Smell Decline as a good Predictor of Sinonasal Polyposis Recurrence after Endoscopic Surgery

Document Type: Original


1 Sinus and Surgical Endoscopic Research Center, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

2 Assistant professor of Otorhinolaryngology-Head & Neck Surgery, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

3 Department of Otorhinolaryngology Head and Neck Surgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.


To evaluate the most sensitive symptom to predict early recurrence of nasal polyposis. Prospective longitudinal cohort study. Tertiary university referral center with accredited otorhinolaryngology residency programs.
 Materials and Methods:
In this prospective study, we evaluated 62 patients with diffuse nasal polyposis. All patients underwent functional endoscopic sinus surgery. The author-devised questionnaire relating to the four major symptoms of chronic rhinosinusitis were answered by patients at the pre-operative visit and at 1, 3, 6, 12, and 24 months after surgery. Patients were followed up with serial endoscopic examinations, and a computed tomography (CT) scan was performed if indicated. 
All 62 patients (37 male, 25 female) completed the study. The mean age was 41.24 ± 12.47 years. All major symptoms showed significant improvement after surgery (P=0.000); however, the severity of symptoms gradually increased in patients with a recurrence of polyposis, but at different points in time (P= 0.008). Sense of smell was the first symptom to deteriorate in patients with relapse (mean, 6 months) followed by nasal secretion (12 months), obstruction and pain
(24 months). Patients with asthma, Samter’s triad, allergic fungal rhinosinusitis (AFRS) and allergic rhinitis showed symptoms of recurrence sooner than other patients (P<0.05). 
The most sensitive symptom for the early detection of recurrence of nasal polyposis is a decrease in the sense of smell. Nasal obstruction and facial pain were observed in the late stage of relapse when frank polyposis formation was established.


Main Subjects

1. Armengot M, Garin L, Carda, C. Eosinophil degranulation patterns in nasal polyposis: an ultrastructural study. Am J Rhnol Allergy 2009; 23(5):466–70.

2. Hedman J, Kaprio J, Poussa T, Nieminen MM. Prevalence of asthma, aspirin intolerance, nasal polyposis and chronic obstructive pulmonary disease in a population-based study. Int J Epidemiol 1999; 28(4):717–22.

3. Klossek JM, Neukirch F, Pribil C, Jankowski R, Serrano E, Chanal I, El Hasnaoui A. Prevalence of nasal polyposis in France: a cross-sectional, case-control study. Allergy 2005;60: 233–7.

4. Portenko GM. Prevalence of polypous rhinosinusitis among the population. Vestn Otorinolaringol 1989(1):52–4.

5. Johansson L, Akerlund A, Holmberg K, Melen I, Bende M. Prevalence of nasal polyps in adults: the Skovde population-based study. Ann Otol Rhinol Laryngol 2003;112(7):625–9.

6. Min YG, Jung HW, Kim HS, Park SK, Yoo KY. Prevalence and risk factors of chronic sinusitis in Korea: results of a nationwide survey. Eur Arch Otorhinolaryngol 1996; 253:435–9.

7. Hadfield PJ, Rowe-Jones JM, Mackay IS. The prevalence of nasal polyps in adults with cystic fibrosis. Clin Otolaryngol Allied Sci 2000;25:           19–22.

8. Alobid I,  Antón E, Armengot M, Chao J, Colás C, del Cuvillo A, et al. SEAIC-SEORL.  Consensus Document on Nasal Polyposis. POLINA Project. J Investig Allergol Clin Immunol. 2011; 21 Suppl 1:1–58.

9. Dufour X, Bedier A, Ferrie JC, Gohler C,  Klossek JM. Diffuse nasal polyposis and comorbidity: study of 65 cases treated by endonasal endoscopic surgery. Ann Otolaryngol Chir Cervicofac. 2004; 121(5):292–7.

10. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997; 117(3):S1–7.

11. Fokkens W, Lund V, Mullol J, group E. European Position Paper on Rhinosinusitis and Nasal Polyps 2007. Rhinology 2008; Suppl 20:       1–111.

12. Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137(3):S1–31.

13. Scadding GK, Durham SR, Mirakian R, Jones NS, Drake-Lee AB, Ryan D, Dixon TA, Huber PA, Nasser SM. BSACI guidelines for the management of rhinosinusitis and nasal polyposis. Clin Exp Allergy 2008; 38:260–75.

