Comparison of Montelukast and Mometasone Furoate in the Prevention of Recurrent Nasal Polyps

Erkan Vuralkan, MD, Cem Saka, MD, Istemihan Akin, MD, Sema Hucumenoglu, MD, Binnur Uzmez Unal, MD, Gokhan Kuran MD, Berrak Ocal, MD

Disclosures

Ther Adv Resp Dis. 2012;6(1):5-10. 

Abstract

Background: The aim of our study was to compare the effects of montelukast and

mometasone furoate nasal spray on the postoperative course of patients with nasal polyposis.

Patients and methods: Fifty patients diagnosed with nasal polyposis between March 2006

and August 2007 were included in the study. All patients underwent bilateral endoscopic

sphenoethmoidectomy and were randomized postoperatively into two groups. Group A (n =

25) received 10 mg montelukast per day and group B (n = 25) received 400 μg mometasone

furoate nasal spray twice daily. All patients were followed up for 6 months. Sino-Nasal

Outcome Test (SNOT)-22 scores, polyp grades, computerized tomography (CT) scores

(Lund–Mackay), eosinophils in peripheral blood and polyp tissue were evaluated before and

after surgery.

Results: There was a significant reduction in SNOT-22 scores in both groups throughout the

study period. There was a significant difference in the recurrence rate between both groups

with a marginal advantage of mometasone furoate nasal spray. Eosinophils in peripheral

blood were found to be effective on the recurrence rate (p < 0.05).

Conclusions: In conclusion, both drugs seem to have a complementary action and further

studies are needed to determine which patients should receive which treatment.

Introduction

Certain applications of medical therapy should have a prominent role in the treatment of nasal

polyposis and can be valuable in reducing the risk of recurrence, especially in patients who

have previously undergone surgical interventions. The goal of long-term medical treatment in

the postoperative phase is to achieve a steady decrease of relevant inflammatory mediators

and thus to prevent the formation of recurrent disease [Picado, 2001; Lamblin et al. 2000]. In

many respects, the methods employed after the operation to maintain healthy and open sinus

cavities may be as important as the initial surgery itself.

Penerapan tertentu dari terapi medis seharusnya memiliki peran penting dalam pengobatan

poliposis nasal dan bisa berarti dalam mengurangi risiko kekambuhan, terutama pada pasien

yang sebelumnya telah mengalami intervensi bedah. Tujuan dari perawatan medis jangka

panjang dalam tahap pasca operasi adalah untuk mencapai penurunan tetap dari mediator

inflamasi yang relevan dan dengan demikian untuk mencegah pembentukan penyakit

berulang [Picado, 2001; Lamblin et al. 2000]. Dalam banyak hal, metode yang digunakan

setelah operasi untuk menjaga rongga sinus yang sehat dan terbuka mungkin sama

pentingnya dengan operasi awal itu sendiri.

Intranasal corticosteroids (ICS) have a strong anti-inflammatory effect and can reduce

eosinophilia as they directly interact with several chemokines and cytokines involved in the

inflammatory process. ICS therapy has a positive effect on objective measures of nasal

patency and has been shown to reduce the size of the polyps. Furthermore, ICS are important

postoperatively, when they help to reduce the recurrence rate [Virolainen and Puhakka, 1980;

Karlsson and Rundcrantz, 1982].

Kortikosteroid intranasal (ICS) memiliki efek anti-inflamasi yang kuat dan dapat mengurangi

eosinofilia karena mereka langsung berinteraksi dengan beberapa kemokin dan sitokin yang

terlibat dalam proses inflamasi. Terapi ICS memiliki efek positif pada langkah-langkah

patensi nasal dan telah terbukti mengurangi ukuran polip. Selain itu, ICS penting pada pasca

operasi, karena mereka membantu untuk mengurangi tingkat kekambuhan [Virolainen dan

Puhakka, 1980; Karlsson dan Rundcrantz, 1982].

Although their efficiency concerning pulmonary function is inferior to that of inhaled

corticosteroids, the leukotriene antagonists are a useful add-on or even substitute in the case

of insufficient steroid compliance or effect [Keith et al. 2009]. Several studies show the

benefit of antileukotriene treatment in patients with aspirin sensitivity [Thomas et al. 2008].

However, the effects of aspirin challenge cannot be suppressed completely.

Meskipun efisiensi ICS mengenai fungsi paru lebih rendah daripada yang kortikosteroid

inhalasi, antagonis leukotrien berguna sebagai add-on (pelengkap/penambah) atau bahkan

pengganti dalam kasus efek / kerja steroid tidak cukup adekuat [Keith et al berguna. 2009].

