CLINICAL STUDY
Histopathological Characteristics of Nasal Polyps in Smokers and Non-Smokers Zeynep Gökçen Kule, MD,* Tulay Erden Habesoglu, MD,* Adnan Somay, MD,† Hande Senem Deveci, MD,* Mustafa Kule, MD,* and Ali Okan Gursel, MD* Objective: It is known that cigarette smoking causes squamous metaplasia in upper and lower airways. We hypothesized that in patients with nasal polyposis, nasal polyps of smokers might reveal some histopathological changes and there might be an increased neoplasia risk. Therefore, in this study, we aimed to explore the effects of smoking on nasal polyp histopathology and clinical measures. Study Design: Retrospective chart review Setting: Fatih Sultan Mehmet Education and Research Hospital Material and Methods: Thirty smoker and 47 non-smoker patients with nasal polyposis who underwent endoscopic sinus surgery between 2007 and 2011 were enrolled in this study to assess effect of smoking on histopathological characteristics of nasal polyps and clinical measures such as endoscopy score, computed tomography score of Lund-Mackay, Nasal Obstruction Symptom Evaluation (NOSE) Scale, presence of allergy and asthma, and blood eosinophil level. Results: No statistically significant differences were found between smoker and non-smoker groups with regard to histopathological findings. Also, there were no significant correlation defined by endoscopy, computed tomography, and NOSE scores of patients between 2 groups. Smoking did not have a significant effect on the presence of allergy or asthma. But blood eosinophil levels were found to be significantly high in the smoker group. Conclusion: This is the first clinical study that investigates the effect of smoking on nasal polyp histopathology. In spite of the fact that smoking is associated with histopathological changes in respiratory mucosa, we did not find any significant change in histopathological characteristics of nasal polyps in smokers. Key Words: Nasal polyposis, histopathology, smoking (J Craniofac Surg 2014;25: 946–949)
N
asal polyposis is a multifactorial disease and affects 2% to 4% of the general population.1,2 They may be seen in different conditions such as chronic rhinosinusitis (CRS), cystic fibrosis, Wegener granulomatosis, and Kartagener syndrome.2 Although the pathogenesis of the polyposis is unclear, a proliferative process associated with fibrosis, atypical gland formation, goblet cell hyperplasia, subepithelial edema, and mononuclear cell infiltration were supposed.3,4 Allergy, infective or immunologic inflammation, and genetic predisposition are of the proposed hypotheses for its pathogenesis.2 However, there has been little research on causes other than on allergens and allergic rhinitis. The upper airway serves as the first line of defense against inhaled pollutants, removing larger particles and soluble gases. Consequently, the cells lining the upper airways are exposed to numerous inhaled pollutants which may contribute to the burden of symptoms and diseases of the upper airway.5 Compared to the lungs, the direct effect of smoking on the upper airway is less extensively studied. Moreover, chronic obstructive pulmonary disease patients report a high prevalence of nasal symptoms and sinusitis.6 Also, most importantly, cigarette smoking may cause squamous metaplasia in upper and lower airways. We hypothesized that in patients with nasal polyposis, nasal polyps of smokers might reveal some histopathological changes and there might be an increased neoplasia risk. Therefore, in this study, we aimed to explore the effects of smoking on nasal polyp histopathology and clinical measures.
PATIENTS AND METHODS Patients The study group consisted of 77 (52 male, 25 female) patients with nasal polyposis who underwent 89 endoscopic sinus surgery (ESS) at Fatih Sultan Mehmet Education and Research Hospital between 2007 and 2011. The mean age of patients was 46.99 ± 13.27 years (range 17–71 years). The study protocol was approved by Fatih Sultan Mehmet Hospital Education and Research Hospital.
Study Design From the *Departments of Otorhinolaryngology and †Pathology, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey. Received May 8, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Tulay Erden Habesoglu, MD, Department of Otorhinolaryngology, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey; E-mail: [email protected] This study was presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Washington, DC, September 9–12, 2012. The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000731
946
Nasal polyposis was diagnosed by endoscopic findings and computed tomography. Patients with sinonasal malignancy, antrochoanal polyp, and systemic diseases were excluded from the study.
Allergy and Asthma Skin prick tests with commercial extracts of the main airborne allergens were performed. Blood eosinophil counts were obtained through routine blood analysis. Patients were consulted to Internal Medicine for the diagnosis of asthma by means of clinical symptoms, physical findings, and pulmonary function tests.
Nasal Symptom Score Nasal obstruction was evaluated by Nasal Obstruction Symptom Evaluation (NOSE) Scale.7
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Nasal polyp histopathology in smokers
Polyp Size
Stromal Cell Atypia
Endoscopic score of polyposis was calculated from 0 to 3 for each nasal cavity: 0, no polyp; 1, mild polyposis limited to middle meatus; 2, moderate polyposis reaching below middle concha; and 3, severe polyposis.8
At a magnification of 100, stromal cell atypia was scored as 0 (absent) or 1 (present). We investigated these histopathological findings in nasal polyp tissues and compared histopathological characteristics of nasal polyps with the extent of the disease and some accompanying factors.
