Journal Reading

The Effect of Preoperative Short Course of Oral Steroids followed by Postoperative Topical Nasal Steroids Sprays on Nasal Polyp

Recurrence after Endoscopic Nasal Polypectomy

Tutors:

dr. Tris Sudyartono, Sp. THT-KL

dr. Santo Pranowo, Sp. THT-KL

dr. Agus Sudarwi, Sp. THT-KL

Presented by:

Caroline (11-2013-083)

Lidya B.E Saptenno (11-2013-151)

Luqman Hakim MJ (11-2013-170)

Departement of Ear Nose and Thorat-Head and Neck

Faculty of Medicine Krida Wacana Christian University

Period 31 Maret 2014-3 Mei 2014

Mardi Rahayu Hospital Kudus

J. Dhaka National Med. Coll. Hos. 2011; 17 (02): 40-43

Original Article

The Effect of Preoperative Short Course of Oral Steroids followed by Postoperative Topical Nasal Steroids Sprays on Nasal Polyp Recurrence after

Endoscopic Nasal Polypectomy

Dr. Khaled Mahmud1, Prof.M.N.Faruque2, Dr. K. A. Faisal3

1 Assistant Professor, ENT, Dhaka National Medical College Hospital, 2Professor ENT, Dhaka National Medical College Hospital. 3RegistratENT, Dhaka National Medical College Hospital.

Abstract:

Objective: To evaluate the effect of preoperative short course of oral steroids followed by postoperative topical nasal steroids sprays on nasal polyp recurrence after endoscopic nasal polypectomy.

Methods: Forty eight patients of both genders with symptoms and signs of nasal polyps were included in this prospective study between January 2006 and December 2009. Their ages ranged between 18 and 60 years. The sample was divided into two groups. Group I constituted 24 patients treated by endoscopic nasal polypectomy without oral and local steroid therapy. Group II consisted of 24 patients also treated by endoscopic nasal polypectomy but received preoperatively 60mg prednisolone tablets daily for one week and postoperatively topical nasal steroid spray (Mometasone furoate suspension) for three months. All patients were followed up for at least one year. Recurrence of nasal polyps was assessed endoscopically at three, six and 12 months after surgery. Any evidence of nasal polyps-formation of whatever size was considered as recurrence.

Results: Forty eight patients (32 males and 16 females) with sinonasal polyposis were included in this study. Male to female ratio was 2:1. Patients’ age ranged from 18 to 60 years; median age was 42 years. Recurrence rates at three, six and 12 months after surgery for the first group of patients were 8.33% (2 patients), 25% (6 patients) and 41.6% (10 patients) accordingly, while the recurrence rates for the second group were 4.1% (1 patient), 8.3% (2 patients) and 12.5% (3 patients) accordingly.

Conclusions: Preoperative short course of oral steroid followed by postoperative nasal steroid spray show significant reduction in the recurrence rate of nasal polyps after endoscopic nasal polypectomy.Key words: Endoscopic nasal polypectomy, Local steroids, Nasal polyps, Oral steroid

Introduction

Nasal polyps are oedematous soft tissue outgrowths of the

nasal mucosa and paranasal sinuses.(1) They are characterized macroscopically by a smooth, shiny, pink or grey surface, and microscopically by an oedematous stroma covered by

respiratory or metaplastic squamous celepithelium.(2)

Sinonasal polyposis is a chronic disorder with major effects on the quality of life of the affected individuals. The management options for sinonasal polyposis are medical treatment, surgery or combined medical and surgical treatment. It is a common practice to use systemic or topical corticosteroids as the first

therapeutic choice,followed by surgery for resistant or

recurrent cases.(3) The prevalence of nasal polyposis in the

general population varies from 1% to 5%.(4) Nasal polyps are usually manifested after the age of 20 years. Male to female

ratio is 2 : 1.(5) Seventy-one percent of patients with nasal

polyps have bronchial asthma,(6) although the mechanisms of nasal polyp formation and growth are still unclear and the role

of allergy is controversial.(7) Nasal polyposis can be accompanied by troublesome or agonizing symptoms that markedly impair one's quality of life; they even can cause

serious orbital and cerebral complication.(8) The main

J. Dhaka National Med. Coll. Hos. 2011; 17 (02): 40-43

presenting symptoms are nasal blockage, rhinorrhea, sneezing, hyposmia, postnasal discharge and sometimes anosomia. Hypoxia, hypercapnia, snoring, sleep disorders and an increased risk of hypertension may develop in patients with

nasal polyposis.(9) Nasal polyps can cause obstruction of the

sinuses resulting in sinusitis and further polyp growth.(5, 10)

