma, which contrasts with the findings of other studies, this can be due to the small sample size and larger study may be undertaken to assess the association between these two conditions.
In our study, the Lund-Mackay scores ranged from 8 to 24, with mean score of 18.03. This finding is consistent with other studies, such as the prospective study by Amodu et al., which involved 60 patients with nasal polyposis and reported a mean Lund-Mackay score of 16.78. In our study, we also observed that higher Lund-Mackay scores were associated with more severe disease and a greater degree of polyposis, which is similar to the findings of other studies [14].
The pathophysiology of chronic rhinosinusitis with nasal polyposis is not fully understood, however, eosinophilic inflammation has been identified to play a key role in pathogenesis of nasal polyposis. We found that majority of patients (70%) had high tissue eosinophilia levels, many histological studies have demonstrated high levels of eosinophil infiltration in nasal polyp tissues [15].
Our study demonstrated that patients with high eosinophil count in polyp tissue had high Lund-MacKay score. Individuals with tissue eosinophil count of > 10 E/HPF had a mean Lund-MacKay score of 13.65 whereas, those with tissue eosinophil count of ≤ 10/HPF) showed a lower mean Lund-Mackay score of 7.18. The results are comparable with other studies which showed that patients with high mucosal eosinophilic count had significant higher mean Lund-MacKay score than those with low mucosal eosinophil count [16, 17].
This observational study highlights a strong association between tissue eosinophil count levels and disease severity, suggesting that tissue eosinophil count could serve as a valuable prognostic marker for assessing the severity of sinonasal disease. The moderate positive correlation found between tissue eosinophil count levels and Lund-Mackay scores underscores the importance of evaluating local eosinophilic inflammation in addition to radiological evaluation in the management of sino-nasal polyposis.
Conclusion
This study demonstrates a positive correlation between tissue eosinophil counts and Lund-Mackay scores, indicating that higher tissue eosinophil count levels are linked to more severe disease. This relationship could be useful in identifying patients who may need more aggressive treatment or more frequent follow-up for optimal management.
Limitations
The study’s sample size of 30 patients limits its generalizability for Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP) patients. Additionally, being conducted at a single institution, the study may be subject to bias related to demographics and treatment practices, which could affect its external validity. Larger, more diverse studies are necessary to externally validate these results and confirm their reliability and clinical significance.
Funding
None
Declarations
Competing interests
The author has informed that the authors have no competing interests to declare that are relevant to the content of this article.
Ethical approval
Ethical approval was secured following international and institutional standards, with written consent maintained by the authors.
Consent to participate
In accordance with international and institutional guidelines, written consent from participants was obtained and is retained by the authors.
Conflict of interest
The authors have no conflicts of interest to disclose.
Footnotes
Publisher’s Note
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