Radiologic Score Paranasal sinus computed tomography (CT) scan was performed in all patients and was staged using Lund-Mackay score system9: 0, no opacity; 1, partial opacity; and 2, total opacity for each sinuses. The osteomeatal complex scores 0 for no obstruction or 2 when obstructed. The total score of the system is 24 bilaterally. ESS was performed using standard techniques under general anesthesia. Patients had received at least 8 weeks of topical nasal corticosteroid in addition to irrigation of the nose with normal saline. During ESS, nasal polyp tissue was obtained from each patient and stained with hematoxylin-eosin. Light microscope was used to evaluate the following histopathological characteristics and scored.10,11
Thickness of the Basement Membrane At a magnification of 400, the thickest part of the basement membrane was measured by an Olympus CX41 microscope with an ocular micrometer. A score was assigned according to the degree of visible basement thickening: 0, none (30 μm).
Goblet Cell Hyperplasia At a magnification of 400, a score was assigned according to the number of goblet cells visible: 0 (20 cells).
Subepithelial Edema At a magnification of 100, a score was assigned according to the degree of subepithelial edema: 0 (none), 1 (mild), 2 (moderate), or 3 (marked).
Submucous Gland Formation At a magnification of 100, a score was assigned according to the number of submucous glands visible in a section: 0 (30 cells).
Eosinophil Infiltration At a magnification of 400, the number of eosinophils present within epithelial cells and in the submucosa was scored as 0 (none), 1 (1–2 eosinophils), 2 (3–10 eosinophils), 3 (11–30 eosinophils), or 4 (>30 eosinophils).
Statistical Analysis All statistical calculations were performed with NCSS 2007 and PASS 2008 Statistical Software (NCSS, Kaysville, UT). In addition to standard descriptive statistical calculations (mean, median, and standard deviation), the Kruskal-Wallis test and the one-way ANOVA test were used in the assessment of parameters according to groups. The Student t test and the Mann-Whitney U test were used for the evaluation of differences between 2 groups. The statistical significance level was established at P less than 0.05, and confidence intervals were 95%.
RESULTS The mean age of patients was 46.99 ± 13.27 years (range 17–71 years), and 85.7% (n = 66) of cases had bilateral disease. Although 25.8% (n = 23) of the patients had no basement membrane thickening, 58.4% (n=52) of patients had mild, 12.4% (n = 11) of patients had medium, and 3.4% (n = 3) of patients had significant basement membrane thickening (Fig. 1). In 27.0% (n = 24) of the patients, less than 3 goblet cells were observed; 36.0% (n = 32) of patients had goblet cells between 3 and 10; 21.3% (n = 19) of patients had 11 to 20, and 15.7% (n = 14) patients had more than 20 goblet cells (Fig. 2). Moreover, 1.1% (n = 1) of patients had no subepithelial edema, but 25.8% (n = 23) of patients had mild, 57.3% (n = 51) of patients had moderate, and 15.7% (n = 14) patients had marked subepithelial edema. In 46.1% (n = 41) of the patients, less than 3 submucosal glands were visualized; 39.3% (n = 35) of cases had between 3 and 10, and 14.6% (n = 13) of cases had more than 11 submucosal glands (Fig. 3). In 16.9% (n = 15) of the cases, no eosinophil was visualized. Furthermore, 37.1% (n = 33) of patients had eosinophils between 1 and 2, 14.6% (n = 13) of cases had between 3 and 10, and 31.5% (n = 28) of patients had more than 11 eosinophils (Fig. 4). Less than 20 lymphocytes were observed in 23.6% (n = 21) of patients. In 47.2% (n = 42) of the cases, between 21 and 50 lymphocytes were visualized; in 7.9% (n = 7) of patients, between 51 and 80 lymphocytes were visualized; and in 15.7% (n = 14) of patients, between 81 and 120 lymphocytes were visualized. Also, 5.6% (n = 5) of patients had greater than 120 lymphocytes. There was no PMNL observed in 16.9% (n = 16) of the cases. Also, 48.3% (n = 43) of patients had PMNL between 1 and 2, 29.2%
Lymphocyte Infiltration At a magnification of 400, the number of lymphocytes present in the submucosa was scored as 0 (none), 1 (120 lymphocytes).
FIGURE 1. Marked thickening of basement membrane (HE, original magnification 400).
Polymorphonuclear Leucocyte Infiltration At a magnification of 400, the number of polymorphonuclear leucocytes (PMNLs) present in submucosa was scored as follows: 0 (none), 1 (1–2 PMNLs), 2 (3–10 PMNLs), or 3 (>10 PMNLs).
Squamous Metaplasia At a magnification of 100, squamous metaplasia was scored as 0 (none), 1 (mild), 2 (moderate), or 3 (marked).
FIGURE 2. Goblet cell hyperplasia in the epithelium (HE, original magnification 400).