Beberapa penelitian menunjukkan manfaat dari pengobatan antileukotriene pada pasien

dengan sensitivitas aspirin [Thomas et al. 2008]. Namun, efek dari aspirin tidak bisa ditekan

sepenuhnya.

The aim of our study was to compare the effects of montelukast and mometasone furoate

nasal spray on the postoperative course of patients with nasal polyposis.

Tujuan dari penelitian ini adalah untuk membandingkan efek montelukast dan furoate

mometasone semprot nasal pada perjalanan pasien pasca operasi dengan poliposis nasal.

Patients and Methods

Study Design

The study protocols were approved by the Institutional Review Board. Fifty patients

undergoing functional endoscopic sinus surgery (FESS) as described in the Messerklinger

technique [Stammberger and Posawetz, 1990] for nasal polyposis between March 2006 and

August 2007 were followed prospectively. Patients were randomized postoperatively into two

groups. Group A (n = 25) received 10 mg montelukast per day and group B (n = 25) received

400 μg mometasone furoate nasal spray twice daily. Nasal irrigation with saline solution was

used by all patients. All patients were followed up for 6 months. Patients with systemic

diseases (diabetes mellitus, etc.), immunological diseases, liver or kidney diseases,

pregnancy, or phenylketonuria were excluded from the evaluation. A uniform history was

documented for each patient, including the location of facial pain and pressure; whether nasal

drainage was anterior or posterior, thick or thin, milky or purulent; the presence of allergic

symptoms such as itchy eyes, watery eyes, itchy nose, seasonality, asthma or aspirin

sensitivity; the presence of nasal obstruction, congestion, anosmia; and previous medical

treatment.

Protokol penelitian telah disetujui oleh Institutional Review Board. Lima puluh pasien yang

menjalani bedah sinus endoskopi fungsional (FESS) seperti yang dijelaskan dalam teknik

Messerklinger [Stammberger dan Posawetz, 1990] untuk poliposis nasal antara Maret 2006

dan Agustus 2007 telah diikuti secara prospektif. Pasien pasca operasi secara acak dibagi

menjadi dua kelompok. Kelompok A (n = 25) menerima 10 mg per hari dan montelukast dan

kelompok B (n = 25) menerima 400 mg furoate mometasone nasal spray dua kali sehari.

Irigasi nasal dengan larutan garam digunakan oleh semua pasien. Semua pasien kemudian

ditindaklanjuti selama 6 bulan. Pasien dengan penyakit sistemik (diabetes mellitus, dll),

penyakit imunologi, penyakit hati atau ginjal, kehamilan, atau fenilketonuria ekslusi. Riwayat

penyakit didokumentasikan untuk setiap pasien, termasuk lokasi nyeri wajah dan tekanan;

apakah drainase hidung di anterior atau posterior, tebal atau tipis, seperti susu atau purulen;

adanya gejala alergi seperti mata gatal, mata berair, gatal hidung, asma atau sensitivitas

aspirin; adanya sumbatan hidung, kongesti, anosmia; dan perawatan medis sebelumnya.

Outcome Measures

The sinus symptoms were analyzed using objective and subjective measures. Each patient

was examined with a nasal speculum and head mirror. The anterior and posterior rhinoscopic

examination was performed again by a 4 mm 0° telescope. Information was recorded on the

presence of findings. Nasal polyps were graded using a staging system [Rasp et al. 2000].

The preoperative and postoperative Lund–Mackay scores were determined objectively by

evaluating the sinus computed tomography (CT) scans. Postoperative CT scans were

performed at the sixth month of the treatment and compared with preoperative scans. A score

from 0 to 24 was calculated as described by Lund–Mackay [Lund and Mackay, 1993]. The

Sino-Nasal Outcome Test (SNOT) 22, a disease-specific questionnaire on rhinosinusitis

symptoms, was performed to compare the treatment efficacy of both groups. Patients rated on

22 different symptoms related to both nasal and general health on a score of 0 (no problem)

to 5 (problem as bad as it can be). SNOT-22 is a modified version of SNOT-20 and the 31-

item Rhinosinusitis Outcome Measure (RSOM-31). In SNOT-22, two items have been added

to the 20-item version: one item on nasal blockage and one item on sense of taste and smell.

SNOT covers a broad range of health and health-related quality of life (QoL) problems

including physical problems, functional limitations, and emotional consequences, as

described by Browne and colleagues [Browne et al. 2007]. In the present study, SNOT-22

was evaluated as a single construct, even if it obviously covers more than one construct. The

first 12 items cover physical symptoms (items 1–12) and the last 10 items (items 13–22)

cover aspects of health-related QoL.

Gejala sinus dianalisis dengan menggunakan langkah-langkah yang obyektif dan subyektif.

