Effect of steroids on nasal polyposis

A STUDY ON THE EFFECT OF PREOPERATIVE SYSTEMIC
CORTICOSTEROIDS ON INTRAOPERATIVE AND EARLY POSTOPERATIVE
OUTCOME IN PATIENTS UNDEGOING FUNCTIONAL ENDOSCOPIC SINUS
SURGERY FOR SINONASAL POLYPOSIS
DISSERTATION SUBMITTED TO THE WEST BENGAL UNIVERSITY OF HEALTH
SCIENCES IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SURGERY IN OTORHINOLARYNGOLOGY
DR.PRASANNA DATTA
SESSION: 2013-2016
DEPARTMENT OF OTORHINOLARYNGOLOGY
MEDICAL COLLEGE AND HOSPITAL, KOLKATA
88, COLLEGE STREET
KOLKATA-700073

De
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GOVERNMENT OF WEST BENGAL
MEDICAL COLLEGE AND HOSPITAL
88, COLLEGE STREET,
KOLKATA-700073
CERTIFICATE
This is to certify that Dr. Prasanna Datta, post graduate student, has carried out the research
work entitled “A STUDY ON THE EFFECT OF PREOPERATIVE SYSTEMIC
CORTICOSTEROIDS ON INTRAOPERATIVE AND EARLY POSTOPERATIVE
OUTCOME IN PATIENTS UNDEGOING FUNCTIONAL ENDOSCOPIC SINUS
SURGERY FOR SINONASAL POLYPOSIS “for the MS degree in ENT of the West
Bengal University of Health Sciences in the session of 2013-2016, at Medical College and
Hospital, Kolkata.
He performed the work independently and sincerely in the department of ENT, Medical
College and Hospital, Kolkata. He has satisfactorily fulfilled the requirement as laid down by
The West Bengal University of Health Sciences, related to the nature and prescribed period
of work for submission of the thesis. So far, I know, he bears a good moral character.
I consider him as a fit candidate for the MS degree in ENT of The West Bengal
University of Health sciences.
I wish him all success in life.
Kolkata Dr. TAPAN KUMAR LAHIRI
Dated: Principal
Medical College & Hospital, Kolkata.

GOVERNMENT OF WEST BENGAL
MEDICAL COLLEGE AND HOSPITAL
88, COLLEGE STREET,
KOLKATA-700073
CERTIFICATE
This is to certify that Dr. Prasanna Datta, post graduate student, has carried out the
research work entitled “A STUDY ON THE EFFECT OF PREOPERATIVE
SYSTEMIC CORTICOSTEROIDS ON INTRAOPERATIVE AND EARLY
POSTOPERATIVE OUTCOME IN PATIENTS UNDEGOING FUNCTIONAL
ENDOSCOPIC SINUS SURGERY FOR SINONASAL POLYPOSIS” for the MS
degree in ENT of the West Bengal University of Health Sciences in the session of
2013-2016, at Medical College and Hospital, Kolkata.
He performed the work independently and sincerely in the department of ENT,
Medical College and Hospital, Kolkata. He has satisfactorily fulfilled the requirement
as laid down by The West Bengal University of Health Sciences, related to the nature
and prescribed period of work for submission of the thesis. So far, I know, he bears a
good moral character.
I consider him as a fit candidate for the MS degree in ENT of The West Bengal
University of Health sciences.
I wish him all success in life.
Kolkata PROF (DR.) RAMANUJ SINHA
Dated: HOD, DEPT. OF ENT
Medical College & Hospital, Kolkata.

CERTIFICATE OF THE GUIDE
There is to certify that Dr. Prasanna Datta, post graduate student, has carried out
the research work entitled A STUDY ON THE EFFECT OF PREOPERATIVE
SYSTEMIC CORTICOSTEROIDS ON INTRAOPERATIVE AND EARLY
POSTOPERATIVE OUTCOME IN PATIENTS UNDEGOING
FUNCTIONAL ENDOSCOPIC SINUS SURGERY FOR SINONASAL
POLYPOSIS for the MS degree in ENT of The West Bengal University of Health
Sciences in the session of 2013-2016, at Medical College and Hospital, Kolkata
under my direct guidance.
He carried out the work himself sincerely and methodically. He has
satisfactorily fulfilled the requirement as laid down by The West Bengal University
of Health Sciences, related to the nature and prescribed period of work for the
submission of the thesis.
He is an eligible candidate for the MS Degree in ENT of The West Bengal
University of Health Sciences.
I wish him success in every sphere of life.
Kolkata DR. ASOK KUMAR SAHA
Dated: Associate Professor
Dept. Of Otorhinolaryngology
Medical College and Hospital,
Kolkata.

DECLARATION
I, Dr. Prasanna Datta, hereby declare that this work entitled” A STUDY ON THE
EFFECT OF PREOPERATIVE SYSTEMIC CORTICOSTEROIDS ON
INTRAOPERATIVE AND EARLY POSTOPERATIVE OUTCOME IN
PATIENTS UNDEGOING FUNCTIONAL ENDOSCOPIC SINUS SURGERY
FOR SINONASAL POLYPOSIS” has been conducted by me for the MS ENT
degree of the West Bengal University of Health Sciences in the session of 2013-
2016, at Medical College and Hospital, Kolkata under direct guidance of Dr. Asok
Kumar Saha, Associate Professor, Dept. Of Otorhinolaryngology, Medical College
and Hospital, Kolkata.
This thesis is submitted to The West Bengal University of Health Sciences
in partial fulfilment of MS ENT degree of The West Bengal University of Health
Sciences.
I further declare that this is an original work and no part of this study has
been previously published or submitted to any university.
Kolkata DR. PRASANNA DATTA
Dated: MS POST GRADUATE TRAINEE
Medical College and Hospital, Kolkata

Acknowledgement
I have been fortunate to receive immense help and co-operation from everybody I went to
with any query or for any suggestion during this study.
At the very outset I wish to thank my parents for making me whatever I am today and
also to my wife for all the pains and sacrifice they undertook only for me.
My respected teacher and guide Dr. Asok Kumar Saha, Associate Professor, Department
of ENT, Medical College and Hospital, Kolkata, was the person who motivated me and
instilled the confidence in me to successfully complete this study series. I would like to
express my deepest gratitude to them for their immense support and patience in guiding
me through any research work with their constant inspiration, guidance, constructive
criticism and novel support.
I must mention Prof.(Dr.)Ramanuj Sinha , Head of the Department , Dept. of ENT,
Prof.(Dr.)Subrata Mukhopadhyay and Prof.(Dr.)Soumendra Nath Banerjee of the
Department ENT, Medical College and Hospital, Kolkata, whose personality and
dynamism has been a constant source of inspiration and motivation for me. Their
suggestion and valuable inputs in this thesis will always be gratefully remembered by me.
I will always remain grateful to Dr.M.Dutta, Dr. S.Kundu, Dr. B. Adhikary, Dr. S.Datta
& Dr. D. Mukherjee who always has been encouraging to me.
I must remain grateful to Anesthesiologist Dr. T.K.Chakraborty and his team for their
warm cooperation during my tenure.
Dr. P.Ghosh and Dr. A. Sil have taught me a lot during this three years and I take this
opportunity to express my gratitude to them.
Dr. R.Singh , the senior resident of our department had selflessly helped me in every
way whenever needed.

Expressing my acknowledgements to my batchmates Dr.Avijit Chowdhury, Dr. Biplab
Deb, Dr. Arijt Jotdar, Dr.Raju Mondal, is never enough because they are the ones who
have made my workplace a home away from home with their affection, advice and
encouragement.
Special thanks to all my beloved juniors specially Dr.Saikat Samadder,Dr.Abir
Chowdhury,Dr.Richard Narjinary,Dr.Nirmalya Roy, D r.Shaoni Sanyal,Dr.Shuvrajit
Das, Dr.Saptarshi Chandar for their time and support during my work.
I express my heartfelt gratitude to my parents: Mr.Prabodh Kumar Datta and Mrs. Mukti
Datta , my wife Mrs.Dipanjana Kar who bore with my tough times and shared the good
times with equal exhilaration and thrill and without their constant support, love, care,
patience and suggestion, this work could not have been possible.
Lastly I will like to thank to all my patients without their unfailing cooperation this study
could not be done.
Kolkata DR. PRASANNA DATTA
Dated: MS POST GRADUATE TRAINEE
Medical College and Hospital, Kolkata

CONTENTS
Page No.
1. INTRODUCTION-------------------------------------------- 1
2.AIMS AND OBJECTIVES---------------------------------- 16
3.MATERIALS AND METHODS---------------------------- 17
4.REVIEW OF LITERATURE-------------------------------- 22
5.RESULTS AND ANALYSIS-------------------------------- 31
6.DISCUSSION-------------------------------------------------- 91
7.SUMMARY AND CONCLUSION------------------------- 103
8.BIBLIOGRAPHY---------------------------------------------- 106
9.ILLUSTRATIONS--------------------------------------------- 113
10.PROFORMA-------------------------------------------------- 117
11. APPENDIX---------------------------------------------------- 128

INTRODUCTION P a g e | 1
INTRODUCTION:
The term Polyp is derived from the Latin word “polypous”. By definition, polyps are soft,
yellowish, boggy structures usually insensitive to touch arising from the lining mucosa of
the nose and paranasal sinuses. Nasal polyps were first described in India and by 1000 BC,
curettes had been devised to remove them.1
The condition occurs in approximately 2% of
the population 2
and is seen in almost all ethnic races in the world. The male: female ratio is
2:1. Various complex mechanisms have now been postulated to describe the etiology. So a
systematic approach is therefore essential for proper management.
A polyp presents in the nasal cavity with a grape-like appearance, having a 'body' and a
'stalk'. The surface is smooth and the colour is more yellow than the pink mucous
membrane of the nasal cavity. Nasal polyps originate in the upper part of the nose around
the openings to the maxillary, sphenoid & ethmoidal sinuses. The polyps protrude into the
nasal cavity from the middle and superior meatus, resulting in Nasal blockage and
abolishing airflow to the olfactory region.Nasal polyposis, consisting of multiple, bilateral
polyps, is part of an inflammatory reaction involving the mucus membrane of the nose, the
paranasal sinuses and often the lower airways.