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Kule et al
TABLE 2. Comparison of Histological Scores Between Smokers and Non-Smokers
Histopathology Thickness of the basement membrane
FIGURE 3. Submucous gland formation in polyp tissue (HE, original magnification 200).
None (n = 23) Mild (n = 52) Moderate and marked (n = 14)
+
P Subepithelial edema
Mild (n = 24) Moderate (n = 51) Marked (n = 14)
+
P Submucous gland formation
FIGURE 4. Marked eosinophils in polyp tissue (HE, original magnification 400).
+ P Goblet cell hyperplasia
FIGURE 5. Mild squamous metaplasia in epithelium and marked subepithelial edema (HE, original magnification 100).
+ P Lymphocyte infiltration
TABLE 1. Distribution of Histological Scores
Thickness of the basement membrane
Goblet cell hyperplasia
Subepithelial edema
Submucous gland formation
Eosinophil infiltration
Lymphocyte infiltration
PMNL infiltration
Squamous metaplasia
948
+ P Eosinophil infiltration
None Mild Moderate Marked 20 None Mild Moderate Marked 11 None 1–2 3–10 >11 120 None 1–2 3–10 >10 None Mild Moderate Marked
n
%
23 52 11 3 24 32 19 14 1 23 51 14 41 35 13 15 33 13 28 21 42 7 14 5 16 43 26 5 67 15 6 1
25.8 58.4 12.4 3.4 27.0 36.0 21.3 15.7 1.1 25.8 57.3 15.7 46.1 39.3 14.6 16.9 37.1 14.6 31.5 23.6 47.2 7.9 15.7 5.6 16.9 48.3 29.2 5.6 75.3 16.9 6.7 1.1
+ P PMNL infiltration
11 (n = 13) 20 (n
= 24) = 32) = 19) = 14)
30 (n
= 15) = 33) = 13) = 28)
51 (n = 26) None 1–2 >3
+
P Squamous metaplasia
Present (n = 22) Absent (n = 67)
+
P
Smoker
Non-Smoker
n (%)
n (%)
8 (34.8%) 20 (38.5%) 5 (35.7%)
15 (65.2%) 32 (61.5%) 9 (64.3%)
0.948 7 (29.2%) 21 (41.2%) 5 (35.7%) 0.600 12 (29.3%) 15 (42.9%) 6 (46.2%) 0.362 7 (29.2%) 12 (37.5%) 9 (47.4%) 5 (35.7%) 0.678 7 (46.7%) 14 (42.4%) 4 (30.8%) 8 (28.6%) 0.555 8 (38.1%) 18 (42.9%) 7 (26.9%) 0.415 7 (46.7%) 18 (41.9%) 8 (25.8%) 0.259 8 (36.4%) 25 (37.3%) 0.936
17 (70.8%) 30 (58.8%) 9 (64.3%) 29 (70.7%) 20 (57.1%) 7 (53.8%) 17 20 10 9
(70.8%) (62.5%) (52.6%) (64.3%)
8 (53.3%) 19 (57.6%) 9 (69.2%) 20 (71.4%) 13 (61.9%) 24 (57.1%) 19 (73.1%) 8 (53.3%) 25 (58.1%) 23 (74.2%) 14 (63.6%) 42 (62.7%)
One-way ANOVA. +
Chi-square test.
(n = 26) patients had PMNL between 3 and 10, and 5.6% (n = 5) patients had more than 11 PMNL. Although there was no squamous metaplasia visualized in the majority (75.3%) of patients, in 16.9% (n = 15) of patients mild, in 6.7% (n = 6) of patients moderate, and in 1.1% (n = 1) marked squamous metaplasia was observed (Fig. 5) (Table 1). No statistically significant differences were found between smoker and non-smoker groups with regard to these histopathological findings (Table 2). Also, there were no significant correlations defined by endoscopy, computed tomography, and NOSE scores of patients between 2 groups. Smoking did not have a significant effect on the presence of allergy or asthma. But blood eosinophil levels were found to be significantly high in the smoker group (Table 3).
DISCUSSION It has been described that nicotine has an effect on the nasal epithelium, regulating physiological processes and influencing cell transport systems.12 Smoking can increase nasal resistance,13 and the direct use of tobacco could be linked to an increased prevalence © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
TABLE 3. Evaluation of Clinical Measures of Smokers and Non-Smokers
Radiologic score NOSE score ++ Blood eosinophil Polyp size
Allergy Asthma
1 Grade 2 Grade 3 Grade Present Absent Present Absent
Smoker
Non-Smoker
Mean ± SD
Mean ± SD
19.45 ± 5.43 13.63 ± 3.35 0.35 ± 0.26 (0.30) n (%) 6 (18.2%) 22 (66.7%) 5 (15.2%) 11 (33.3%) 22 (66.7%) 6 (18.2%) 27 (81.8%)
18.64 ± 5.62 13.24 ± 3.27 0.26 ± 0.23 (0.20) n (%) 12 (21.4%) 32 (57.1%) 12 (21.4%) 12 (21.4%) 44 (78.6%) 14 (25.0%) 42 (75.0%)
0.810 0.383 0.043* + P 0.655
0.215 0.457
Chi-square test.