14. Dalziel K, Stein K, Round A, Garside R, Royle P. Systematic review of endoscopic sinus surgery for nasal polyps. Health Technol Assess 2003; 7: iii: 1–159.

15. Akhtar S, Ikram M, Azam I, Dahri T. Factors associated with recurrent nasal polyps: a tertiary care experience. J Pak Med Assoc. 2010; 60(2): 102–4.

16. Garrel R, Gardiner Q, Khudjadze M, Demoly P, Vergnes C, Makeieff M, Guerrier B, Crampette L. Endoscopic surgical treatment of sinonasal polyposis-medium term outcomes (mean follow-up of 5 years). Rhinology 2003; 41:91–96.

17. Braun JJ, Haas F, Conraux C. Polyposis of the nasal sinuses. Epidemiology and clinical aspects of 350 cases. Treatment and results with a follow-up over 5 years on 93 cases. Ann Otolaryngol Chir Cervicofac. 1992; 109(4):189–99.

18. Dufour X, Bedier A, Ferrie JC, Gohler C, Klossek JM. Diffuse nasal polyposis and endonasal endoscopic surgery: long-term results, a 65-case study. Laryngoscope. 2004; 114(11):    1982–7.

19. Albu S, Tomescu E, Mexca Z, Nistor S, Necula S, Cozlean A. Recurrence rates in endonasal  surgery for polyposis. Acta Otorhinolaryngol Belg.  2004;58(1):79–86.

20. Rombaux P, De Toeuf C, Hamoir M, Eloy P, Bertrand B. Sinus-nasal polyposis: one-year outcome after endoscopic sinus surgery followed by topical corticosteroid therapy in 72 patients. Ann Otolaryngol Chir Cervicofac.  2001; 118(5): 291–8.

21. Cortesina G, Cardarelli L, Riontino E, Majore L, Ragona R, Bussi M. Multi-center study of recurrent nasal sinus polyposis: prognostic factors and possibility of prophylaxis. Acta Otorhinolaryngol Ital. 1999; 19(6):315–24.

22. Lund VJ, Mackay IS. Staging in rhinosinusitus. Rhinology 1993; 31(4):183–4.

23. Lildholdt T, Rundcrantz H, Bende M, Larsen K. Glucocorticoid treatment for nasal polyps. The use of topical budesonide powder, intramuscular betamethasone, and surgical treatment. Arch Otolaryngol Head Neck Surg 1997; 123:595–600.

24. Toledano Muñoz A, Herraiz Puchol C, Navas Molinero C, Garcia Simal M, Navarro Cunchillos M, Galindo Campillo AN. Epidemiological study in patients with nasal polyposis. Acta Otorrinolaringol Esp 2008; 59(9):438–43.

25. Bhattacharyya N. Clinical and symptom criteria for the accurate diagnosis of chronic rhinosinusitis. Laryngoscope 2006;116:1–22.

26. Litvack JR, Mace JC, Smith TL. Olfactory function and disease severity in chronic rhinosinusitis. Am J Rhinol Allergy 2009; 23(2):139–44.

27. Soler ZM, Sauer DA, Mace J, Smith TL. Relationship between clinical measures and histopathologic findings in chronic rhinosinusitis. Otolaryngol Head Neck Surg 2009;141(4):454–61.

28. Oka H, Tsuzuki K, Takebayashi H, Kojima Y, Daimon T, Sakagami M. Olfactory changes after endoscopic sinus surgery in patients with chronic rhinosinusitis. Auris Nasus Larynx 2013; 40(5): 452–7.

29. Yamagishi M, Hasegawa S, Suzuki S, Nakamura H, Nakano Y. Effect of surgical treatment of olfactory disturbance caused by localized ethmoiditis. Clin Otolaryngol Allied Sci 1989;14:405–9.

 30. Pade J, Hummel T. Olfactory function following nasal surgery. Laryngoscope 2008; 118: 1260–4.

31. Jiang RS, Lu FJ, Liang KL, Shiao JY, Su MC, Hsin CH, et al. Olfactory function in patients with chronic rhinosinusitis before and after functional endoscopic sinus surgery. Am J Rhinol 2008; 22(4): 445–8.