The etiology of nasal polyps is largely unknown and has long been a topic of debate.
Although historically many have believed polyps to be a manifestation of allergy, in part
because of the histologic prominence of eosinophils, epidemiologic evidence for this is
lacking. The incidence of allergy is not higher in patients with nasal polyps than in the
population as a whole, or do polyp patients have elevated rates of positive allergy skin
tests(3).Nasal polyps are associated with number of systematic diseases including aspirin
intolerance, intrinsic asthma, primary ciliary dyskinesia, and cystic fibrosis.
Recent evidence suggests an important role for proinflammatory cytokines,
chemokines, and chemotactic factors in the pathogenesis of inflammatory polyps, along
with a variety of Environmental, genetic, and biochemical factors that have previously
been proposed. (4)
The disease is now regarded as part of spectrum of chronic rhinosinusitis.5 In fact some
otolaryngologists consider that most polyps are due to infective sinusitis or other diseases
of the upper respiratory tract and that only a few are the results of allergy.(6,7)
Pro-inflammatory cytokines like interleukin (IL) 1, IL-3, IL-4, IL-5, IL-6, IL-8 and IL-10
are responsible for the chemical reactions in polyps. Immunoglobulins like IgG, IgA, IgM
& IgE have also been detetected along with adhesion molecules like vascular adhesion
molecule 1(VCAM-1) and growth factor such as tumor necrosis factor(TNF), platelet

derived growth factor, vascular permeable factors(VPFs), vascular endothelial growth
factors(VEGFs), insulin like growth factor(I) and stem cell factor. Both interleukin IL-3
and IL-4, as well as IL-1 and tumour necrosis factor (TNF) can induce VCAM-1
expression in microvascular endothelium from the polyps.The interaction between
adhesion molecules VLA-4 and VCAM-1 play an important role in extravasations of
eosinophils into nasal polyps. (8)
Gross Appearance
When significant intranasal polyposis is present, polyps can easily be seen by anterior
rhinoscopy. Grossly, they are translucent to pale gray, pear shaped, smooth, soft, and
freely mobile. Polyps arise from the lateral nasal wall and in many cases are limited to the
middle meatus, where they can only be visualized endoscopically. Inflammatory polyps
are usually seen bilaterally. Histologically, polyps are composed of a fibromyxomatous
stroma covered by typical respiratory epithelium that may display benign squamous cell
metaplasia. The epithelium displays very few nerve endings and submucosal glands and
the basement membrance is thickened. As compared to adjacent lateral nasal wall mucosa,
there is marked abundance of eosinophils and mast cells in inflammatory polyps. (9)

Symptoms of nasal polyps:
• Nasal discharge
• Nasal obstruction
• Itching
• Headache, facial pain
• Fullness in the ears
• Postnasal drip
• Anosmia or hyposmia
• Epistaxis
• Snoring
• Hypertelorism or altered craniofacial structure
Rarely:
• Proptosis, diplopia
• Reduced vision
• Symptoms of raised intracranial tension
Polyps are oedematous, semi translucent masses in the nasal and paranasal cavities that
have no pain fibres. There are two types of polyps: ethmoidal and antrochoanal. Ethmoidal

polyps are more common, emerge from the ethmoid sinus via the ostiomeatal complex,
and are bilateral. In contrast, antrochoanal polyps arise from the maxillary sinus via the
middle meatus and are unilateral .Antrochoanal polyps are less likely to be associated with
allergic disease. The presence of unilateral polyps is uncommon and should prompt
consideration of more severe diseases, including inverted papilloma and nasal tumours.
Although the cause of nasal polyposis remains elusive, it probably represents a
heterogeneous disease with varied causes, including allergic and infectious conditions and
aspirin sensitivity. Allergic disease most likely plays a role, and up to 60%of patients with
polyposis will have atopy.Additionally, IgE is increased locally within polyp tissue. Local
IgE production and a type I mediated allergic reaction may have a role in the etiology of
polyposis.
A unique subset of adult patients with nasal polyposis will also have aspirin
hypersensitivity with aspirin –induced bronchial asthma and/or aspirin-induced rhinitis
(aspirin-exacerbated respiratory disease, or Samter triad). In this group of patients,
defective inhibition of the cyclo-oxygenase enzyme 1 in the arachidonic acid pathway
leads to the excessive production of leukotrienes. The ingestion of aspirin leads to

symptoms of bronchospasm and/or rhinitis 30 minutes to 4 hours later.Symptoms of
worsening asthma, nasal polyposis, and rhinitis develop slowly over years despite
avoidance of the drug. It is important to recognize and treat his sensitivity because these
patients are more likely to require repeated surgical interventions for polyp management.
The diagnosis is made through challenge testing with lysine-aspirin by an
allergist/immunologist.Desensitization and long term aspirin therapy can be effective in
treating up to 60% of these patients. The role of bacterial infections and super antigen
activation of T lymphocytes remains controversial. Studies reveal an increased
colonization of S.aureus in patients with nasal polyps of aspirin-sensitive asthma versus
controls. S.aureus produces enterotoxins that act as superantigens, directly activating T
lymphocytes, as in atopic dermatitis. Additionally, patients with nasal polyposis have an
increased local presence of S.aureus enterotoxin –specific IgE. This IgE is not found in the
serum, suggesting that a type I mediated allergic reaction to the enterotoxin may occur
within the paranasal sinuses, resulting in the formation of nasal polyps.

INVESTIGATIONS
Extensive polyps are easily visible on anterior rhinoscopy and appear as whitish,
translucent structures. Very early polyps may be detected only following diagnostic nasal
endoscopy where their extent can be ascertained and the disease can be staged. The 3-tier
staging system devised by Lund and Kennedy is as follows:
0, no polyps
1, confined to middle meatus
2, beyond middle meatus
Lildholdt and colleagues used a slightly varied system to assess the effect of multiple
treatment methods. The 4-point system developed used the upper and lower edges of the
inferior turbinate as a landmark to describe polyp extension. The highest score available
extended to the inferior edge of the inferior turbinate , essentially contacting the floor and
filling the nasal cavity.11 The staging system aid in determining effectiveness of
conservative treatment and need for subsequent surgical intervention. A diagnostic nasal
endoscopy is of special significance in case of complaints of nasal obstruction when
anterior rhinoscopy appears apparently normal wherein polyps obstructing the choana can
be detected. It also enables in determining the origin of a single unilateral polyp. A polyp
in the middle meatus would in all probability be an “Antrochoanal polyp” having its origin
in the maxillary sinus while a polyp encountered between the septum and the middle
turbinate will have its origin from the sphenoid sinus in most of the cases.

IMAGING:
The CT scan of the paranasal sinuses is of paramount importance when surgical
intervention is considered. The scans have to be done following optimum medical
treatment when the exact extent of the disease not amenable to medical treatment will
become evident. CT imaging remains in its ability an excellent diagnostic modality to
provide a road map for surgical planning. The bony windows have to be in all three planes,
i.e. axial, saggital and coronal so that three dimensional (3D) anatomy of the sinuses can
be better understood. This is of particular significance in key areas like the frontal recess
where understanding the anatomy of the frontal air cell system is crucial to surgery and
complete disease removal is important. Soft tissue windows may be obtained in the
coronal plane. A plain CT scan of the paranasal sinuses suffices to give all the relevant
information in case of nasal polyposis. In case of suspected tumours one may need a scan
with contrast. Nasal polyps appear as partial or complete opacification of the involved
paranasal sinuses with infundibulum widening.12. Expansion of the ethmoidal air cells
may be evident and there may be thinning of the bony septae and margins in long standing
disease.
An MRI is done in case of suspected orbital or intracranial extension of disease.MRI
gives better soft tissue delineation and aids in differentiating between polyps, retro-
obstructive sinusitis and tumours.

Medical Management:
Nasal polyps are considered as a local manifestation of a systematic problem. Appropriate
and early treatment can bring notable benefits to patients and medical management forms
the mainstay in the treatment of this condition. Corticosteroids either oral or in the form of
intranasal sprays are now the universally accepted drugs of choice and remain the
mainstay of therapy for nasal polyposis. The mechanism of action involves the down
regulation of inflammatory protein encoding genes by the activation of intracellular
glucocorticoid receptors.13, 14
Oral steroids are indicated in case of extensive disease, when hyposmia or anosmia is
the main complaints or when surgical intervention is planned. They are very effective in
reducing polyp size and improving symptoms and their use remains near universal in the
treatment of nasal polyposis despite their well-documented side effects.
When surgery is planned, oral steroids have to be started 10-12 days prior. They cause
reduction in the disease which in turn makes understanding of the anatomical landmarks
better. There is reduced bleeding contributing significantly to easier surgery.

Dosage:
Oral Prednisolone is administered in a dose of 1mg/kg/day and is tapered over 10-12 days.
Newer oral steroids such as methyl prednisolone have a greater anti-inflammatory potency
and a lesser tendency to induce sodium and water retention. Deflazacort has a lesser
tendency towards induction of weight gain as well as lesser diabetes and osteoporosis
inducing potential. The blood sugar needs to be monitored closely and calcium
supplementation has to be given during the course of oral steroids.
Intranasal tropical steroids sprays have made a tremendous impact on the treatment of
nasal polyposis. They act locally by inhibiting the inflammatory cascade. Nasal topical
steroids have been shown to decrease polyp size as well as improve nasal symptoms.13
The use of these steroids postoperatively has also proved to reduce recurrence and the
need for systemic therapy.15 A wide range of steroid nasal sprays are now available , the
most common being budesonide, mometasone and fluticasone.
Local decongestants like oxymetazoline or xylometazoline are prescribed when nasal
blockage is the predominant symptom. Antibiotics may be needed in case of superadded
bacterial infection when the nasal discharge is purulent and is accompanied by headache
and facial pain.

Immunomodulators:
Immunomodulators are being used with success in patients with eosinophilic asthma,
otherwise known as patients with unified airway disease. In these patients, treatment with
anti-IL-5 results in improved serum eosinophils levels, asthma control and FEVI levels.16
Omalizumab is a humanized antibody which reduces serum levels of free IgE.
Mepolizumab and Reslizumab are humanized monoclonal against IL-5 which eliminates
eosinophils from blood. Although the cost of Immunomodulators limits their overall use,
they can still be regarded as a crucial step in the individualized treatment of nasal
polyposis.

Surgical Treatment:
Endoscopic sinus surgery is the surgery of choice for nasal polyposis which is planned
following optimal medical treatment. Surgery aims at decreasing the amount of
inflammatory load making medical treatment more effective. It improves symptoms of
nasal blockage, re-establishes ventilation and drainage of the sinuses and contributes
considerably to an overall improvement in the quality of life. The patients however need to
be counselled preopreatively as regards the recurrent nature of disease.
Several hurdles like distortion of anatomy, loss of landmarks and bleeding may be
encountered while operating on a patient with extensive nasal polyps.
Newer equipment like the microdebrider therefore has become indispensable in surgery
for nasal polyposis. Continuous suction and irrigation keeps the field free of blood and
improves visualization. Cutting blades having various angulations make it possible to
reach different areas in the nose and allows disease to be removed therein. There is less
tissue trauma which results in better postoperative healing.
Following adequate decongestion of the nose, the polyps in the nasal cavity are first
removed or debrided so as to establish the constant landmarks. The standard steps of
surgery for endoscopic sinus surgery are then followed. The uncinate process is removed
along its entire vertical and horizontal extent.The maxillary sinus ostium is then identified
and widened. Polyps within the maxillary sinus are removed. Angle instruments, curved
debrider blades and angled scopes may be needed to access the lumen of the maxillary

sinus in order to remove the disease lying therein. The frontal recess area is then tackled
and the frontal sinus ostium is visualized.Following this, the anterior ethmoid sinuses are
cleared. The ground lamella is identified and the posterior ethmoid sinuses are then
cleared. After identifying the last posterior ethmoidal air cell, dissection is continued in the
inferomedial direction to open the sphenoid sinuses.Incase there is difficulty in identifying
the anterior wall of the sphenoid sinus due to presence due to presence of polyps, the
sphenoid sinus can be accessed medially by passing the endoscope between the middle
turbinate and the septum. The natural ostium of the sinus lies approximately 1.5 cm above
the upper border of the choana. Utmost care has to be exercised while removing polyps
from within the sphenoid sinus especially from its lateral wall since the carotid artery and
the optic nerve are closely related to it. Complete disease removal is of utmost importance
and goes a long way in preventing recurrences. Landmarks of the lamina papyracea
laterally, orbital apex posterolaterally, skull base superiorly and the middle and superior
turbinates medially have to be kept in mind and not violated. Close attention must be paid
to mucosa preservation since it contributes towards better postoperative healing. Success
in outcomes of ESS in patients with chronic rhinosinusitis with polyposis is heavily
dependent on reducing postoperative scarring, oedema, and crusting that can inhibit
natural ciliary function and sinus drainage. Occasionally there may be difficulty in
identifying the ostia of the maxillary or the sphenoid sinus due to extensive polyps
blocking them. These can be identified by visualizing air bubbles egressing from them
which then guide the surgeon towards the ostia. Polyps near the skull base or lamina
papyracea should never be pulled .The use of blunt curettes facilities safe disease removal