++
made in polyp tissues in smokers. In our study, we also aimed to explore the effects of smoking on nasal polyp histopathology as well as investigating the effect of smoking on clinical measures in nasal polyposis patients who were current smokers. We did not find any significant change in the histopathology of nasal polyp tissues in smokers when compared to non-smokers. We also think that the next step should be to investigate histopathological changes in a larger population or to investigate molecular changes in polyp tissues in smokers for the best reasons in this issue.
REFERENCES
Student t test. +
Nasal polyp histopathology in smokers
Mann-Whitney U test.
*P < 0.05
of sinusitis.14 Also, a study of retrospective cases found that smoking predicted poorer postoperative recovery after endoscopic surgery for CRS.15,16 However, in another study, no relationship was observed between smoking and predictive factors for CRS, such as CT evaluation and endoscopic examination.17 Yee et al have shown that CRS patients who were current smokers had a predominance of squamous metaplasia in the olfactory sensory epithelium when compared with non-smokers.18 In another study examining the effect of smoking on histology in nasal mucosa of smokers, it was found that stromal edema, congestion, epithelial thickness, and diffuse lymphocytic infiltration increased significantly in the nasal mucosa of individuals who smoke.19 On the other hand, according to Higgins et al, smoking and passive smoking can elevate matrix metalloproteinase 9, which is thought to contribute to the pathophysiology of allergy. They also implied that cigarette smoke was a common irritant that impacts the innate immune function of the sinonasal epithelial cells, and creates local irritation and cytotoxic effects.20 Also, Rouhos et al found in their study that smokers with asthma showed significantly higher fractional exhaled nitric oxide, which is useful in assessing eosinophilic airway inflammation.21 Nasal polyps is one of the most popular pathology in the upper airway tract. It may usually coexist with CRS, allergy, and asthma. Therefore, it was suggested that smoking could also affect nasal polyp histopathology like CRS, allergy, and asthma. Erbek et al studied 125 patients with nasal polyposis investigating the effects of smoking on the polyp stage, paranasal sinus CT score, total IgE levels, blood eosinophil count, and symptom scores.22 They did not find any significant relationship between smokers and non-smokers in terms of polyp stage, CT scores, total IgE levels, and blood eosinophil count. Also, the incidence of allergy, asthma, or aspirin sensitivity was not different between the groups. Only symptom scores of nasal obstruction were significantly different in smokers. In our study, in contrast to Higgins et al and Rouhos et al,20,21 we did not find any significant effect of smoking on the presence of allergy or asthma, but blood eosinophil levels were found to be significantly high in smoker group. Also, we did not find any significant correlation defined by endoscopy, CT, and NOSE scores of patients between 2 groups as in the study of Erbek et al except for the NOSE scores. Although histopathological evaluation on the effect of smoking on healthy nasal mucosa or nasal mucosa of CRS patients was documented before, to date, no histopathological evaluation was
1. Bachert C, Hörmann K, Mösges R, et al. An update on the diagnosis and treatment of sinusitis and nasal polyposis. Allergy 2003;58:176–191 2. Ardehali MM, Amali A, Bakhshaee M, et al. Histopathologic characteristics of inferior turbinate vs ethmoidal polyp in chronic rhinosinusitis. Ann Diagn Pathol 2011;15:233–236 3. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997;117:S1–S7 4. Georgitis JW, Matthews BL, Stone B. Chronic sinusitis: characterization of cellular influx and inflammatory mediators in sinus lavage fluid. Int Arch Allergy Immunol 1995;106:416–421 5. Samet JM. Adverse effects of smoke exposure on the upper airway. Tob Control 2004;13(Suppl 1):i57–i60 6. Vachier I, Vignola AM, Chiappara G, et al. Inflammatory features of nasal mucosa in smokers with and without COPD. Thorax 2004;59:303–307 7. Stewart MG, Witsell DL, Smith TL, et al. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004;130:157–163 8. Lildholdt T, Rundcrantz H, Lindqvist N. Efficacy of topical corticosteroid powder for nasal polyps: a double-blind, placebo-controlled study of budesonide. Clin Otolaryngol Allied Sci 1995;20:26–30 9. Lund VJ, Mackay IS. Staging in rhinosinusitus. Rhinology 1993;31:183–184 10. Dhong HJ, Kim HY, Cho DY. Histopathologic characteristics of chronic sinusitis with bronchial asthma. Acta Otolaryngol 2005;125:169–176 11. Ardehali MM, Amali A, Bakhshaee M, et al. The comparison of histopathological characteristics of polyps in asthmatic and nonasthmatic patients. Otolaryngol Head Neck Surg 2009;140:748–751 12. Blank U, Rückes C, Clauss W, et al. Effects of nicotine on human nasal epithelium: evidence for nicotinic receptors in non-excitable cells. Pflugers Arch 1997;434:581–586 13. Bascom R, Kulle T, Kagey-Sobotka A, et al. Upper respiratory tract