Setiap pasien diperiksa dengan spekulum nasal dan cermin. Pemeriksaan rhinoscopic

anterior dan posterior dilakukan lagi oleh teleskop 4 mm 0 °. Informasi dicatat pada setiap

temuan yang didapatkan. Polip nasal dinilai menggunakan sistem staging [Rasp et al. 2000].

Skor Lund-Mackay untuk pra operasi dan pasca operasi ditentukan secara obyektif dengan

mengevaluasi sinus dengan menggunakan CT scan. CT scan pascaoperasi dilakukan pada

bulan keenam dari pengobatan dan dibandingkan dengan CT scan pra operasi. Skor 0-24

dihitung seperti yang dijelaskan oleh Lund-Mackay [Lund dan Mackay, 1993]. The Sino-

Nasal Outcome Test (SNOT) 22, sebuah kuesioner penyakit tertentu pada gejala rinosinusitis,

dilakukan untuk membandingkan efektivitas pengobatan pada kedua kelompok. Pasien

dinilai pada 22 gejala yang berbeda terkait dengan kedua hidung dan kesehatan umum pada

skor 0 (tidak ada masalah) sampai 5 (seburukapapun yang dapat terjadi). SNOT-22 adalah

versi modifikasi dari SNOT-20 dan 31-item Rhinosinusitis Outcome Measure (RSOM-31).

Dalam SNOT-22, dua item telah ditambahkan ke versi 20-item: satu item pada hidung

tersumbat dan satu item pada indera perasa dan penciuman. SNOT mencakup berbagai

kesehatan dan kualitas hidup terkait kesehatan (kualitas hidup) termasuk masalah fisik,

keterbatasan fungsional, dan konsekuensi emosional, seperti yang dijelaskan oleh Browne

dan r ekan [Browne et al. 2007]. Dalam penelitian ini, SNOT-22 dievaluasi sebagai konstruk

tunggal, bahkan jika itu jelas mencakup lebih dari satu konstruk. 12 item pertama meliputi

gejala fisik (item 1-12) dan 10 item terakhir (item 13-22) mencakup aspek kualitas hidup

yang berhubungan dengan kesehatan

A complete blood count with a differential was performed. The percentage of eosinophils and

the total eosinophil count were calculated by automatic analysis. Biopsy of nasal polyps was

performed before surgery and at the sixth month of treatment. Histologic analysis was

performed on specimens of polyps in all patients by a pathologist blinded to the outcome. All

specimens were examined microscopically and the number of eosinophils was counted per

high-power field (HPF, ×40). Counts were performed for five separate HPFs per specimen.

These five counts were then averaged to calculate the average number of polyp eosinophils

per HPF. Preoperative and postoperative biopsy and peripheral eosinophil results were

compared.

Hitung darah lengkap dengan diferensial telah dilakukan. Persentase eosinofil dan total

jumlah eosinofil dihitung dengan analisis otomatis. Biopsi dari polip nasal dilakukan sebelum

operasi dan pada bulan keenam pengobatan. Analisis histologi dilakukan pada spesimen

polip pada semua pasien oleh ahli patologi untuk hasilnya. Semua spesimen diperiksa secara

mikroskopis dan jumlah eosinofil dihitung per lapang dengan daya tinggi (HPF, × 40).

Hitungan dilakukan pada lima HPFS secara terpisah per spesimen. Kelima hitungan

kemudian di rata-rata untuk menghitung rata-rata jumlah eosinofil polip per HPF. Biopsi dan

eosinofil perifer hasil pra operasi dan pasca operasi kemudian dibandingkan

Statistical Analyses

Data were analyzed using Statistical Package for Social Sciences (SPSS) software (version

11.0). All differences associated with a chance probability of 0.05 or less were considered

statistically significant. Mean differences between preoperative and postoperative scores were

evaluated for statistical significance using within-subjects t-tests for Lund–Mackay scores,

polyp grades, symptom scores, eosinophil results of the biopsy and blood. Mean differences

between two groups were evaluated for significance using independent-samples t-test.

Data dianalisis menggunakan statistik Package for Social Sciences (SPSS) software (versi

11.0). Semua perbedaan yang berhubungan dengan probabilitas peluang 0,05 atau kurang,

dianggap signifikan secara statistik. Perbedaan rata-rata antara pra operasi dan pasca operasi

skor dievaluasi untuk signifikansi statistik dengan menggunakan subyek t-tes untuk skor

Lund-Mackay, nilai polip, skor gejala, hasil eosinofil dari biopsi dan darah. Perbedaan rata-

rata antara dua kelompok dievaluasi untuk signifikansi menggunakan independent-sample t-

test.