in these areas. Close attention has to be paid to preserve the integrity of the middle
turbinate. In the postoperative period, antibiotics and decongestants may be continued for
a week to ten days. Regular nasal douching with saline is advised. Topical steroid nasal
sprays may be started after a week.
Meticulous care of the operated nasal cavity in the immediate postoperative period has
to be exercised. The patients may be require two three visits scheduled a week apart for
cleaning the nose. During these visits crusts, fibrinous material and discharge are removed.
Adhesion between the middle turbinate and lateral nasal wall if any, need to be broken so
as to keep the operated cavity open and well aerated. This prevents the development of
dense synechiae postoperatively. Some amount of postoperative polypoidal changes in the
mucosa are to be expected. This cobblestone appearance must not to be confused with
recurrence of polyps and has to be left well alone wherein it settles down in due course of
time.17
The usage of preoperative systemic corticosteroids for a period of 5 days prior to
surgery on intraoperative and early postoperative outcome in patients undergoing
Functional Endoscopic Sinus Surgery for sinonasal polyposis in the Indian setting needs to
be evaluated in detail to ascertain its effect on the final outcome.
The use of preoperative systemic steroids (PSS) in endoscopic sinus surgery (ESS) has been
a topic of debate among otolaryngologists for many years now. Until recently, most of the

evidence to support PSS use in ESS was largely anecdotal and based on expert opinion.
Although some recent randomized and blinded trials have been published, opinions among
these studies are highly variable. The objective of this study is to identify the Intraoperative
and early postoperative outcome regarding the use of PSS in nasal polyposis. A lot of
researches were done on the use of preoperative systemic corticosteroids for nasal polyps.
Most of the papers advise to use oral steroids 10-12 days before surgery. As there are many
adverse effects of steroids, research works on the application of oral steroids for very short
period is lacking. Our aim of the study was to evaluate the effect of short course of oral
steroid on Intraoperative bleeding. Bleeding impairs the surgical field visibility. Profuse
bleeding during endoscopic sinus surgery leads to increased laceration of nasal mucosa,
injury to important structures, increased operation time, postoperative scarring and
synechia. Excessive insult to nasal mucosa causes impaired mucocilliary flow, which leads
to crusts formation. In my study also the early postoperative outcome were analysed. The
relation between oral steroid and postoperative outcome was also evaluated in the study.
Very few studies were done on early postoperative outcome following the use of short
course of oral steroids. My aim is also to evaluate whether short course of oral steroid has
favourable or no effect on postoperative outcome.

AIMS & OBJECTIVES P a g e | 16
AIMS & OBJECTIVES:
AIMS:
The aim of the study was to evaluate the use of preoperative systemic steroids
(PSS) on the Intraoperative effect (bleeding) and early (within 4 weeks)
postoperative outcome in the patients undergoing endoscopic sinus surgery for
sinonasal polyposis.
OBJECTIVES:
• To assess the effect of steroids over sinonasal mucosa and polyp during
operation.
• To assess the effect of steroids in intra operative bleeding and surgical field
visibility.
• To compare early postoperative (within 4 weeks) outcome (scarring and crust
formation) and subjective improvement (as per SNOT 22) between the two
groups.

Materials and Methods P a g e | 17
Materials and Methods:
Place of Work: Department of Otorhinolaryngology-Head and Neck Surgery,
MEDICAL COLLEGE, KOLKATA
Study Population: Patients attending Otorhinolaryngology OPD at Medical
College and Hospital, Kolkata with sinonasal polyposis
Study Period: December, 2013 to September, 2015.
Sample size: 70 cases.
Study design: Hospital based longitudinal prospective interventional analytical
study.
Study tool: Tools to be used as mentioned in the Proforma-detailed history,
Clinical examination and investigation

CONTROL: Patients not receiving oral steroid.
METHODS OF DATA COLLECTION: Information had been collected
from the patients on the basis of predesigned data sheet and findings of relevant
clinical examination, radiological and endoscopical investigation.
Patients selected for the study would be given oral prednisolone at the dose of
1mg/kg/day for a period of 5 days prior to the scheduled date of surgery.
Pre-operative, per-operative and post-operative data will be studied and analysed
Using suitable statistical methods as required.
Inclusion Criteria
Patients with sinonasal polyposis refractory to conservative treatment for at least 3months.

Exclusion Criteria
• Nasal mass other than sinonasal polyposis (e.g. fungal polyposis,
papilloma, malignancy, rhinosporidiosis).
• Nasal mass with history of recurrent epistaxis.
• Patients not willing to participate in the study.
• Patients with diabetes, hypertension, renal failure, history of cerebral
stroke.
• Patients with previous h/o FESS.

Methodology:
The Study was conducted in the Department of Otorhinolaryngology-Head Neck surgery,
Medical College, Kolkata between December, 2013 to September, 2015.
Prior to study initiation the protocol informed documents were approved by the
Institutional Ethnical Committee. Total 70 patients having sinonasal polyps were included
in the study written informed consent was obtained from each study participant. In case of
adolescent subjects (between 12-18 yrs) consent was provided by legal guardian. All the
recruited patients, after thorough history, general examination and ENT examination, were
examined by Nasal Endoscopy and CT scans. Pre-operative DNE was done using 0˚ rigid
endoscope and findings were evaluated as per LUND-KENNEDY SCORING SYSTEM
[11]
. DNE was done before giving oral steroids. All the patients underwent pre operative
biopsy. CT scans were carried out using 3mm thickness in axial and coronal planes with
saggital reconstruction. The results were evaluated as per LUND-MACKAY SCORING
SYSTEM
[11]
.
The selected patients were divided into two groups containing equal number of patients.
The patients are allocated randomly in the two groups. All the patients having intranasal
steroids pre-operatively were advised to stop their medication 4 weeks prior to surgery.

The group A patients received oral prednisolone 1mg/kg/day for a period of 5 days prior to
the surgery. The Group B patients received no oral steroids.
All the operations were done in General Anaesthesia. The lateral wall of the nose& around
the attachment of middle turbinate was infiltrated with 2% lignocaine with adrenaline
solution. 0˚, 30˚ and 45˚rigid endoscopes with high definition monitor were used in the
cases as required. No powered instruments like microdebrider were used in the operation.
Following procedures like uncinectomy, maxillary antrostomy, anterior ethmoidectomy,
posterior ethmoidectomy, sphenoidotomy were done in the cases whenever needed. Intra
operative bleeding was evaluated using BOEZAART-VANDERMERWE GRADING
SYSTEM.
[55]
Patients were discharged after 3 days removing the nasal packs. Post-
operative saline nasal douching was advised in all the patients. No inhalation steroids were
given till 1 month. Post-operative DNE was done by 0 degree rigid endoscope in 1st
, 2nd
,
3rd
and 4th
week in all 70 patients. These results were evaluated by LUND-KENNEDY
SCORING SYSTEM. A subjective evaluation of all the patients was done using a
questionnaire SNOT-22 at the 4th
week visit.
These data were evaluated and compared in both the groups using suitable statistical
method as required. The effect of steroids in these two groups was studied based on the
results obtained. Statistical calculation is done using SPSS software.

REVIEW OF LITERATURE P a g e | 22
REVIEW OF LITERATURE:
Sinonasal polyps are benign lesions arising from the mucosa of the paranasal sinuses
(commonly at the outflow tract of one or more of the sinuses) or from the mucosa of the
nasal cavity.[18]
Various studies have provided different estimates about the prevalence
of sinonasal polyposis in the general population but it is generally accepted that its
prevalence is around 4%.[19]
However, cadaveric studies have pegged the prevalence at
around 40%.[20]
The disease is thought to affect the adult population predominantly and
is usually seen in patients older than 20 years of age.
The chief presenting symptom of sinonasal polyposis is usually variable amount of nasal
obstruction but complaints of rhinorrhoea, postnasal drip, olfactory abnormalities with
alteration of taste are also common.[21]
Clinical examination usually reveals single or
multiple pale, grey polypoid masses arising most frequently from the middle meatus and
prolapsing into the nasal cavity. They consist of loose connective tissue, oedema,
inflammatory cells, and some capillaries and glands. They are covered with different types
of epithelium, most commonly pseudostratified respiratory epithelium with goblet cells
and ciliated cells. Studies have shown that eosinophils are the most common inflammatory
cells in sinonasal polyposis. [22]

The etiology of sinonasal polyposis is unknown. Some theories consider polyps a
consequence of conditions which cause chronic inflammation in the nose and paranasal
sinuses characterized by stromal oedema and variable cellular infiltrate. [23]
It has been assumed for decades that the presence of allergy predisposes an individual to
sinonasal polyposis because the symptoms of rhinorrhoea and mucosal swelling are
usually present in both diseases along with eosiniophilic abundance in nasal secretions.
However, epidemiological studies provide little evidence to support this relationship
with sinonasal polyposis found in only 1%–2% of patients with positive skin prick tests.
[24]
In addition, studies have shown that sinonasal polyposis is no more common in
atopic individuals.[25]
Studies have however shown that total and specific IgE as well as
other allergic-type histologic features of polyps are unrelated to positive skin prick tests
but did correlate with the levels of eosinophils.[26]
Medical management of sinonasal polyposis is usually started with topical nasal steroids
[27]
in the form of sprays or drops along with the treatment of any underlying cause or
comorbid allergy. Steroids have been shown to improve nasal breathing, improve
symptoms of rhinitis, and reduce the size of sinonasal polyposis along with the rate of
recurrence.[28]
Despite this proven symptomatic benefit, there remains debate however
about the efficacy of steroids in reduction of the proportion of patients requiring
surgery.[29]
One trial has certainly showed a reduced rate of surgical treatment, but it is
acknowledged that further research is required in this area.[30]