environmental tobacco smoke sensitivity. Am Rev Respir Dis 1991;143:1304–1311 14. Lieu JE, Feinstein AR. Confirmations and surprises in the association of tobacco use with sinusitis. Arch Otolaryngol Head Neck Surg 2000;126:940–946 15. Briggs RD, Wright ST, Cordes S, et al. Smoking in chronic rhinosinusitis: a predictor of poor long-term outcome after endoscopic sinus surgery. Laryngoscope 2004;114:126–128 16. Krzeski A, Galewicz A, Chmielewski R, et al. Influence of cigarette smoking on endoscopic sinus surgery long-term outcomes. Rhinology 2011;49:577–582 17. Smith TL, Mendolia-Loffredo S, Loehrl TA, et al. Predictive factors and outcomes in endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope 2005;115:2199–2205 18. Yee K, Pribitkin E, Cowart B, et al. Smoking-associated squamous metaplasia in olfactory mucosa of patients with chronic rhinosinusitis. Toxicol Pathol 2009;37:594 19. Hadar T, Yaniv E, Shvili Y, et al. Histopathological changes of the nasal mucosa induced by smoking. Inhal Toxicol 2009;21:1119–1122 20. Higgins TS, Reh DD. Environmental pollutants and allergic rhinitis. Curr Opin Otolaryngol Head Neck Surg 2012;20:209–214 21. Rouhos A, Ekroos H, Karjalainen J, et al. Smoking attenuates increase in exhaled nitric oxide in atopic but not in nonatopic young adults with asthma. Int Arch Allergy Immunol 2010;152:226–232 22. Erbek SS, Erbek S, Budakoğlu I, et al. The relationship between smoking and nasal polyposis. Kulak Burun Bogaz Ihtis Derg 2008;18:216–220
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
949
Histopathological Characteristics of Nasal Polyps in Smokers and Non-Smokers Zeynep Gökçen Kule, MD,* Tulay Erden Habesoglu, MD,* Adnan Somay, MD,† Hande Senem Deveci, MD,* Mustafa Kule, MD,* and Ali Okan Gursel, MD* Objective: It is known that cigarette smoking causes squamous metaplasia in upper and lower airways. We hypothesized that in patients with nasal polyposis, nasal polyps of smokers might reveal some histopathological changes and there might be an increased neoplasia risk. Therefore, in this study, we aimed to explore the effects of smoking on nasal polyp histopathology and clinical measures. Study Design: Retrospective chart review Setting: Fatih Sultan Mehmet Education and Research Hospital Material and Methods: Thirty smoker and 47 non-smoker patients with nasal polyposis who underwent endoscopic sinus surgery between 2007 and 2011 were enrolled in this study to assess effect of smoking on histopathological characteristics of nasal polyps and clinical measures such as endoscopy score, computed tomography score of Lund-Mackay, Nasal Obstruction Symptom Evaluation (NOSE) Scale, presence of allergy and asthma, and blood eosinophil level. Results: No statistically significant differences were found between smoker and non-smoker groups with regard to histopathological findings. Also, there were no significant correlation defined by endoscopy, computed tomography, and NOSE scores of patients between 2 groups. Smoking did not have a significant effect on the presence of allergy or asthma. But blood eosinophil levels were found to be significantly high in the smoker group. Conclusion: This is the first clinical study that investigates the effect of smoking on nasal polyp histopathology. In spite of the fact that smoking is associated with histopathological changes in respiratory mucosa, we did not find any significant change in histopathological characteristics of nasal polyps in smokers. Key Words: Nasal polyposis, histopathology, smoking (J Craniofac Surg 2014;25: 946–949)
N
asal polyposis is a multifactorial disease and affects 2% to 4% of the general population.1,2 They may be seen in different conditions such as chronic rhinosinusitis (CRS), cystic fibrosis, Wegener granulomatosis, and Kartagener syndrome.2 Although the pathogenesis of the polyposis is unclear, a proliferative process associated with fibrosis, atypical gland formation, goblet cell hyperplasia, subepithelial edema, and mononuclear cell infiltration were supposed.3,4 Allergy, infective or immunologic inflammation, and genetic predisposition are of the proposed hypotheses for its pathogenesis.2 However, there has been little research on causes other than on allergens and allergic rhinitis. The upper airway serves as the first line of defense against inhaled pollutants, removing larger particles and soluble gases. Consequently, the cells lining the upper airways are exposed to numerous inhaled pollutants which may contribute to the burden of symptoms and diseases of the upper airway.5 Compared to the lungs, the direct effect of smoking on the upper airway is less extensively studied. Moreover, chronic obstructive pulmonary disease patients report a high prevalence of nasal symptoms and sinusitis.6 Also, most importantly, cigarette smoking may cause squamous metaplasia in upper and lower airways. We hypothesized that in patients with nasal polyposis, nasal polyps of smokers might reveal some histopathological changes and there might be an increased neoplasia risk. Therefore, in this study, we aimed to explore the effects of smoking on nasal polyp histopathology and clinical measures.