Results

Fifty surgical procedures were performed for a previously untreated nasal polyposis from

March 2006 to August 2007 (23 female, 27 male; age range 30–66 years, median 48.50 ±

9.16). The mean age of patients in group A and group B was 49.44 ± 7.20 years and 47.56 ±

10.85 years, respectively. Five patients in group A were diagnosed with asthma and three of

them were aspirin-sensitive patients. Four patients in group B were diagnosed with asthma

and two of them were aspirin-sensitive patients.

Lima puluh prosedur bedah dilakukan untuk poliposis nasal yang sebelumnya tidak diobati

dari Maret 2006 sampai Agustus 2007 (23 perempuan, 27 laki-laki, rentang usia 30-66 tahun,

rata-rata 48.50 ± 9.16). Usia rata-rata pasien dalam kelompok A dan kelompok B adalah

49.44 ± 7.20 tahun dan 47,56 ± 10,85 tahun, masing-masing. Lima pasien dalam kelompok

A didiagnosis dengan asma dan tiga dari mereka adalah pasien dengan sensitif aspirin. Empat

pasien dalam kelompok B didiagnosis dengan asma dan dua di antaranya adalah pasien

dengan sensitif aspirin

Figures 1 and 2 show preoperative and postoperative stages of the polyps in group A and

group B, respectively. The mean preoperative CT scan score in this study was 16.32 ± 5.78

(5–24) in group A and 16.96 ± 5.27 (6–24) in group B. The preoperative Lund–Mackay

scores were not statistically different (p > 0.05). The mean postoperative CT scan score was

7.48 ± 3.36 (4–15) in group A and 8.52 ± 5.67 (2–22) in group B. r Wrong, It should be

with Table 1 shows the preoperative and postoperative SNOT-22 scores of group A and

group B. There was no significant difference between two treatment groups in terms of

SNOT-22 scores in either the preoperative or postoperative period (p = 0.245 and 0.361,

respectively). For group A (the montelukast group), the mean SNOT-22 sum score was 32.44

± 14.46 preoperatively and 7.13 ± 4.90 in the postoperative period. For group B (mometasone

furoate), the mean SNOT-22 sum score was 34.04 ± 11.58 preoperatively and 6.67 ± 5.16 in

the postoperative period.

Grafik1 dan 2 menunjukkan pra operasi dan pasca operasi tahap polip dalam kelompok A

dan kelompok B , masing-masing. Rerata skor CT scan pra operasi dalam penelitian ini

adalah 16.32 ± 5.78 ( 5-24 ) pada kelompok A dan 16,96 ± 5.27 ( 6-24 ) pada kelompok B.

pra operasi skor Lund - Mackay tidak berbeda secara statistik ( p > 0,05 ) . Rerata

pascaoperasi skor CT scan adalah 7.48 ± 3.36 ( 4-15 ) pada kelompok A dan 8,52 ± 5,67 ( 2-

22 ) pada kelompok B. r .Wrong , itu harus dengan Tabel 1 menunjukkan pra operasi dan

pasca operasi SNOT - 22 skor grup A dan grup B. Tidak ada perbedaan yang signifikan

antara dua kelompok perlakuan dalam hal SNOT - 22 skor baik dalam pra operasi atau

periode pasca operasi ( p = 0.245 dan 0.361 , masing-masing) . Untuk kelompok A

( kelompok montelukast ) , rata-rata jumlah skor SNOT - 22 adalah 32,44 ± 14,46 sebelum

operasi dan 7.13 ± 4,90 pada periode pasca operasi . Untuk kelompok B ( furoate

mometasone ) , rata-rata jumlah skor SNOT - 22 adalah 34,04 ± 11,58 sebelum operasi dan

6.67 ± 5.16 pada periode pasca operasi .

(Enlarge Image)

Figure 1.

Preoperative and postoperative stages of the polyps in group A.

(Enlarge Image)

Figure 2.

Preoperative and postoperative stages of the polyps in group B.

The mean number of preoperative and postoperative peripheral eosinophils for group A was

0.31 ± 0.04 × 103/μl and 0.28 ± 0.16 × 103/μl, respectively. There was no significant

difference between the number of these peripheral eosinophils (p > 0.05). The mean number

of preoperative and postoperative peripheral eosinophils for group B was 0.32 ± 0.21 ×

103/μl and 0.31 ± 0.20 × 103l/μl, respectively. The difference between the number of these

peripheral eosinophils was not significant (p > 0.05).