Systemic steroids are usually reserved for advanced or refractory cases. The duration of
treatment is usually kept short due to the risk of adverse side effects. [31]
The adverse
effects of short-term steroid use include glucose intolerance, hypertension, adrenal
suppression, gastro-intestinal bleeding, and altered mental state. However, benefits of
using systemic steroids have been reportd in literature. A study using prednisolone
showed improvement of symptoms, especially obstruction and anosmia, as well as
resolution of CT scan findings in 52% of the cases.[32]
Hissaria et al (2006) also reported
a significant difference in nasal symptoms and endoscopic findings with prednisolone
usage.[33]
Other medical therapies have been used for treatment of sinonasal polyposis.
Leukotrienes receptor antagonists have recently been shown to be effective [34]
but
larger scale trials are required to prove their efficacy.
Surgical therapy is reserved for cases refractory to medical treatment. No single surgical
technique has proved to be entirely curative and patients often undergo repeat
procedures despite also receiving long-term medical therapy. Surgical techniques have
been significantly refined over the past 20 years with the advent of functional
endoscopic sinus surgery (FESS). [35]
With a better understanding of the anatomy of the
osteomeatal complex and pathways of mucocilliary clearance, FESS is now the
mainstay of treatment for sinonasal polyposis. It involves restoring sinus drainage by

careful removal of sinonasal polyposis or other soft tissue obstructing the natural sinus
ostia. [36]
Endoscopic sinus surgery (ESS) is the currently accepted surgical intervention for
treatment of refractory chronic rhinosinusitis and other conditions of the sinuses.
Though relatively safe, there is potential for both minor and severe complications,
including cerebral spinal fluid leak, orbital or intracranial injury, meningitis, synechiae,
and bleeding. Minor complications have been noted to occur in less than 4% of cases;
with major complications occurring in approximately 1%.Surgical field visualization is
essential for successful outcomes from this procedure and to minimize development of
these complications. Bleeding in the surgical field can be progressive and even
detrimental, causing prolonged operative time, incomplete surgical interventions, and
increased complications due to difficulty visualizing and identifying landmarks with
subsequent injury of important anatomical structures.
[37]
Nasal polyps are associated with the inflammation of the nasal cavity and the sinus
mucosa. When medical treatment cannot solve a patient's problem, a functional
endoscopic sinus surgery may be indicated. Bleeding impairs the surgery field during
operation and increases the operation risk and time. Pre-operative corticosteroids can
reduce bleeding during surgery. In this study, they have evaluated the effect of pre-
operative single-dose prednisolone (1 mg/Kg/dose 24 h before surgery) versus 5-day

prednisolone (1 mg/Kg/day before operation) on the bleeding volume and the surgery
field quality during FESS. It was found that the 5 day course of steroid can reduce blood
loss during surgery.
[38]
Preoperative administration of systemic corticosteroids improves the perioperative
visibility by reducing blood loss and shortens the operation time. The optimum dose
and duration have not been established and require further studies.
[39]
In another study it is found that use of a 5 day course of prednisolone at the dose of
30mg can improve the surgical field visibility significantly. Total blood loss and
visualization of the surgical field during the surgical procedure were compared in 2
groups of 18 patients each with severe nasal polyposis. The groups were similar in
respect to age, body mass index, general health status, incidence of allergy, bronchial
asthma, aspirin triad, and stage of disease. One group received 30 mg of prednisone
daily for 5 consecutive days before the operation. The second group served as a control.
[40]
Impairment of the surgical view by bleeding in endoscopic ethmoidectomy for chronic
rhinosinusitis with nasal polyps (CRSwNP) contributes to the risk of skull base injuries.
The aim of the study was to investigate the effect of a short course of a systemic
corticoid treatment on bleeding and surgical field quality during endoscopic
ethmoidectomy for CRSwNP. A prospective study was conducted on 40 patients.

Before surgery, 21 of them (group B) were treated with 1 mg/kg per day of prednisolone
for seven days. They were compared with the 19 other patients (group A) on
intraoperative blood loss and surgery duration. Preoperative treatment with systemic
corticosteroids does not seem to reduce surgical blood loss. However, a decrease in the
procedure's duration was noted. By reducing mucous inflammation, this treatment could
improve the local conditions and help the surgeon in the mucous eradication.
[41]
Controlling the inflammatory reaction of chronic sinusitis and nasal polyp by
preoperative treatment is the most important factor to reduce bleeding while undergoing
endoscopic sinus surgery. However, the followings are also important factors to reduce
bleeding in endoscopic sinus surgery, such as adequate use of vasoconstrictor in the
middle nasal meatus during surgery, the use of deliberate hypotension during surgery,
controlling the high risk factors by preoperative treatment and reducing trauma during
surgery, etc.
[42]
Nasal polyposis is not a life-threatening disorder but has a great impact on the quality of
life. Steroids constitute the first line of treatment of nasal polyps. The aims of the study
were to evaluate the quality of life in nasal polyp patients after: (1) a short course of oral
steroids; and (2) a long-term treatment with intranasal steroids. Patients with severe
nasal polyps received either oral prednisone (n = 60) or no steroid treatment (control
group, n = 18) for 2 weeks. Patients treated with steroids were also followed-up and
evaluated after 12, 24, and 48 additional weeks with intranasal budesonide treatment.

These results suggest that the treatment with a short-course of oral steroids improves the
quality of life of patients with severe nasal polyps and that this effect is maintained by a
long-term treatment with intranasal steroids.
[43]
Chronic rhinosinusitis (CRS) is the inflammation of the nasal and paranasal sinus
mucosa persisting for at least 12 weeks. The success of endoscopic sinus surgery (ESS)
depends on minimising oedema and intraoperative bleeding. For this purpose, some
surgeons advocate the use of preoperative systemic steroids (SS). Our aim was to assess
if the administration of preoperative SS in patients with CRS with or without nasal
polyps (NP) facilitates the surgical procedure. Non-randomized clinical trial in CRS
patients with or without NP. Patients in the ESS group received oral prednisone
preoperatively, whereas the control group did not. The visibility of the surgical field,
intraoperative bleeding and surgery duration were recorded. Even though all the
parameters decreased with the preoperative administration of SS, only operative
bleeding was significantly reduced in patients with CRS with NP.
[44]
In another study a total of 60 patients with sinonasal polyposis were given oral
glucocorticoid therapy (1 mg/kg) for 20 days. Patient symptoms were evaluated with
the Sino-Nasal Outcome Test 20 (SNOT-20). Computerized tomography (CT)
images of the paranasal sinus were acquired before and after treatment and were

evaluated with the Kennedy scoring system. Evaluation of paranasal CTs showed
complete disease resolution in 15 patients and partial disease resolution in 25
patients. Patients with complete and partial resolutions,based on CT images,
exhibited significant decreases in disease stages. Statistical analysis revealed a
significant change in the SNOT-20 results (P < 0.01). There were no statistically
significant differences among the evaluations based on the paranasal sinus CTs, the
SNOT-20, and the SNOT-20 combined with a subjective selection of the five most
disturbing symptoms (SNOT-20(+5)) (P > 0.05). The results showed a strong
correlation between radiological changes and improvements in quality of life,
assessed with the SNOT-20 or the SNOT-20(+5).
[45]
Castro et al (2013) conducted a survey on the use of preoperative systemic
corticosteroids (PSS). They had found steroids to be useful to control intra operative
bleeding. A total of 173 members answered the questionnaire. Although most
respondents believe that there is inadequate evidence to support their use, 88.82% of
the study population does use PSS in their practice. The most common diagnosis
among respondents for using PSS is chronic rhinosinusitis with polyps (CRSwNP),
which is consistent with the literature available. They also found statistically
significant differences between PSS use in private vs academic practice, showing a
trend toward more aggressive management in academic-affiliated physicians.

The current study shows that most of the respondents in their group do in fact see an
advantage in the use of PSS before ESS. The data also highlights the opinion of most
experts that more research with higher levels of evidence is still lacking.
[46]
The use of preoperative systemic steroids (PSS) in endoscopic sinus surgery (ESS)
has been a topic of debate among otolaryngologists for many years now. Until
recently, most of the evidence to support PSS use in ESS was largely anecdotal and
based on expert opinion. Although some recent randomized and blinded trials have
been published, opinions among these studies are highly variable. The objective of
this study is to identify the Intraoperative and early postoperative outcome regarding
the use of PSS in nasal polyposis.

RESULTS AND ANALYSIS P a g e | 31
RESULTS AND ANALYSIS:
In the present study conducted in MEDICAL COLLEGE & HOSPITAL, KOLKATA, over
a period of two years, total 70 patients were selected. Along with relevant history, detail
general & ENT examination were done, followed by proper investigations like pre –
operative diagnostic nasal endoscopy with biopsy and contrast enhanced CT scan of nose &
paranasal sinuses. These 70 patients were divided randomly in two groups containing 35
each. The steroid group patients received a course of oral corticosteroids 5 days prior to
surgery. The non-steroid group patients received no oral steroids.
After endoscopic sinus surgery patients were discharged at 3rd
post operative day &
followed up at weekly interval for 4 weeks. During surgery the surgeon was unaware about
the group of the patient.
AGE DISTRIBUTION:
In the present study the age of the patients ranging from 10 years to 50 years. No patients
were found below 10 years & above 51 years. Maximum number of patients was found in the
3rd
decade (total 33 patients, 47.14%). Next most common was age group 11- 20 years (total
19 patients, 27.14%). Mean age is 25.64.

Table 1: AGE DISTRIBUTION
Age Group(years) Number of Patients Percentage (%)
11-20 19 27.14
21-30 33 47.15
31-40 16 22.86
41-50 2 2.85
Figure 1: Bar diagram showing Age Distribution (n=70)
19
33
16
2
0
5
10
15
20
25
30
35
11 to 20 21 to 30 31 to 40 41 to 50
Age Distribution

SEX DISTRIBUTION:
Among 70 patients, 44 were male (62.86%). Rest 26 were female (37.14%). Male: Female
1.69: 1.
Figure2: Pie diagram showing Distribution of sex (n=70)
AGE WISE SEX DISTRIBUTION:
Among male maximum number of patients were found in 21-30 years of age group
(21patients; 30%). Maximum number of female patients was in 21-30 years of age group (14
patients, 20%).
44
26
Male(62.86%)
Female(37.14%)

TABLE 2: AGE WISE SEX DISTRIBUTION
AGE GROUP MALE FEMALE
NUMBER PERCENTAGE NUMBER PERCENTAGE
11- 20 9 12.86% 8 11.43%
21- 30 21 30% 14 14%
31-40 12 17.14% 4 4%
41-50 2 2.86% 0 0%
FIGURE 3: BAR DIAGRAM SHOWING AGE WISE SEX DISTRIBUTION (n=70)
9
21
12
2
8
14
4
0
5
10
15
20
25
11 to 20 21 to 30 31 to 40 41 to 50
MALE
FEMALE

RADIOLOGICAL STUDY OF NOSE & PARANASAL SINUSES:
Contrast enhanced CT scans (3mm cut) were in all the patients. Axial, coronal & saggital cut
were done in all 70 subjects. Involvement of the paranasal sinuses were evaluated using the
LUND-MACKAY SCORING SYSTEM. According to the scoring, ostiomeatal complex
was involved in all 70 patients, followed by maxillary antrum (60patients, 85.71%). Anterior
ethmoid involvement was 60%.
TABLE 3: INVOLVEMENT PARANASAL SINUSES
(LUND-MACKAY SCORING)
NUMBER
( EACH OUT OF 70)
PERCENTAGE (%)
OMC 70 100%
ANTERIOR
ETHMOIDS
42 60%
POSTERIOR
ETHMOIDS
21 30%
MAXILLARY
ANTRUM
60 85.71%
FRONTAL SINUS 5 7.14%
SPHENOID SINUS 1 1.43%

LUND-KENNEDY ENDOSCOPIC SCORING:
Pre-operative diagnostic nasal endoscopy was done in all the patients with 0 degree rigid
endoscope. These results were evaluated using LUND-KENNEDY ENDOSCOPIC
SCORING system.
EXTENT OF THE POLYP:
Total 29 patients (41.43%) having polyp beyond the middle meatus but within the nasal cavity
(score 2). 16 patients (22.86%) having score 3 i.e. polyp beyond the nasal cavity.25 patients
(35.71%) had polyp within the middle meatus (score 1).
FIGURE 4: PIE CHART SHOWING EXTENT OF POLYP (n=70)
35.71%
41.43%
22.86%
A(Score 1)
B(Score 2)
C(Score 3)