PATIENTS AND METHODS Patients The study group consisted of 77 (52 male, 25 female) patients with nasal polyposis who underwent 89 endoscopic sinus surgery (ESS) at Fatih Sultan Mehmet Education and Research Hospital between 2007 and 2011. The mean age of patients was 46.99 ± 13.27 years (range 17–71 years). The study protocol was approved by Fatih Sultan Mehmet Hospital Education and Research Hospital.
Study Design From the *Departments of Otorhinolaryngology and †Pathology, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey. Received May 8, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Tulay Erden Habesoglu, MD, Department of Otorhinolaryngology, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey; E-mail: [email protected] This study was presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Washington, DC, September 9–12, 2012. The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000731
946
Nasal polyposis was diagnosed by endoscopic findings and computed tomography. Patients with sinonasal malignancy, antrochoanal polyp, and systemic diseases were excluded from the study.
Allergy and Asthma Skin prick tests with commercial extracts of the main airborne allergens were performed. Blood eosinophil counts were obtained through routine blood analysis. Patients were consulted to Internal Medicine for the diagnosis of asthma by means of clinical symptoms, physical findings, and pulmonary function tests.
Nasal Symptom Score Nasal obstruction was evaluated by Nasal Obstruction Symptom Evaluation (NOSE) Scale.7
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Nasal polyp histopathology in smokers
Polyp Size
Stromal Cell Atypia
Endoscopic score of polyposis was calculated from 0 to 3 for each nasal cavity: 0, no polyp; 1, mild polyposis limited to middle meatus; 2, moderate polyposis reaching below middle concha; and 3, severe polyposis.8
At a magnification of 100, stromal cell atypia was scored as 0 (absent) or 1 (present). We investigated these histopathological findings in nasal polyp tissues and compared histopathological characteristics of nasal polyps with the extent of the disease and some accompanying factors.
Radiologic Score Paranasal sinus computed tomography (CT) scan was performed in all patients and was staged using Lund-Mackay score system9: 0, no opacity; 1, partial opacity; and 2, total opacity for each sinuses. The osteomeatal complex scores 0 for no obstruction or 2 when obstructed. The total score of the system is 24 bilaterally. ESS was performed using standard techniques under general anesthesia. Patients had received at least 8 weeks of topical nasal corticosteroid in addition to irrigation of the nose with normal saline. During ESS, nasal polyp tissue was obtained from each patient and stained with hematoxylin-eosin. Light microscope was used to evaluate the following histopathological characteristics and scored.10,11
Thickness of the Basement Membrane At a magnification of 400, the thickest part of the basement membrane was measured by an Olympus CX41 microscope with an ocular micrometer. A score was assigned according to the degree of visible basement thickening: 0, none (30 μm).
Goblet Cell Hyperplasia At a magnification of 400, a score was assigned according to the number of goblet cells visible: 0 (20 cells).
Subepithelial Edema At a magnification of 100, a score was assigned according to the degree of subepithelial edema: 0 (none), 1 (mild), 2 (moderate), or 3 (marked).
Submucous Gland Formation At a magnification of 100, a score was assigned according to the number of submucous glands visible in a section: 0 (30 cells).
Eosinophil Infiltration At a magnification of 400, the number of eosinophils present within epithelial cells and in the submucosa was scored as 0 (none), 1 (1–2 eosinophils), 2 (3–10 eosinophils), 3 (11–30 eosinophils), or 4 (>30 eosinophils).
Statistical Analysis All statistical calculations were performed with NCSS 2007 and PASS 2008 Statistical Software (NCSS, Kaysville, UT). In addition to standard descriptive statistical calculations (mean, median, and standard deviation), the Kruskal-Wallis test and the one-way ANOVA test were used in the assessment of parameters according to groups. The Student t test and the Mann-Whitney U test were used for the evaluation of differences between 2 groups. The statistical significance level was established at P less than 0.05, and confidence intervals were 95%.