Polyp tissues were examined in all patients. The mean number of preoperative and

postoperative tissue eosinophils for group A was 23.55 ± 22.88 and 33.38 ± 28.90,

respectively. There was a significant difference between the number of these tissue

eosinophils in recurrence (p < 0.05). The mean number of preoperative and postoperative

tissue eosinophils for group B was 23.85 ± 19.56 and 26.99 ± 21.12, respectively.

CT scans, the number of tissue and peripheral eosinophils, and sinonasal symptoms were

evaluated by Student's t-test in group A and group B. The difference between preoperative

and postoperative results in group A was significant (p < 0.05). There was a significant

difference between preoperative and postoperative results in group B except for the sense of

smell scores (p < 0.05). CT scans and sinonasal symptoms of group A and group B were

compared by independent samples t-test. The difference between the two groups was

observed to be significant with regard to the sense of smell (p < 0.05).

There were 12 (48%) recurrences in group A and 5 (20%) recurrences in group B at the sixth

month of the treatment.

Discussion

The management of patients with nasal polyps constitutes a significant part of the workload

of otorhinolaryngologists. Nasal polyps cause morbidity including nasal obstruction,

rhinorrhea and anosmia. The incidence of nasal polyps rises in the second and third decades.

There is a consensus on male predominance (2–4/1) [Bernstein et al. 1995]. The mean age

was determined to be 48.50 ± 9.16 in our study, which included 27 male and 23 female

patients.

Pengelolaan pasien dengan polip nasal merupakan bagian penting dari kerja

otorhinolaryngologists. Polip nasal menyebabkan morbiditas termasuk obstruksi hidung,

rhinorrhea dan anosmia. Insiden polip nasal meningkat pada dekade kedua dan ketiga. Ada

konsensus tentang dominasi laki-laki (2-4/1) [Bernstein et al. 1995]. Usia rata-rata 48.50 ±

9.16 dalam penelitian kami, yang meliputi 27 laki-laki dan 23 pasien perempuan.

The pathophysiological significance of cellular immunity in nasal polyps is well known [Tan,

1998]. Intense eosinophilia is a feature of nasal polyps and 80–90% of nasal polyps are

eosinophilic [Meco and Oberascher, 2004]. The histological appearance and ultrastructure of

various types of nasal polyps have been studied [Davidsson and Hellquist, 1993; Tos et al.

1990]. The characteristic features include large quantities of extracellular edema and an

inflammatory cell infiltrate consisting of mast cells, eosinophils, lymphocytes and plasma

cells, and eosinophils is often observed to be dominant. There is an uneven distribution of

goblet cells [Tos and Mogensen, 1977] and submucosal glands [Baraniuk, 1997] in the

epithelium with smaller quantities of both compared with nasal mucosa. In our histological

examinations, 94% of polyps were eosinophilic. The ratio of the chronic inflammatory polyps

was 6%.

Signifikansi patofisiologi imunitas seluler pada polip nasal telah diketahui [Tan, 1998].

Eosinofilia intens adalah fitur dari polip nasal dan 80-90% dari polip nasal adalah eosinofilik

[Meco dan Oberascher 2004]. Gambaran histologis dan ultrastruktur dari berbagai jenis polip

nasal telah dipelajari [Davidsson dan Hellquist, 1993; Tos et al. 1990]. Ciri-cirinya antara lain

jumlah besar edema ekstraseluler dan infiltrasi sel radang yang terdiri dari sel-sel mast,

eosinofil, limfosit dan sel plasma, dan eosinofil sering dominan. Ada distribusi yang tidak

merata dari sel goblet [Tos dan Mogensen, 1977] dan kelenjar submukosa [Baraniuk, 1997]

dalam epitel dengan jumlah yang lebih kecil dari kedua dibandingkan dengan mukosa

hidung. Dalam pemeriksaan histologis kami, 94% dari polip yang eosinofilik. Rasio polip

inflamasi kronis adalah 6%.

The role of eosinophils in asthma and other allergic diseases has been investigated, and this

may be relevant to polyp pathogenesis. Stimulation of such an effector capability by

structural cell-derived cytokines would undoubtedly represent a major amplification pathway

of the inflammatory response in nasal polyps [Bernstein et al. 1995]. Leukotrienes, derivates

of arachidonic acid, are generated during allergic and inflammatory respiratory diseases

[Baraniuk, 1997; Wardlaw et al. 1989]. Leukotrienes have a wide range of actions such as

inducing bronchoconstriction, vasodilation, vascular permeability, chemotaxis and mucus

secretion. Nasal polyps have higher levels of leukotriene C4 and B4 than normal mucosa

[Jung et al. 1987].