DISCHARGE:
33 patients (47.14%) had clear discharge (score 1). 7 patients (10%) had purulent or thick
discharge (score 2). Rest 30 patients (42.86%) had no discharge (score 0).
FIGURE 5: PIE CHART SHOWING TYPES OF DISCHARGE (n=70)
42.86%
47.14%
10%
A(Score 0)
B(Score 1)
C(Score 2)

OEDEMA OF NASAL MUCOSA:
55 patients (78.57%) had no oedema on nasal mucosa (score 0). Rest 15 patients (21.43%) had
mild oedema (score 1).
FIGURE 6: PIE CHART SHOWING TYPES OF OEDEMA (n=70)
78.57%
21.43%
0%
A(Score0)
B(Score1)
C(Score2)

A. STEROID GROUP PATIENT (n=35):
This group comprises of 35 patients. They received oral prednisolone @ dose of 1mg/kg/day,
5 days prior to the scheduled date of surgery.
AGE DISTRIBUTION:
16 patients (45.71%) were found in 21-30 years of age group, followed by 11 patients
(31.43%) in 11-20years of age group. The table is given below.
TABLE 4: AGE DISTRIBUTION IN STEROID GROUP
AGE GROUP NUMBER PERCENTAGE
11-20 11 31.43%
21-30 16 45.71%
31-40 7 20%
41-50 1 2.86%

FIGURE 7: BAR CHART SHOWING AGE DISTRIBUTION IN STEROID
GROUP (n=35).
SEX DISTRIBUTION (n=35):
Among 35 patients, 25 patients (71.43%) were male. Rest 10 patients (28.57%) were female.
Male: Female = 2.5: 1.
11
16
7
1
0
2
4
6
8
10
12
14
16
18
11 to 20 21 to 30 31 to 40 41 to 50
Number

FIGURE 8: PIE CHART SHOWING SEX DISTRIBUTION (n=35)
Maximum number patients were seen in 21-30 years of age group (12 patients, 34.29%). No
patients were seen below 10 years & above 51 years of age. The female were predominant in
11-20 years of age group (5 patients; 14.29%). The table of distribution is shown below.
TABLE 5: AGE WISE SEX DISTRIBUTION (n=35)
11- 20 6 17.14% 5 14.29%
21- 30 12 34.29% 4 11.43%
31-40 6 17.14% 1 2.86%
41-50 1 2.86% 0 0%
71.43%
28.57%
Male
Female

FIGURE 9: BAR CHART SHOWING AGE WISE SEX DISTRIBUTION (n=35)
LUND KENNEDY ENDOSCOPIC SCORING:
All the patients in the steroid group (group A) patients underwent pre operative diagnostic
endoscopic endoscopy with biopsy by 0 degree rigid endoscope before giving them oral
steroids. The results were analysed as per LUND KENNEDY ENDOSCOPIC SCORING
SYSTEM.
EXTENT OF THE POLYP:
Total 14 patients (40%) had polyps beyond the middle meatus but within the nasal cavity
(score 2). 9 patients presented with polyps beyond the nasal cavity (score 3).Rest 12 patients
(34.29%) had polyps within the middle meatus.
6
12
6
1
5
4
1
0
2
4
6
8
10
12
14
11 to 20 21 to 30 31 to 40 41 to 50
Male
Female

FIGURE 10: PIE CHART SHOWING EXTENT OF POLYPS (n=35)
DISCHARGE:
17 patients (48.57%) had no discharge from their nose (score 0). 14 patients (40%) had thin,
hyaline discharge. Only 4 patients (11.43%) were found to have thick, purulent discharge from
their nose.
0
34.29%
40%
25.71%
Score 0
Score 1
Score 2
Score 3

OEDEMA OF THE NASAL MUCOSA:
34 patients (97.14%) had no oedema of nasal mucosa. Rest only 1 patient (2.86%) had mild
oedema of the nasal mucosa.
48.57%
40%
11.43%
Score 0
Score 1
Score 2
97.14%
2.86% 0%
Score 0
Score 1
Score 2

FIGURE 12: PIE CHART SHOWING OEDEMA OF THE NASAL MUCOSA (n=35)
PRE-OPERATIVE SNOT:
All the 35 patients were asked to mark the 4 parameters of the SNOT22 questionnaire. These
were: NEED TO BLOW YOUR NOSE, POST NASAL DISCHARGE, DIFFICULTY TO
DETECT SMELL, NASAL DISCHARGE.
NEED TO BLOW NOSE (TOTAL SCORE 5):
Total 10 patients scored 3, 4 patients scored 5 and 8 patients scored 4.
FIGURE 13: BAR CHART SHOWING NOSE BLOWING (N=35)
0
2
4
6
8
10
12
score 0 score 1 score 2 score 3 score 4 score 5
number

POST NASAL DISCHARGE (TOTAL SCORE 5):
10 patients scored 4, 9 patients scored 5, 8 patients scored 3.
FIGURE 14: BAR CHART SHOWING PND (n=35)
DIFFICULTY TO FEEL SMELL (TOTAL SCORE 5):
The bar diagram showing the distribution follows.
0
2
4
6
8
10
12
number

FIGURE 15: BAR CHART SHOWING DIFFICULTY IN SMELL (n=35)
RUNNING NOSE (n=35):
0
2
4
6
8
10
12
14
number
0
2
4
6
8
10
12
number

FIGURE 16: BAR CHART SHOWING NASAL DISCHARE (n=35)
MEASUREMENT OF INTRAOPERETIVE BLEEDING:
Bleeding during endoscopic sinus surgery was one of the important factors of the study.
Excessive bleeding during surgery threatens the surgical field visibility which may cause more
laceration to the nasal mucosa which may cause scarring, crust formation, synechia formation
post operatively increasing the morbidity. Intraoperative bleeding was evaluated using the
BOEZAART-VANDERMERWE GRADING SYSTEM. It has five grades. The grading
system was given elaborately in the proforma.
In the present study, 20 patients (57.14%) had grade 2 bleeding. 9 patients (25.71%) had grade
3 bleeding. Only 2 patients (5.71%) had grade 4 bleeding which was very difficult to control.
The following bar charts shows the types of bleeding evaluated as per the grading system.

FIGURE 17: BAR CHART SHOWING INTRAOPERATIVE BLEEDING.
POST OPERATIVE OUTCOME:
Post operative objective measurement was done by LUND-KENNEDY SCORING &
subjective outcome was analysed using a questionnaire SNOT 22.
LUND-KENNEDY SCORING:
Post operative diagnostic nasal endoscopy was done at weekly interval for 4 weeks. Scarring
& crusting were noted in the post-operative nasal cavity. Patients were advised not to use any
kind of intranasal inhalation steroids in this period. All patients were prescribed normal
4
20
9
2
0
5
10
15
20
25
Grade 1 Grade 2 Grade 3 Grade 4
Number

saline nasal douching to clean their nose. Data were collected in every week & evaluated as
per LUND-KENNEDY SCORING.
SCARRING (1ST
WEEK):
20 patients (57.14%) had mild scarring in the nasal cavity (score 1). 4 patients (11.43%) had
no scarring (score 0). Rest 11 patients (31.43%) had severe scarring in the nasal cavity (score
3).
FIGURE 18: PIE CHART SHOWING SCARRING (1ST
WEEK)
CRUSTING (1ST WEEK):
20 patients (57.14%) had mild crusts (score 1). Rest 15 patients had severe crusts almost
blocking the nasal cavity (score 2). No patients were found to have score 0.
11.43%
57.14%
31.43%
Score 0
Score 1
Score 2

FIGURE 19: PIE CHART SHOWING CRUSTS (1ST WEEK)
SCARRING (2ND
WEEK):
In the 2nd
week follow up 18 patients (51.43%) had score 1 on endoscopic findings.11
patients (31.43%) had score 0 & 6patients were found having severe scarring (score 2). The
pie chart is given below showing the distribution as mentioned above.
57.14%
42.86% Score 0
Score 1
Score 2

FIGURE 20: PIE CHART SHOWING SCARRING (2ND
WEEK)
CRUSTING (2ND
WEEK):
29 patients (82.86%) had mild crusts in their nasal cavity (score1). 6 patients had severe
crusts almost blocking their nasal cavity (score2).
31.43%
51.43%
17.14%
Score 0
Score 1
Score 2

FIGURE 21: PIE CHART SHOWING CRUSTS (2ND
WEEK)
SCARRING (3RD
WEEK):
25 patients (71.43%) had score 0. 9 patients (25.71%) had score 1 and rest 1 patient (2.86%)
had score 2. The scarring had decreased significantly in 3rd
week.
0%
82.86%
17.14%
Score 0
Score 1
Score 2
71.43%
25.71%
2.86%
Score 0
Score 1
Score 2

FIGURE 22: PIE CHART SHOWING SCARRING (3RD
WEEK)
CRUSTING (3RD
WEEK):
24 patients (68.57%) had mild crusts (score 1). 7 patients (20%) had no crusts (score 0). Rest
4 patients (11.43%) scored 2.
FIGURE 23: PIE CHART SHOWING CRUSTS (3RD
WEEK)
SCARRING (4TH
WEEK):
28 patients (80%) had score 0. 7 patients (20%) scored 1. No patients were found to have
severe scarring. Scarring improved significantly in 4th
week.
20%
68.57%
11.43%
Score 0
Score 1
Score 2

FIGURE 24: PIE CHART SHOWING SCARRING (4TH
WEEK)
CRUSTING (4TH
WEEK):
22 patients (62.86%) had no crusts in their nasal cavities (score 0). 12 patients had (34.29%)
scored 1. Only 1(2.86%) scored 2. The pie chart follows.
80%
20%
0%
Score 0
Score 1
Score 2

FIGURE 25: PIE CHART SHOWING (4TH
WEEK)
SUBJECTIVE OUTCOME:
Subjective improvement is measured using a 22 questionnaire based format (SNOT22) at
the time of 4 th post operative visit. We have selected 4 questions from the format &
applied to all patients. These 4 questions are the most common complaints of the patients,
so we selected them. Response of each questions were evaluated. The details of SNOT
22(SINO NASAL OUTCOME TEST) is given in the proforma. These 4 questions are
given below with detailed analysis. Maximum score of each question is 5.
62.86%
34.28%
2.86%
Score 0
Score 1
Score 2

10 patients (28.57%) scored 0. 12 patients (34.29%) scored 1. 5 patients scored 2. 6 patients
scored 3 & rest 2 patients scored 4.
FIGURE 26: BAR CHART SHOWING NOSE BLOWING (n-35)
11 patients scored 0. 15 patients scored 1. The bar chart showing details follows.
0
2
4
6
8
10
12
14
SCORE 0 SCORE 1 SCORE2 SCORE3 SCORE4
NUMBER

FIGURE 27: BAR CHART SHOWING POST NASAL DISCHARGE (n=35)
DIFFICULTY TO FEEL SMELL (TOTAL SCORE-5):
Total 17 patients scored 0. Only 2 patients scored 2. Rest 16 patients scored 1.
0
2
4
6
8
10
12
14
16
SCORE 0 SCORE 1 SCORE 2 SCORE 3
NUMBER

0
2
4
6
8
10
12
14
16
18
score 0 score 1 score 2

RUNNING NOSE (TOTAL SCORE 5):
10 patients scored 0. 19 patients scored 1, 4 patients scored 2. 2 patients scored 3.
FIGURE 29: BAR CHART SHOWING RUNNING NOSE (n=35)
B.THE NON STEROID GROUP (n=35):
This group of patients had received no oral steroids pre operatively. They acted as control
group. All patients underwent pre operative DNE with biopsy & contrast enhanced CTscans
of the nose & paranasal sinuses. Intraoperative bleeding monitored by BOEZAART-
0
2
4
6
8
10
12
14
16
18
20
score 0 score 1 score 2 score 3
number