RESULTS The mean age of patients was 46.99 ± 13.27 years (range 17–71 years), and 85.7% (n = 66) of cases had bilateral disease. Although 25.8% (n = 23) of the patients had no basement membrane thickening, 58.4% (n=52) of patients had mild, 12.4% (n = 11) of patients had medium, and 3.4% (n = 3) of patients had significant basement membrane thickening (Fig. 1). In 27.0% (n = 24) of the patients, less than 3 goblet cells were observed; 36.0% (n = 32) of patients had goblet cells between 3 and 10; 21.3% (n = 19) of patients had 11 to 20, and 15.7% (n = 14) patients had more than 20 goblet cells (Fig. 2). Moreover, 1.1% (n = 1) of patients had no subepithelial edema, but 25.8% (n = 23) of patients had mild, 57.3% (n = 51) of patients had moderate, and 15.7% (n = 14) patients had marked subepithelial edema. In 46.1% (n = 41) of the patients, less than 3 submucosal glands were visualized; 39.3% (n = 35) of cases had between 3 and 10, and 14.6% (n = 13) of cases had more than 11 submucosal glands (Fig. 3). In 16.9% (n = 15) of the cases, no eosinophil was visualized. Furthermore, 37.1% (n = 33) of patients had eosinophils between 1 and 2, 14.6% (n = 13) of cases had between 3 and 10, and 31.5% (n = 28) of patients had more than 11 eosinophils (Fig. 4). Less than 20 lymphocytes were observed in 23.6% (n = 21) of patients. In 47.2% (n = 42) of the cases, between 21 and 50 lymphocytes were visualized; in 7.9% (n = 7) of patients, between 51 and 80 lymphocytes were visualized; and in 15.7% (n = 14) of patients, between 81 and 120 lymphocytes were visualized. Also, 5.6% (n = 5) of patients had greater than 120 lymphocytes. There was no PMNL observed in 16.9% (n = 16) of the cases. Also, 48.3% (n = 43) of patients had PMNL between 1 and 2, 29.2%
Lymphocyte Infiltration At a magnification of 400, the number of lymphocytes present in the submucosa was scored as 0 (none), 1 (120 lymphocytes).
FIGURE 1. Marked thickening of basement membrane (HE, original magnification 400).
Polymorphonuclear Leucocyte Infiltration At a magnification of 400, the number of polymorphonuclear leucocytes (PMNLs) present in submucosa was scored as follows: 0 (none), 1 (1–2 PMNLs), 2 (3–10 PMNLs), or 3 (>10 PMNLs).
Squamous Metaplasia At a magnification of 100, squamous metaplasia was scored as 0 (none), 1 (mild), 2 (moderate), or 3 (marked).
FIGURE 2. Goblet cell hyperplasia in the epithelium (HE, original magnification 400).
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Kule et al
TABLE 2. Comparison of Histological Scores Between Smokers and Non-Smokers
Histopathology Thickness of the basement membrane
FIGURE 3. Submucous gland formation in polyp tissue (HE, original magnification 200).
None (n = 23) Mild (n = 52) Moderate and marked (n = 14)
+
P Subepithelial edema
Mild (n = 24) Moderate (n = 51) Marked (n = 14)
+
P Submucous gland formation
FIGURE 4. Marked eosinophils in polyp tissue (HE, original magnification 400).
+ P Goblet cell hyperplasia
FIGURE 5. Mild squamous metaplasia in epithelium and marked subepithelial edema (HE, original magnification 100).
+ P Lymphocyte infiltration
TABLE 1. Distribution of Histological Scores
Thickness of the basement membrane
Goblet cell hyperplasia
Subepithelial edema
Submucous gland formation
Eosinophil infiltration
Lymphocyte infiltration
PMNL infiltration
Squamous metaplasia
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+ P Eosinophil infiltration
None Mild Moderate Marked 20 None Mild Moderate Marked 11 None 1–2 3–10 >11 120 None 1–2 3–10 >10 None Mild Moderate Marked
n
%
23 52 11 3 24 32 19 14 1 23 51 14 41 35 13 15 33 13 28 21 42 7 14 5 16 43 26 5 67 15 6 1
25.8 58.4 12.4 3.4 27.0 36.0 21.3 15.7 1.1 25.8 57.3 15.7 46.1 39.3 14.6 16.9 37.1 14.6 31.5 23.6 47.2 7.9 15.7 5.6 16.9 48.3 29.2 5.6 75.3 16.9 6.7 1.1
+ P PMNL infiltration
11 (n = 13) 20 (n
= 24) = 32) = 19) = 14)
30 (n
= 15) = 33) = 13) = 28)
51 (n = 26) None 1–2 >3
+
P Squamous metaplasia
Present (n = 22) Absent (n = 67)
+
P
Smoker
Non-Smoker
n (%)
n (%)
8 (34.8%) 20 (38.5%) 5 (35.7%)
15 (65.2%) 32 (61.5%) 9 (64.3%)
0.948 7 (29.2%) 21 (41.2%) 5 (35.7%) 0.600 12 (29.3%) 15 (42.9%) 6 (46.2%) 0.362 7 (29.2%) 12 (37.5%) 9 (47.4%) 5 (35.7%) 0.678 7 (46.7%) 14 (42.4%) 4 (30.8%) 8 (28.6%) 0.555 8 (38.1%) 18 (42.9%) 7 (26.9%) 0.415 7 (46.7%) 18 (41.9%) 8 (25.8%) 0.259 8 (36.4%) 25 (37.3%) 0.936
17 (70.8%) 30 (58.8%) 9 (64.3%) 29 (70.7%) 20 (57.1%) 7 (53.8%) 17 20 10 9
(70.8%) (62.5%) (52.6%) (64.3%)
8 (53.3%) 19 (57.6%) 9 (69.2%) 20 (71.4%) 13 (61.9%) 24 (57.1%) 19 (73.1%) 8 (53.3%) 25 (58.1%) 23 (74.2%) 14 (63.6%) 42 (62.7%)
One-way ANOVA. +
Chi-square test.