32. Soler ZM, Sauer DA, Mace JC, Smith TL. Ethmoid histopathology does not predict olfactory outcomes after endoscopic sinus surgery. Am J Rhinol Allergy 2010;24(4):281–5.

33. Pearlman AN, Chandra RK, Chang D, Conley DB, Tripathi-Peters A, Grammer LC, Schleimer RT, Kern RC. Relationships between severity of chronic rhinosinusitis and nasal polyposis, asthma, and atopy. Am J Rhinol Allergy 2009;23(2):145–8.

34. Settipane GA, Chafee FH. Nasal polyps in asthma and rhinitis. A review of 6,037 patients. J Allergy Clin Immunol 1977; 59(1):17–21.

35. Settipane G. Epidemiology of nasal polyps. In: Settipane G, LV, Bernstein JM, Tos M, editor. Nasal polyps: epidemiology, pathogenesis and treatment. Rhode Island: Oceanside Publications; 1997: pp. 17–24.

36. Vento SI, Ertama LO, Hytonen ML, Wolff CH, Malmberg CH. Nasal polyposis: clinical course during 20 years. Ann Allergy Asthma Immunol 2000;85(3): 209–14.

37. Bunnag C, Pacharee P, Vipulakom P, Siriyananda C. A study of allergic factor in nasal polyp patients. Ann Allergy 1983;50(2):126–32.

38. Drake-Lee A. Nasal polyps. In: Mygind N, NR, editor. Allergic and non-allergic rhinitis. Copenhagen: Munksgaard; 1993.

39. Fereidouni M, Hossini RF, Azad FJ, Assarehzadegan MA, Varasteh A. Skin prick test reactivity to common aeroallergens among allergic rhinitis patients in Iran. Allergol Immunopathol (Madr). 2009 Mar–Apr; 37(2):73–9.

40. Bakhshaee M, Jabbari F, Ghassemi MM, Hourzad Sh, Deutscher R, Nahid K. The Prevalence of Allergic Rhinitis in Patients with Chronic Rhinosinusitis. Iran J Otorhinolaryngol 2014; 26(4):77.

41. Muñoz del Castillo F, Jurado-Ramos A, Fernández-Conde BL, Soler R, Barasona MJ, Cantillo E, et al. Allergenic profile of nasal polyposis. J Investig Allergol Clin Immunol 2009;19(2):110–16.

42. Haye R, Aanesen JP, Burtin B, Donnelly F, Duby C. The effect of cetirizine on symptoms and signs of nasal polyposis. J Laryngol Otol 1998; 112: 1042–6.

43. Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in
collaboration with the World Health Organization, GA(2) LEN and AllerGen). Allergy 2008;63 Suppl 86:8–160.

44. Schubert MS. Allergic fungal sinusitis: pathophysiology, diagnosis and management. Med Mycol. 2009;47 Suppl 1:S324–30.

45. Bakhshaee M, Fereidouni M, Mohajer MN, Majidi MR, Azad FJ, Moghiman T. The prevalence of allergic fungal rhinosinusitis in sinonasal polyposis. Eur Arch Otorhinolaryngol.  2013; 270(12):3095–8.

46. Rugina M, Serrano E, Klossek JM, Crampette L, Stoll D, Bebear JP, et al. Epidemiological and clinical aspects of nasal polyposis in France; the ORL group experience. Rhinology 2002;40(2):     75–9.

47. Toledano Muñoz A, Herráiz Puchol C, Navas Molinero C, García Simal M, Navarro Cunchillos M, Galindo Campillo AN. Estudio epidemiológico en pacientes con poliposis nasal. Acta Otorrinolaringol Esp. 2008; 59(9):438–43.

48. Albu S, Tomescu E, Mexca Z, Nistor S, Necula S, Cozlean A. Recurrence rates in endonasal surgery for polyposis. Acta Otorhinolaryngol Belg 2004; 58(1):79–86.

49. L. Johansson AÖ, Holmberg K, Melân I, Stierna P, Bende M. Evaluation of Methods for Endoscopic Staging of Nasal Polyposis. Acta Otolaryngologica 2000; 120(1):72–6.

50. Kaplan BA, Kountakis SE. Role of nasal endoscopy in patients undergoing endoscopic sinus surgery. Am J Rhinol 2004; 18(3):161–4.