Peran eosinofil pada asma dan penyakit alergi lainnya telah diteliti, dan ini mungkin relevan

dengan patogenesis polip. Stimulasi seperti kemampuan efektor oleh sitokin sel yang

diturunkan secara struktural pasti akan mewakili jalur amplifikasi utama dari respon

inflamasi dalam polip nasal [Bernstein et al. 1995]. Leukotrien, turunan dari asam arakidonat,

yang dihasilkan selama penyakit pernafasan alergi dan inflamasi [Baraniuk, 1997; Wardlaw

et al. 1989]. Leukotrien memiliki berbagai tindakan seperti menginduksi bronkokonstriksi,

vasodilatasi, permeabilitas vaskuler, kemotaksis dan sekresi lendir. Polip hidung memiliki

tingkat leukotriene C4 dan B4 dari mukosa normal [Jung et al. 1987].

In this study, we considered the effect of leukotrienes in the formation of nasal polyps. One

group of patients received leukotrienes receptor antagonist and the other group were

administered intranasal steroid spray. Our data also showed that patients with recurrence of

nasal polyps had higher levels of tissue eosinophil counts compared to patients without

recurrence. We did not detect significantly higher levels of peripheral eosinophilia in any of

the groups. The finding of high levels of tissue eosinophils shows the effect of eosinophils in

the formation of nasal polyps.

Dalam penelitian ini, kami mempertimbangkan efek leukotrien dalam pembentukan polip

nasal. Satu kelompok pasien menerima antagonis reseptor leukotrien dan kelompok lainnya

diberikan spray intranasal steroid. Data kami juga menunjukkan bahwa pasien dengan

kekambuhan polip nasal memiliki kadar jumlah eosinofil jaringan dibandingkan dengan

pasien tanpa kekambuhan. Kami tidak mendeteksi tingkat lebih tinggi dari eosinofilia perifer

di salah satu kelompok. Temuan tingkat tinggi eosinofil jaringan menunjukkan efek eosinofil

dalam pembentukan polip nasal.

The management options for nasal polyposis include observation, medical treatment, and

surgery alone or in combination with medical treatment. Surgical procedures alone are

insufficient to treat the underlying inflammation of the nasal mucosa. Supplementary medical

treatment is always necessary to prevent recurrence [Holmberg and Karlsson, 1996]. The

most important drugs for the treatment of nasal polyposis are corticosteroids. They can be

used systemically or topically [Kutting et al. 2000; Parnes and Chuma, 2000]. Corticosteroids

are generally very effective in asthma and rhinitis. Clinical experience shows that nasal

polyps and chronic sinusitis respond less to corticosteroids than bronchial asthma and rhinitis

[Picado, 2001]. Few studies have demonstrated the effectiveness of corticosteroids in chronic

sinusitis and nasal polyposis [Lund et al. 1998]. ICSs improve nasal obstruction but only

partially reduce the size of polyps and have an insignificant effect on the sense of smell

[Kuran et al. 2002]. As reported in one study, the use of ICSs had an eligible effect on the

inflammation of paranasal sinuses [Lund et al. 1998]. Poor efficacy of ICSs in nasal polyps is

associated with two factors. The first factor is the relative corticosteroid resistance induced by

the very active inflammatory process. Corticosteroids have more effectiveness on eosinophils

in normal mucosa than on eosinophils in nasal polyps. The second factor is the difference

observed in topically applied ICSs in reaching the polyps [Mullul et al. 1995]. Steroids can

be used systemically; however, systemic steroids should be used only for short-term

treatment due to the risk of systemic side effects. In our study, recurrence of nasal polyps was

determined in 20% of the patients who were treated with intranasal steroid. We evaluated the

paranasal sinus CT scans before treatment and at the end of the sixth month. The statistical

relation of these results was found to be significant (p < 0.05). Patients who used ICSs

reported a postoperative reduction in the symptoms except for the sense of smell.

Pilihan manajemen untuk poliposis nasal meliputi observasi, perawatan medis, dan operasi

sendiri atau dalam kombinasi dengan pengobatan medis. Prosedur bedah saja tidak cukup

untuk mengobati peradangan yang mendasari mukosa hidung. Perawatan medis tambahan

selalu diperlukan untuk mencegah terulangnya [Holmberg dan Karlsson, 1996]. Obat-obatan

yang paling penting untuk pengobatan poliposis nasal adalah kortikosteroid. Kortikosteroid

dapat digunakan secara sistemik atau topikal [Kutting et al. 2000; Parnes dan Chuma 2000].

Kortikosteroid umumnya sangat efektif dalam asma dan rhinitis. Pengalaman klinis

menunjukkan bahwa polip nasal dan sinusitis kronis kurang sensitif terhadap kortikosteroid

dibandingkan pada penyakit asma dan rhinitis [Picado 2001]. Beberapa penelitian telah

menunjukkan efektivitas kortikosteroid pada sinusitis kronis dan polip nasal [Lund et al.