VANDARMERWE GRADING. Post operative outcome analysed using LUND-
KENNEDY SCORING & SNOT 22.
AGE DISTRIBUTION:
18 patients (51.43%) were found in the 21-30 age group. 9 patients (25.71%) were found in
the 11-20 age groups. The table follows below.
TABLE 6: AGE DISTRIBUTION (n=35)
AGE GROUP NUMBER PERCENTAGE
11-20 9 25.71%
21-30 18 51.43%
31-40 7 20%
41-50 1 2.86%

FIGURE 30: BAR CHART SHOWING AGE DISTRIBUTION (n=35)
SEX DISTRIBUTION:
19 patients (54.29%) were male. Rest 16 patients (45.71%) were female. Male: Female =
1.19: 1. The pie chart is given showing the sex distribution.
9
18
7
1
0
2
4
6
8
10
12
14
16
18
20
11 to 20 21 to 30 31 to 40 41 to 50
Age

FIGURE 31: PIE CHART SHOWING SEX DISTRIBUTION (n=35)
8 male patients were in 21-30 age groups. 11 female patients were in 21-30 age groups.
TABLE 7: AGE WISE SEX DISTRIBUTION
11- 20 4 11.43% 4 11.43%
21- 30 8 22.86% 11 31.43%
31-40 6 17.14% 1 2.86%
41-50 1 2.86% 0 0%
54.29%
45.71% Male
Female

FIGURE 32: BAR CHART SHOWING AGE WISE SEX DISTRIBUTION (n=35)
LUND-KENNEDY ENDOSCOPIC SCORING (n=35):
Like the steroid group these patients also underwent pre operative diagnostic nasal
endoscopy with 0 degree rigid endoscope.
EXTENT OF POLYPS (n=35):
14 patients (40%) had polyps within the nasal cavity. Only 7 patients (20%) had polyp
outside the nasal cavity. The pie charts follows below.
4
8
6
1
4
11
1
0
2
4
6
8
10
12
11 to 20 21 to 30 31 to 40 41 to 50
Male
Female

FIGURE 33: PIE CHART SHOWING EXTENT OF POLYPS (n=35)
DISCHARGE:
13 patients (37.14%) had no discharge (score 0). 19 patients (54.29%) had thin, clearly
discharge (score 1). Rest 3 patients had thick, purulent discharge (score 3).
40%
40%
20%
Score 1
Score 2
Score 3

37.14%
54.29%
8.57%
Score 0
Score 1
Score 2

OEDEMA:
30 patients had no oedema of the nasal mucosa (score 0). Only 5 patients (14.29%) had mild
oedema of the nasal mucosa (score 1). No patient had severe oedema of the nasal mucosa
(score 3).
FIGURE 35: PIE CHART SHOWING OEDEMA (n=35)
MEASUREMENT OF INTRAOPERATIVE BLEEDING:
Intraoperative bleeding is measured by BOEZAART-VANDERMERWE GRADING
system. It has five grading based on the use of suction & surgical field visibility. The details
of the grading are mentioned in the proforma. The bar chart is given below showing the
different grades of bleeding.
85.71%
14.29%
0%
Score 0
Score 1
Score 2

14 patients (40%) had grade 3 bleeding. 9 patients (25.71%) had grade 4 bleeding. 12
patients (34.29%) had grade 2 bleeding. There was no grade 0 and grade 1 bleeding.
FIGURE 36: BAR CHART SHOWING GRADING OF BLEEDING (n=35)
PRE-OPERATIVE SNOT:
The bar chart follows below.
12
14
9
0
2
4
6
8
10
12
14
16
Grade 2 Grade 3 Grade 4

FIGURE 37: BAR CHART SHOWING NOSE BLOWING (n=35)
0
2
4
6
8
10
12
number
0
2
4
6
8
10
12
14
number

FIGURE 38: BAR CHART SHOWING POST NASAL DISCHARGE (n=35)
DIFFICULTY IN SMELL (TOTAL SCORE 5):
0
2
4
6
8
10
12
14
number

FIGURE 40: BAR CHART SHOWING RUNNING NOSE (n=35)
POST-OPERATIVE OUTCOME:
All the 35 patients were discharged from the hospital on the 3rd
post-operative day after
removing of nasal packs. They were followed up at weekly interval for 4weeks. Post
operative all were advised not to use any kind of inhalation steroids as it may cause false
positive results. Objective outcome were analysed using LUND-KENNEDY
ENDOSCOPIC SCORING & subjective outcome analysed using SNOT 22.
LUND-KENNEDY SCORING (POST-OPERATIVE):
0
2
4
6
8
10
12
14
16
18
20
number

SCARRING (1ST
WEEK):
17 patients (48.57%) had mild scarring (score 1). 17 patients (48.57%) scored 2. Rest
1patient scored 0.
FIGURE 41: PIE CHART SHOWING SCARRING OF NASAL MUCOSA (n=35)
CRUSTING (1ST
WEEK):
25 patients (71.43%) had severe crusting in the nasal cavity. 10 patients (28.57%) had mild
crust (score 1). No patients scored 0. The pie chart follows.
2.86%
48.57%
48.57%
Score 0
Score 1
Score 2

FIGURE 42: PIE CHART SHOWING CRUSTING (1ST
WEEK)
SCARRING (2ND
WEEK):
23 patients (65.71%) scored 1. 10 patients (28.57%) scored 2. 2 patients (5.71%) were found
to have no scarring in their nasal cavity.
0%
28.57%
71.43%
Score 0
Score 1
Score 2
5.72%
65.71%
28.57%
Score 0
Score 1
Score 2

FIGURE 43: PIE CHART SHOEING SCARRING (2ND
WEEK)
CRUSTING (2ND
WEEK):
21patients (60%) had severe crusting in their nasal cavities (score 2). 14 patients (40%)
scored 1. No patients had scored 0.
FIGURE 44: PIE CHART SHOWING CRUSTING (2ND
WEEK)
SCARRING (3RD
WEEK);
26 patients (74.29%) scored 1. 6patients (17.14%) had score 2. Rest 3 patients (8.57%) had
score 0.
0%
40%
60%
Score 0
Score 1
Score 2

FIGURE 45: PIE CHART SHOWING SCARRING (3RD
WEEK)
CRUSTING (3RD
WEEK):
At the 3rd
post-operative visit 24 patients (68.57%) had score 1. 11 patients (31.43%)
scored0. No patients scored 2.
8.57%
74.29%
17.14%
Score 0
Score 1
Score 2

FIGURE 46: PIE CHART SHOWING CRUSTING (3RD
WEEK)
31.43%
68.57%
0%
Score 0
Score 1
Score 2

SCARRING (4TH
WEEK);
9 patients (25.71%) scored 0. Rest 26 patients (74.29%) scored 1.
FIGURE 47: PIE CHART SHOWING SCARRING (4th
WEEK)
CRUSTING (4TH
WEEK):
20 patients (57.14%) had no crusts in their nasal cavities on 4th
week. Only 15 patients
(42.86%) had mild crusts in their nasal cavities.
25.71%
74.29%
0%
Score 0
Score 1
Score 2

FIGURE 48: PIE CHART SHOWING CRUSTING (n=35)
SUBJECTIVE OUTCOME:
Subjective outcome was analysed using SINONASAL OUTCOME TEST-22. We have
selected 4 questions from the questionnaire and applied to all 35 patients. It is described
below. We have omitted other 18 questions. Each question has a maximum score 5.
7 patients scored 0. 15 patients scored 1, 10 patients scored 2, 2 patients scored 3 and 1
patients scored 4.
score 0
score 1
score 2

FIGURE 49: BAR CHART SHOWING NOSE BLOWING
9 patients scored 0, 14 patients scored 1, 11 patients scored 2 and 1 patient scored 3.
0
2
4
6
8
10
12
14
16
score 0 score 1 score 2 score 3 score 4
number

FIGURE 50: BAR CHART SHOWING POST NASAL DISCHARGE
DIFFICULTY TO FEEL SMELL (TOTAL SCORE 5):
10 patients scored 0, 13 patients score 1, 9 patients scored 2, 3 patients scored 3.
FIGURE 51: BAR CHART SHOWING DIFFICULTY TO SMELL
0
2
4
6
8
10
12
14
16
number
0
2
4
6
8
10
12
14

Total 8 patients score 0, 16 patients scored 1, 10 patients scored 2, 1 patient scored 3.
FIGURE 52: BAR CHART SHOWING RUNNY NOSE
0
2
4
6
8
10
12
14
16
18
score 0 score 1 score 2 Category 4
number

STATISTICAL ANALYSIS:
The data obtained through the study analysed using chi-square test. The odds-ratio and p
value were calculated. The details are given below.
INTRAOPERATIVE BLEEDING:
Intraoperative bleeding Moderate and heavy
Bleeding(grade 3,4,5)
Mild and absent
bleeding
(grade 0,1,2)
Non steroid 23 12
steroid 11 24
Odds ratio is 4.181. The Chi Square value is 8.2353, p=0.0004.
Interpretation: Chance of moderate and heavy bleeding 4.181 times higher in non
steroid group than the steroid group and this association is statistically significant
(p=0.0004) as Chi square value is 8.2353.

FIGURE 53: COMPONENT BAR DIAGRAM SHOWING ASSOCIATION
BETWEEN INTRAOPERATIVE BLEEDING WITH STEROID AND NON
STEROID GROUP.
SUBJECTIVE OUTCOME:
NEED TO BLOW NOSE:
NOSE BLOWING PRESENT(SCORE 1,2,3,4,5) ABSENT(SCORE 0)
NON STEROID 28 7
STEROID 25 10
23
12
11
24
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Moderate Bleeding Mild Bleeding
Steroid
Non Steroid

Interpretation: Chance of Presence of Nose Blowing 1.6 times higher in non steroid
group than the steroid group though this association is statistically not significant
(p=0.403) as Chi square value is 0.6992
FIGURE 54. COMPONENT BAR DIAGRAM SHOWING ASSOCIATION
BETWEEN PRESENCE AND ABSENCE OF NOSE BLOWING WITH NON
STEROID AND STEROID GROUP.
28
7
25
10
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
NB Present NB Absent
Steroid
Non Steroid

POST NASAL DISCHARGE:
Interpretation: Chance Presence of PND 1.32 times higher in non steroid group than the
steroid group though this association is statistically not significant (p=0.28) as Chi square
value 0.597.
26
9
24
11
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
PND Present PND Absent
Steroid
Non Steroid
PND PRESENT(SCORE1,2,3,4,5) ABSENT(SCORE 0)
NON STEROID 26 9
STEROID 24 11

FIGURE 55.COMPONENT BAR DIAGRAM SHOWING ASSOCIATION
BETWEEN PRESENCE AND ABSENCE OF POST NASAL DISCHARGE WITH
NON STEROID AND STEROID GROUP.
DIFFICULTY TO DETECT SMELL:
Interpretation: Chance difficulty to detect Smell 2.36 times higher in non steroidal group
than the steroidal group though this association is statistically not significant (p=0.086) as
Chi square value 2.9543.
SMELL PRESENT(SCORE 1,2,34,5) ABSENT(SCORE 0)
NON STEROID 25 10
STEROID 18 17

FIGURE 56.COMPONENT BAR DIAGRAM SHOWING ASSOCIATION
BETWEEN PRESENCE AND ABSENCEOF SMELL WITH NON STEROID AND
STEROID GROUP.
RUNNING NOSE:
RUNNY NOSE PRESENT(SCORE 1,2,3,4,5) ABSENT(SCORE 0)
NON STEROID 27 8
STEROID 25 10
25
10
18
17
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Smell Present Smell Absent
Steroid
Non Steroid

Interpretation: Chance Presence of Running Nose 1.35 times higher in non steroidal
group than the steroidal group though this association is statistically not significant
(p=0.584) as Chi square value is 0.2991.
BETWEEN PRESENCE AND ABSENCE OF RUNNING NOSE WITH NON
STEROID AND STEROID GROUP.
OBJECTIVE OUTCOME (LUND-KENNEDY SCORING):
SCARRING:
SCARRING PRESENT(SCORE 1,2) ABSENT(SCORE 0)
NON STEROID 26 9
STEROID 7 28
27
8
25
10
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Runny Nose Present Runny Nose Absent
Steroid
Non Steroid

Odds ratio is 11.56. The Chi Square value is 20.6962, p<0.000.
Interpretation: Chance of presence of scarring is 11.56 times higher in non steroidal
group than the steroidal group and this association is statistically significant (p<0.000) as
Chi square value is 20.6962.
BETWEEN PRESENCE AND ABSENCE OF SCARRING WITH NON STEROID
AND STEROID GROUP.