(n = 26) patients had PMNL between 3 and 10, and 5.6% (n = 5) patients had more than 11 PMNL. Although there was no squamous metaplasia visualized in the majority (75.3%) of patients, in 16.9% (n = 15) of patients mild, in 6.7% (n = 6) of patients moderate, and in 1.1% (n = 1) marked squamous metaplasia was observed (Fig. 5) (Table 1). No statistically significant differences were found between smoker and non-smoker groups with regard to these histopathological findings (Table 2). Also, there were no significant correlations defined by endoscopy, computed tomography, and NOSE scores of patients between 2 groups. Smoking did not have a significant effect on the presence of allergy or asthma. But blood eosinophil levels were found to be significantly high in the smoker group (Table 3).
DISCUSSION It has been described that nicotine has an effect on the nasal epithelium, regulating physiological processes and influencing cell transport systems.12 Smoking can increase nasal resistance,13 and the direct use of tobacco could be linked to an increased prevalence © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
TABLE 3. Evaluation of Clinical Measures of Smokers and Non-Smokers
Radiologic score NOSE score ++ Blood eosinophil Polyp size
Allergy Asthma
1 Grade 2 Grade 3 Grade Present Absent Present Absent
Smoker
Non-Smoker
Mean ± SD
Mean ± SD
19.45 ± 5.43 13.63 ± 3.35 0.35 ± 0.26 (0.30) n (%) 6 (18.2%) 22 (66.7%) 5 (15.2%) 11 (33.3%) 22 (66.7%) 6 (18.2%) 27 (81.8%)
18.64 ± 5.62 13.24 ± 3.27 0.26 ± 0.23 (0.20) n (%) 12 (21.4%) 32 (57.1%) 12 (21.4%) 12 (21.4%) 44 (78.6%) 14 (25.0%) 42 (75.0%)
0.810 0.383 0.043* + P 0.655
0.215 0.457
Chi-square test.
++
made in polyp tissues in smokers. In our study, we also aimed to explore the effects of smoking on nasal polyp histopathology as well as investigating the effect of smoking on clinical measures in nasal polyposis patients who were current smokers. We did not find any significant change in the histopathology of nasal polyp tissues in smokers when compared to non-smokers. We also think that the next step should be to investigate histopathological changes in a larger population or to investigate molecular changes in polyp tissues in smokers for the best reasons in this issue.
REFERENCES
Student t test. +
Nasal polyp histopathology in smokers
Mann-Whitney U test.
*P < 0.05
of sinusitis.14 Also, a study of retrospective cases found that smoking predicted poorer postoperative recovery after endoscopic surgery for CRS.15,16 However, in another study, no relationship was observed between smoking and predictive factors for CRS, such as CT evaluation and endoscopic examination.17 Yee et al have shown that CRS patients who were current smokers had a predominance of squamous metaplasia in the olfactory sensory epithelium when compared with non-smokers.18 In another study examining the effect of smoking on histology in nasal mucosa of smokers, it was found that stromal edema, congestion, epithelial thickness, and diffuse lymphocytic infiltration increased significantly in the nasal mucosa of individuals who smoke.19 On the other hand, according to Higgins et al, smoking and passive smoking can elevate matrix metalloproteinase 9, which is thought to contribute to the pathophysiology of allergy. They also implied that cigarette smoke was a common irritant that impacts the innate immune function of the sinonasal epithelial cells, and creates local irritation and cytotoxic effects.20 Also, Rouhos et al found in their study that smokers with asthma showed significantly higher fractional exhaled nitric oxide, which is useful in assessing eosinophilic airway inflammation.21 Nasal polyps is one of the most popular pathology in the upper airway tract. It may usually coexist with CRS, allergy, and asthma. Therefore, it was suggested that smoking could also affect nasal polyp histopathology like CRS, allergy, and asthma. Erbek et al studied 125 patients with nasal polyposis investigating the effects of smoking on the polyp stage, paranasal sinus CT score, total IgE levels, blood eosinophil count, and symptom scores.22 They did not find any significant relationship between smokers and non-smokers in terms of polyp stage, CT scores, total IgE levels, and blood eosinophil count. Also, the incidence of allergy, asthma, or aspirin sensitivity was not different between the groups. Only symptom scores of nasal obstruction were significantly different in smokers. In our study, in contrast to Higgins et al and Rouhos et al,20,21 we did not find any significant effect of smoking on the presence of allergy or asthma, but blood eosinophil levels were found to be significantly high in smoker group. Also, we did not find any significant correlation defined by endoscopy, CT, and NOSE scores of patients between 2 groups as in the study of Erbek et al except for the NOSE scores. Although histopathological evaluation on the effect of smoking on healthy nasal mucosa or nasal mucosa of CRS patients was documented before, to date, no histopathological evaluation was
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© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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