1998]. ICSS meningkatkan sumbatan hidung, tetapi hanya sebagian saja yang dapat

mengurangi ukuran polip dan memiliki efek signifikan pada indera penciuman [Kuran et al.

2002]. Sebagaimana dilaporkan dalam sebuah penelitian, penggunaan ICSS memiliki efek

yang memenuhi syarat pada peradangan sinus paranasal [Lund et al. 1998].. Kemanjuran dari

ICSS di polip nasal dikaitkan dengan dua faktor. Faktor pertama adalah perlawanan

kortikosteroid relatif disebabkan oleh proses inflamasi yang sangat aktif. Kortikosteroid

lebih efektif pada eosinofil di mukosa normal daripada di eosinofil pada polip hidung. Faktor

kedua adalah perbedaan yang diamati pada ICSS topikal / oles dalam mencapai polip

[Mullul et al. 1995]. Steroid dapat digunakan secara sistemik; Namun, steroid sistemik harus

digunakan hanya untuk pengobatan jangka pendek karena risiko efek samping sistemik.

Dalam penelitian kami, kekambuhan polip nasal ditentukan dalam 20% dari pasien yang

diobati dengan steroid intranasal. Kami mengevaluasi paranasal sinus dengan CT scan

sebelum pengobatan dan pada akhir bulan keenam. Hubungan statistik hasil ini ditemukan

menjadi signifikan (p <0,05). Pasien yang menggunakan ICSS melaporkan penurunan pada

gejala kecuali untuk indera penciuman pada pasca operasi

There is limited knowledge on the possible role of antileukotrienes in the control of sinonasal

polyposis. Dahlén and colleagues showed that the 5-lipoxygenase inhibitor zileuton

diminished nasal dysfunction with remarkable return of smell, less nasal congestion and a

trend for less stuffiness and higher nasal inspiratory flow in aspirin-sensitive asthmatics

[Dahlén et al. 1998]. Kutting and colleagues evaluated the efficacy of short term oral steroid

therapy combined with montelukast in nasal polyposis [Kutting et al. 2000]. Patients were

evaluated by endoscopic examinations, symptom scores and MRI. This therapeutic procedure

proved to be beneficial in seven patients. Ragab et al. assessed the efficiency of montelukast

in nasal polyps by using nasal endoscopy, acoustic rhinometry and visual analog scale.

Clinical improvement in nasal polyposis occurred in 64% of aspirin-tolerant patients and in

50% of aspirin-sensitive patients [Ragab et al. 2001]. Jung and colleagues reported an

increase in the levels of leukotrienesin in the polyp tissues of patients with Samter's triad

[Jung et al. 1987]. In another study, patients were treated with zafirlukast and zileuton, and a

decrease was reported in the symptoms and sizes of polyps [Parnes and Chuma, 2000]. In our

study, recurrence of nasal polyps was detected in 48% of the patients who used montelukast.

We evaluated the paranasal sinus CT scans before the treatment and at the end of the sixth

month. The statistical relation of these results was found to be significant (p < 0.05). Patients

who used montelukast reported a postoperative reduction in the symptoms. No side effects of

montelukast and mometasone were observed.

Terdapat pengetahuan yang terbatas pada kemungkinan peran antileukotrienes dalam

pengendalian poliposis sinonasal. DAHLEN dan koleganya menunjukkan bahwa 5-

lipoxygenase inhibitor zileuton berkurangnya disfungsi hidung dengan return yang luar biasa

bau, berkurangnya sumbatan hidung dan berkurangnya sesak di hidung dan aliran inspirasi

yang lebih tinggi pada penderita asma dengan sensitif aspirin [DAHLEN et al. 1998].

Kutting dan rekan mengevaluasi efikasi jangka pendek terapi steroid oral yang

dikombinasikan dengan montelukast di poliposis nasal [Kutting et al. 2000]. Pasien

dievaluasi dengan pemeriksaan endoskopi, skor gejala dan MRI. Prosedur terapi ini terbukti

bermanfaat pada tujuh pasien. Ragab et al. menilai efisiensi montelukast dalam polip hidung

dengan menggunakan endoskopi hidung, rhinometry akustik dan skala analog visual.