CRUSTING:
26
9
7
28
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Scarring Present Scarring Absent
Steroid
Non Steroid
CRUSTING PRESENT(SCORE 1,2) ABSENT(SCORE 0)
NON STEROID 15 20
STEROID 13 22

Interpretation: Chance Presence of Crusting 1.27 times higher in non steroid group than
the steroid group though this association is statistically not significant (p=0.626) as Chi
square value 0.2381.
BETWEEN PRESENCE AND ABSENCE OF CRUSTING WITH NON STEROID
AND STEROID GROUP.
15
20
13
22
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Crusting Present Crusting Absent
Steroid
Non Steroid

DISCUSSION P a g e | 91
DISCUSSION:
In the present study carried out in MEDICAL COLLEGE, KOLKATA, from September
2013 to September 2015, patients presenting with sinonasal polyps were evaluated by
detailed history and physical examination supplemented with radiological and
endoscopical investigation, preoperative biopsy and histopathological examination and
postoperative endoscopic examination weekly for 4 weeks. Subjective evaluation of these
patients was done by 4 parameters, selected from SNOT22 questionnaire. These 4
questions were the most common presenting symptoms of the patients. It was done on 4
postoperative visits of the patients.
Total 70 patients were included in the study. They were divided randomly in two groups
containing 35 patients in each group. The first group received preoperative systemic
corticosteroids (PSS) and the later served as control group.
1. In the present study the age limit of the patients was from 10 years to 50 years. No patients
below 10 years and above 51 years were found in the study. Maximum patients (33 patients,
47.14%) were found in 3rd
decade, i.e. 21 to 30 years of age group. Least incidence
(2patients, 2.85%) was seen in 41 to 50 years of age group. The mean age was 25.64. In a
study done by Settipane et al (1996), it is found that nasal polyps predominantly affect
adults and usually present in patients older than 20. They are uncommon in children under 10
and may be the presenting feature of cystic fibrosis.
[47]
So this finding correlates with my

study. In other study done by Larsen et al; among 252 patients they found nasal polyps
affecting mostly 40-60 years of age group. Patients aged over 80 years least likely to be
affected.
[48]
Their findings are not supporting my result.
2. Among the 70 patients, 44 patients (62.86%) were male; rest 26 patients (37.14%) were
female. Male: Female ratio was 1.69: 1. Settipane et al (1996) also found that the disease is
more prevalent among males. They reported the same ratio is 2:1 in their paper.
[47]
So this
also qualifies my result. Larsen et al found that the male: female ratio was 2.9 in the age
group of 40-50.
[48]
3. Among male maximum number of patients were found in 21-30 years of age group
(21patients; 30%). Maximum number of female patients was in 21-30 years of age group (14
patients, 20%). Mean age of male and female was 27.32 and 24.51 respectively. Settipane et
al (1996) found in their review of 211 patients there was an equal distribution of male and
female patients; 50.2% vs. 49.8%. Data published more recently the Danish national health
insurance system to identify patients treated for NP differs with this prior observation.
Larsen et al observed that increased incidence of NP in the males above the age of 20 years
as compared with the age matched females.
[48]

4. In the steroid group 35 patients were included randomly. Among 35 patients, 16 patients
(45.71%) were found in 21-30 years of age group, followed by 11 patients (31.43%) in 11-
20years of age group. Among 35 patients, 25 patients (71.43%) were male. Rest 10 patients
(28.57%) were female. Male: Female = 2.5: 1. Maximum number patients were seen in 21-30
years of age group (12 patients, 34.29%). No patients were seen below 10 years & above 51
years of age. The female were predominant in 11-20 years of age group (5 patients; 14.29%).
This finding correlates with the work of Settipane et al (1996).
[47]
5. The non steroid or the control group also contains 35 patients; which were included in the
group randomly. Among these 35 patients, 18 patients (51.43%) were found in the 21-30 ages
group. 9 patients (25.71%) were found in the 11-20 age groups. 19 patients (54.29%) were
male. Rest 16 patients (45.71%) were female. Male: Female = 1.19: 1. 8 male patients were in
21-30 age groups. 11 female patients were in 21-30 age groups.
6. Radiological study of the 70 patients was done by contrast enhanced CT scan of the nose
and paranasal sinuses. 3mm axial, coronal and saggital cut was done. Extent of the
involvement of the disease was evaluated by LUND- MACKAY SCORING. According to
the scoring, ostiomeatal complex was involved in all 70 patients, followed by maxillary
antrum (60patients, 85.71%). Anterior ethmoid involvement was 60%. Posterior ethmoid
involvement was 30%. Frontal sinus involvement was 7.14%. Least involved sinus in
sinonasal polyp was sphenoid sinus; 1.43%. So according to the finding of my study

osteomeatal complex was most commonly involved in the patients presenting with sinonasal
polyps, followed by anterior ethmoid. The least common involved sinus is sphenoid sinus.
According to Diagnostic tool in Rhinology EAACI position paper (2011),
[49]
imaging of
the nose and Sino-nasal cavity is used as an objective diagnostic tool in establishing the
diagnosis and in staging the severity of rhinosinusitis (RS) and nasal polyposis (NP). The
diagnosis of RS with/without NP is based on the presence of characteristic clinical symptoms,
which are confirmed by either nasal endoscopy or radiographic imaging. Computerized
tomography (CT) scans provide substantial information about paranasal sinus anatomy and are
mandatory for safe endoscopic sinus surgery. Unlike standard X-ray and ultrasonography
(USG), CT scans of the Sino-nasal cavity and magnetic resonance imaging provide objective
information on the extent of sinus disease and are the most frequently used objective tools in
staging of severity of the disease (with the exception of endoscopic staging of polyp size).
Following the introduction of CT scans in the 1970s and the concepts of functional endoscopic
sinus surgery (FESS) in the 1980s, CT scanning has become the most important imaging
modality and helped the development of endoscopic surgery of the sinuses and skull base.
Coronal sections have been the most requested plane on CT imaging of the nose and sinuses
as this closest resembles the surgical anatomy encountered in endoscopic sinus surgery,
presenting ostiomeatal complex (unit) and relationship between sinuses, orbit, and skull base.
The Lund-Mackay score would better quantify severity of the disease, although no system
currently available allows clinicians to judge the evolution of this disease or to indicate
prognosis. The Lund Mackay system is based on scoring each sinus with 0-2 points (0- no
pathology, 1 point any partial opacity, 2 points- total opacity), giving a score of 0-12 per side.

However, even this system does not result in significant correlation with symptom severity
scores. Normal Lund-Mackay score for adults is 4.26 (95% CI, 3.43 to 5.10) and for children
it is 2, 81 (95% confidence interval, 2.40 to 3.22), with only 19, 3% having a score of 0.
[49]
According to Hamilos DL et al; the most commonly involved sinuses in both acute and
chronic sinusitis are the maxillary and the anterior ethmoid sinuses.
[50]
7. Endoscopic evaluation of the polyps were done by LUND-KENNEDY SCORING. In my
study all the patients underwent preoperative diagnostic nasal endoscopy using 0 degree rigid
endoscope. Total 29 patients (41.43%) having polyp beyond the middle meatus but within the
nasal cavity (score 2). 16 patients (22.86%) having score 3 i.e. polyp beyond the nasal
cavity.25 patients (35.71%) had polyp within the middle meatus (score 1). 33 patients
(47.14%) had clear discharge (score 1). 7 patients (10%) had purulent or thick discharge
(score 2). Rest 30 patients (42.86%) had no discharge (score 0). 55 patients (78.57%) had no
oedema on nasal mucosa (score 0). Rest 15 patients (21.43%) had mild oedema (score 1). In
the steroid group of 35 patients Total 14 patients (40%) had polyps beyond the middle meatus
but within the nasal cavity (score 2). 9 patients presented with polyps beyond the nasal cavity
(score 3).Rest 12 patients (34.29%) had polyps within the middle meatus. 17 patients
(48.57%) had no discharge from their nose (score 0). 14 patients (40%) had thin, hyaline
discharge. Only 4 patients (11.43%) were found to have thick, purulent discharge from their
nose. 34 patients (97.14%) had no oedema of nasal mucosa. Rest only 1 patient (2.86%) had
mild oedema of the nasal mucosa. In the control group; 14 patients (40%) had polyps within

the nasal cavity. Only 7 patients (20%) had polyp outside the nasal cavity. 13 patients
(37.14%) had no discharge (score 0). 19 patients (54.29%) had thin, clearly discharge (score
1). Rest 3 patients had thick, purulent discharge (score 3). 30 patients had no oedema of the
nasal mucosa (score 0). Only 5 patients (14.29%) had mild oedema of the nasal mucosa (score
1). No patient had severe oedema of the nasal mucosa (score 3). According to Nair et al
(2010), the lund-kennedy scoring is the most popular for endoscopic evaluation.
[51]
T.Metin
et al also have the same opinion in their publication.
[52]
8. In the steroid group, 20 patients (57.14%) had grade 2 bleeding. 9 patients (25.71%) had
grade 3 bleeding. Only 2 patients (5.71%) had grade 4 bleeding which was very difficult to
control. In the control group 14 patients (40%) had grade 3 bleeding. 9 patients (25.71%) had
grade 4 bleeding. 12 patients (34.29%) had grade 2 bleeding. There was no grade 0 and grade
1 bleeding. The comparative bar chart follows.
FIGURE 61: COMPARATIVE BAR CHART SHOWING INTRAOPERATIVE
BLEEDING

0
2
4
6
8
10
12
14
16
18
20
GRADE 0 GRADE 1 GRADE 2 GRADE 3 GRADE 4 GRADE 5
STEROID
NON-STEROID
On statistical analysis, Odds ratio is 4.181. The Chi Square value is 8.2353, p=0.0004.
Chance of moderate and heavy bleeding 4.181 times higher in non steroid group than the
steroid group and this association is statistically significant (p=0.0004) as Chi square
value is 8.2353. The grading of bleeding is based on BOEZAART-VANDERMERWE
GRADING. For statistical analysis, we have further divided the bleeding into two groups
i.e. moderate and heavy bleeding (grade 3, 4, 5) and mild and no bleeding (grade 0, 1, 2).
Castro et al. (2013)
[46]
conducted a survey on the use of preoperative systemic
corticosteroids (PSS). They had found steroids to be useful to control intra operative
bleeding. A total of 173 members answered the questionnaire. Although most respondents
believe that there is inadequate evidence to support their use, 88.82% of the study
population does use PSS in their practice. The most common diagnosis among respondents
for using PSS is chronic rhinosinusitis with polyps (CRSwNP), which is consistent with
the literature available. They also found statistically significant differences between PSS

use in private vs academic practice, showing a trend toward more aggressive management
in academic-affiliated physicians. The current study shows that most of the respondents in
their group do in fact see an advantage in the use of PSS before ESS. Sieskiewicz et al
(2006)
[40]
showed that use of a 5 day course of prednisolone at the dose of 30mg can
improve the surgical field visibility significantly. Total blood loss and visualization of the
surgical field during the surgical procedure were compared in 2 groups of 18 patients each
with severe nasal polyposis. The groups were similar in respect to age, body mass index,
general health status, incidence of allergy, bronchial asthma, aspirin triad, and stage of
disease. One group received 30 mg of prednisone daily for 5 consecutive days before the
operation. The second group served as a control. Atighechi S et al (2013)
[38]
evaluated
the effect of pre-operative single-dose prednisolone (1 mg/Kg/dose 24 h before surgery)
versus 5-day prednisolone (1 mg/Kg/day before operation) on the bleeding volume and the
surgery field quality during FESS. It was found that the 5 day course of steroid can reduce
blood loss during surgery. Giordano et al (2009)
[41]
conducted on 40 patients. Before
surgery, 21 of them (group B) were treated with 1 mg/kg per day of prednisolone for seven
days. They were compared with the 19 other patients (group A) on intraoperative blood
loss and surgery duration. Preoperative treatment with systemic corticosteroids does not
seem to reduce surgical blood loss. Fraire et al (2013)
[44]
conducted a non-randomized
clinical trial in CRS patients with or without NP. Patients in the ESS group received oral
prednisone preoperatively, whereas the control group did not. The visibility of the surgical
field, intraoperative bleeding and surgery duration were recorded. Even though all the

parameters decreased with the preoperative administration of SS, only operative bleeding
was significantly reduced in patients with CRS with NP.
9. Objective outcome was analysed using Lund-Kennedy Scoring. Each patient was
evaluated endoscopically each week for 4 weeks. 20 patients (57.14%) had mild scarring in
the nasal cavity (score 1). 4 patients (11.43%) had no scarring (score 0). Rest 11 patients
(31.43%) had severe scarring in the nasal cavity (score 3). 20 patients (57.14%) had mild
crusts (score 1). Rest 15 patients had severe crusts almost blocking the nasal cavity (score 2).
No patients were found to have score 0. In the 2nd
week follow up 18 patients (51.43%) had
score 1 on endoscopic findings.11 patients (31.43%) had score 0 & 6patients were found
having severe scarring (score 2). 29 patients (82.86%) had mild crusts in their nasal cavity
(score1). 6 patients had severe crusts almost blocking their nasal cavity (score2). 25 patients
(71.43%) had score 0. 9 patients (25.71%) had score 1 and rest 1 patient (2.86%) had score 2.
The scarring had decreased significantly in 3rd
week. 24 patients (68.57%) had mild crusts
(score 1). 7 patients (20%) had no crusts (score 0). Rest 4 patients (11.43%) scored 2. 28
patients (80%) had score 0. 7 patients (20%) scored 1. No patients were found to have severe
scarring. Scarring improved significantly in 4th
week. 22 patients (62.86%) had no crusts in
their nasal cavities (score 0). 12 patients had (34.29%) scored 1. Only 1(2.86%) scored 2.
In non-steroid group, 17 patients (48.57%) had mild scarring (score 1). 17 patients (48.57%)
scored 2. Rest 1patient scored 0. 25 patients (71.43%) had severe crusting in the nasal cavity.
10 patients (28.57%) had mild crust (score 1). No patients scored 0. 23 patients (65.71%)
scored 1. 10 patients (28.57%) scored 2. 2 patients (5.71%) were found to have no scarring in

their nasal cavity. 21patients (60%) had severe crusting in their nasal cavities (score 2). 14
patients (40%) scored 1. No patients had scored 0. 26 patients (74.29%) scored 1. 6patients
(17.14%) had score 2. Rest 3 patients (8.57%) had score 0. At the 3rd
post-operative visit 24
patients (68.57%) had score 1. 11 patients (31.43%) scored0. No patients scored 2. 9 patients
(25.71%) scored 0. Rest 26 patients (74.29%) scored 1. 20 patients (77.14%) had no crusts in
their nasal cavities on 4th
week. Only 15 patients (22.86%) had mild crusts in their nasal
cavities. On statistical analysis, it is found that chance of presence of scarring is 11.56 times
higher in non steroidal group than the steroidal group and this association is statistically
significant (p<0.000) as Chi square value is 20.6962. Chance Presence of Crusting 1.27
times higher in non steroid group than the steroid group though this association is statistically
not significant (p=0.626) as Chi square value 0.2381.
Schlosser et al 2015
[54]
conducted a study on 183 CRS patients and 48 non-CRS control
patients. Approximately 50% of patients achieve perfect or near perfect endoscopy (LKES 0
to 2) after ESS. Postoperative endoscopy correlated with total SNOT-22 scores (r = 0.278, p
< 0.001), with the strongest correlations to rhinologic and extra nasal sub domains in the
nasal polyp cohort. Improved postoperative endoscopy was associated with decreased
antibiotic and oral steroid usage, but had little association with missed productivity. Among
patients who achieved near perfect postoperative endoscopy, are those with nasal polyposis.

10. In my study; subjective evaluation was done by SNOT 22. 4 parameters were used to
assess the subjective outcome. These were; need to blow nose, post nasal discharge,
difficulty to detect smell and runny nose. These 4 parameters were the most common
symptoms of the 70 patients. Both preoperative and post operative data were taken. Post
operative evaluation was done at 4th
post-operative visit. In the steroid group,10 patients
(28.57%) scored 0. 12 patients (34.29%) scored 1. 5 patients scored 2. 6 patients scored 3 &
rest 2 patients scored 4 in need to blow your nose parameter (total score 5). 11 patients
scored 0. 15 patients scored 1 in post nasal discharge parameter (total score 5). Total 17
patients scored 0. Only 2 patients scored 2. Rest 16 patients scored 1 in difficulty to smell
parameter (total score 5). 10 patients scored 0. 19 patients scored 1, 4 patients scored 2. 2
patients scored 3 in runny nose parameter.
In the control group, 7 patients scored 0. 15 patients scored 1, 10 patients scored 2, 2 patients
scored 3 and 1 patients scored 4 in need to blow your nose parameter. 9 patients scored 0, 14
patients scored 1, 11 patients scored 2 and 1 patient scored 3 in post nasal discharge
parameter. 10 patients scored 0, 13 patients score 1, 9 patients scored 2, 3 patients scored 3 in
difficulty to smell parameter (total score 5). Total 8 patients score 0, 16 patients scored 1, 10
patients scored 2, 1 patient scored 3 in runny nose parameter (total score 5). On statistical
analysis; Chance of Presence of Nose Blowing 1.6 times higher in non steroid group than the
value is 0.6992. Chance Presence of PND 1.32 times higher in non steroid group than the

value 0.597. Chance difficulty to detect Smell 2.36 times higher in non steroidal group than
the steroidal group though this association is statistically not significant (p=0.086) as Chi
square value 2.9543. Chance Presence of Runny Nose 1.35 times higher in non steroidal
group than the steroidal group though this association is statistically not significant (p=0.584)
as Chi square value is 0.2991.

CONCLUSION P a g e | 103
CONCLUSION:
Sinonasal polyps are benign lesions arising from the mucosa of the paranasal sinuses
(commonly at the outflow tract of one or more of the sinuses) or from the mucosa of the
nasal cavity.[18]
Various studies have provided different estimates about the prevalence of
sinonasal polyposis in the general population but it is generally accepted that its prevalence
is around 4%.[19]
The chief presenting symptom of sinonasal polyposis is usually variable
amount of nasal obstruction but complaints of rhinorrhoea, postnasal drip, olfactory
abnormalities with alteration of taste are also common.[21]
When surgery is planned, oral
steroids have to be started 10-12 days prior. They cause reduction in the disease which in
turn makes understanding of the anatomical landmarks better. There is reduced bleeding
contributing significantly to easier surgery. The mechanism of action involves the down
regulation of inflammatory protein encoding genes by the activation of intracellular
glucocorticoid receptors.13, 14 .Oral steroids has a tendency to induce sodium and water
retention, impaired metabolism of glucose, weight gain, altered mental orientation.
A lot of researches were done on the use of preoperative systemic corticosteroids for nasal
polyps. Most of the papers advise to use oral steroids 10-12 days before surgery. As there
are many adverse effects of steroids, research works on the application of oral steroids for
very short period is lacking. Our aim of the study was to evaluate the effect of short course
of oral steroid on Intraoperative bleeding. Bleeding impairs the surgical field visibility.
Profuse bleeding during endoscopic sinus surgery leads to increased laceration of nasal

mucosa, injury to important structures, increased operation time, postoperative scarring and
synechia. Excessive insult to nasal mucosa causes impaired mucocilliary flow, which leads
to crusts formation. In my study also the early postoperative outcome were analysed. The
relation between oral steroid and postoperative outcome was also evaluated in the study.
Very few studies were done on early postoperative outcome following the use of short
course of oral steroids. My aim is also to evaluate whether short course of oral steroid has
favourable or no effect on postoperative outcome.
Total 70 patients were included in my study. They were divided equally in two groups. The
first group was given short course of oral steroid (oral prednisolone for 5 days) and the
second group served as control group. Among 70 patients, 44 were male (62.86%). Rest 26
were female (37.14%). Male: Female 1.69: 1. Maximum number of patients was found in
the 3rd
decade (total 33 patients, 47.14%).
Intraoperative bleeding was evaluated using the Boezaart- Vandermerwe grading.
[55]
On statistical analysis, Chance of moderate and heavy bleeding 4.181 times higher in non
steroid group than the steroid group and this association is statistically significant
(p=0.0004) as Chi square value is 8.2353. On Chance of presence of scarring is 11.56
times higher in non steroidal group than the steroidal group and this association is
statistically significant (p<0.000) as Chi square value is 20.6962. Other parameters like
crusting, post nasal discharge, difficulty to feel smell, etc had favourable results in the
steroid group but their association is statistically not significant.

Use of short course of preoperative systemic corticosteroids (oral prednisolone @ 1mg/kg
for 5 days before the scheduled date of endoscopic sinus surgery) reduces blood loss
during FESS efficiently. Decrease bleeding during surgery, improves the visibility of
surgical field, lessens the operative time and prevents injury to important anatomical
structures. Preoperative systemic steroid (PSS) is also beneficial to reduce postoperative
scarring of nasal mucosa. Other parameters of early postoperative outcome(both subjective
and objective) like crusting, post nasal discharge, difficulty to feel smell, running nose,
need to blow nose etc showed better quality of life in the steroid group compared to
control or non-steroid group but the result is statistically not significant.

Effect of steroids on nasal polyposis

Effect of steroids on nasal polyposis

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