Perbaikan klinis dalam poliposis nasal terjadi pada 64% pasien dengan toleran aspirin dan

pada 50% pasien dengan sensitive aspirin [Ragab et al. 2001]. Jung dan rekan melaporkan

peningkatan kadar leukotrienesin dalam jaringan polip pasien dengan Samter s triad [Jung et

al. 1987]. Dalam penelitian lain, pasien diobati dengan zafirlukast dan zileuton, dan

dilaporkan terdapat penurunan gejala dan ukuran polip [Parnes dan Chuma 2000]. Dalam

penelitian kami, kekambuhan polip nasal terdeteksi pada 48% dari pasien yang menggunakan

montelukast. Kami mengevaluasi sinus paranasal dengan CT scan sebelum pengobatan dan

pada akhir bulan keenam. Hubungan statistik hasil ini ditemukan menjadi signifikan (p

<0,05). Pasien yang menggunakan montelukast melaporkan terjadinya gejala pada pasca

operasi. Tidak ada efek samping dari montelukast dan mometason yang diamati

QoL is a general term integrating several aspects of life such as physical, psychological,

social, economical, emotional, cognitional, and sexual dimensions. A disturbance in any one

of these aspects will in turn affect the other domains and influence the overall QoL. The

measures of QoL have evolved as the emphasis on medical care has shifted from symptom

scores and objective test results to an assessment of the patient-centered effect of disease and

response to treatment. In general, there are two major types of QoL instruments used in

clinical trials: generic and specific. Generic measures allow comparison across different

disorders, severities of disease, and interventions, whereas disease-specific scales contain

items most relevant to the condition under study and that most likely will change with

effective therapy. In this study, the SNOT-22, a disease-specific questionnaire, was used to

evaluate the subjective outcomes. We believe that SNOT-22 may well be used on a regular

basis by the clinician to obtain information about the full range of problems associated with

rhinosinusitis. It can aid researchers in diagnosing and assessing the degree and effect of

rhinosinusitis on health status, and of treating patients with chronic rhinosinusitis (CRS). If

routinely used, it is suggested that the SNOT-22 can measure the effectiveness of treatment,

including surgery, and maybe identify patient factors that predict maximum treatment

response [Buckland et al. 2003]. According to the SNOT-22 measurements, the patients in

the two groups showed marked improvement in their subjective symptoms, which did not

differ significantly between the groups.

Kualitas hidup (Quality of Life –QoL) adalah istilah umum yang mengintegrasikan beberapa

aspek kehidupan seperti fisik, psikologis, sosial, ekonomi, emosional, cognitional, dan

dimensi seksual. Gangguan pada salah satu aspek ini pada gilirannya akan mempengaruhi

domain lain dan mempengaruhi kualitas hidup secara keseluruhan. Langkah-langkah

pencapaian kualitas hidup telah berevolusi menjadi hal yang ditekankan dalam perawatan

medis, yang mana telah bergeser dari skoring gejala dan hasil tes secara obyektif menjadi

penilaian pasien yang berpusat pada efek dari penyakit dan respon terhadap pengobatan.

Secara umum, ada dua jenis utama dari instrumen kualitas hidup yang digunakan dalam uji

klinis: generik dan spesifik. Langkah-langkah generik memungkinkan perbandingan seluruh

gangguan yang berbeda, keparahan penyakit, dan intervensi, sedangkan skala penyakit

tertentu berisi item yang paling relevan dengan kondisi yang diteliti dan yang kemungkinan

besar akan berubah dengan terapi yang efektif. Dalam penelitian ini, SNOT-22, sebuah

kuesioner penyakit tertentu, digunakan untuk mengevaluasi hasil subyektif. Kami percaya

bahwa SNOT-22 juga dapat digunakan secara rutin oleh dokter untuk memperoleh informasi

tentang berbagai masalah yang terkait dengan rinosinusitis. Hal ini dapat membantu peneliti

dalam mendiagnosis dan menilai derajat dan akibat rinosinusitis pada status kesehatan, dan

mengobati pasien dengan rinosinusitis kronis (CRS). Jika rutin digunakan, disarankan bahwa

SNOT-22 dapat mengukur efektivitas pengobatan, termasuk pembedahan, dan mungkin

mengidentifikasi faktor-faktor pasien yang memprediksi respon pengobatan maksimum

[Buckland et al. 2003]. Menurut pengukuran dengan menggunakan SNOT-22 , pasien dalam

dua kelompok menunjukkan peningkatan yang nyata dalam gejala subyektif mereka, yang

tidak berbeda secara signifikan antara kelompok.

Conclusion

We conclude that antileukotriene agents and intranasal corticosteroids seemed to have a

complementary action, yet further studies are needed to determine which patients should

receive which treatment.

Kami menyimpulkan bahwa agen antileukotriene dan kortikosteroid intranasal memiliki

peran sebagai pelengkap, namun penelitian lebih lanjut diperlukan untuk menentukan pasien

dengan kriteria seperti apa yang seharusnya menerima treatmen ini.

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