Corticosteroids reduce inflammation by decreasing the infiltration of inflammatory cells, especially mast cells and eosinophills. They also diminish the hyper-reactivity and vascular permeability of the nasal mucosa, and they might

decrease the reactive mediators from the mast cells.(10, 11) A short course of preoperative oral steroids greatly facilitates functional endoscopic sinus surgery by reduction of polyp size.(12,13) Recurrence of nasal polyps after endoscopic sinus surgery may be the result of severe inflammatory reactions

during the mucosal healing period. (14) Therefore, postoperative topical nasal steroid sprays are used to suppress these reactions and allow the reestablishment of the normal

epithelial architecture and local defenses.(15,16) They are also frequently used to manage persistent sinonasal symptoms after

surgery (17) and to decrease the recovery rate of bacteria from sinus cavity following functional endoscopic sinus surgery

(FESS) surgery.(16) Nowadays, FESS is one of the most

common procedures performed by rhinologists.(18) The incidence of serious complications of FESS has been reported

to be 0.5% or less.(19) The most common complications include bleeding, infection, orbital injury, cerebrospinal fluid leak, naso-lacrimal duct injury and carotid injury. The purpose of this study is to evaluate the benefit of a preoperative short course of oral steroids followed by postoperative topical nasal steroid sprays on decreasing the recurrence of nasal polyps after endoscopic nasal polypectomy.

Methods

This prospective study was conducted at the Ear, Nose, Throat (ENT) Department at Dhaka national medical college & hospital from Jan 2006 to Dec-2009 .48 patients of both genders with symptoms and signs of nasal polyps were included in this study. The age of the patients ranged from 18 to 60 years (median age 42 years). Patients were divided into two groups:

1. Group I comprised 24 patients treated by endoscopic nasal polypectomy without preoperative oral and postoperative local steroid therapy.

2. Group II comprised 24 patients treated by endoscopic nasal polypectomy who received preoperatively 60 mg prednisolone tablets daily in three equal divided doses (20 mg × 3) for one week and postoperatively by topicalnasal steroid spray

(Mometasone furoatesuspension) of two 50 micrograms metered doses in each nostril twice daily (total daily dose 400 mcg) for one month then reduced to two metered doses in each nostril once daily (total daily dose 200mcg) for two months. All patients were followed up for at least one year. Recurrence of nasal polyps was assessed endoscopically at three, six and 12 months after surgery. Any evidence of nasal polyp formation of any size was considered as a recurrence. All patients underwent full medical examination including upper airway endoscopy, chest X-ray,pulmonary function tests, coronal and axial CTscans for sinuses. Patients with history of previous nasal polypectomy, hypertension, gastric problems, diabetes mellitus, cystic fibrosis, allergic fungal sinusitis, aspirin intolerance, herpes keratitis, glaucoma, psychiatric disorders, advanced osteoporoses and tuberculosis were excluded from this study. Endoscopic nasal polypectomy was performed under general anesthesia in a standard anterior to posterior approach. Anterior nasal packing was removed on the next day and all patients were discharged on oral antibiotics of one week course..

Results

48 patients (32 males and 16 females) with sinonasal polyposis were included in this study.Table I. Symptoms of nasal polyps at presentation (N=48)Patients %

Patients %Nasal obstruction 40 83.3Rhinorrhea 36 75Recurrent URTI 32 66.6Sneezing 30 62.5Postnasal discharge 28 58.33Headache 26 54.16Hyposmia 18 37.5Facial pain 10 20.8

Table II. Percentage of recurrence in both groups3 months 6 months 12 monthsPatients % Patients % Patients %

3 Months 6 months 12 months

Patients % Patients % Patients %

Group 1 2 8.33 6 25 10 41.6

Group 2 1 4.1 2 8.3 3 12.5

Male to female ratio was 2 : 1. The patients’ age ranged from

18 to 60 years and median age was 42 years. Nasal obstruction was the most common symptom present in 40 patients (83.3%), followed by rhinorrhea in 36 patients (75%), recurrent attacks of upper respiratory tract infection in 32 patients (66.6%), sneezing in 30 patients (62.5%), postnasal

J. Dhaka National Med. Coll. Hos. 2011; 17 (02): 40-43

drip in 28 patients (58.33%), headache in 26 patients (54.16%), hyposmia in 18 patients (37.5%) and facial pain in 10 patients (20.8%) as shown in Table I. Out of 24 patients in Group I who were treated by endoscopic nasal polypectomy without pre- and postoperative steroids, recurrence was observed in 2 patients (8.33%) after three months of surgery compared with only one patient (4.1%) in the second group of patients who were given preoperative oral prednisolone and postoperative topical nasal steroid spray (mometasone furoate suspension) twice daily. After six months of surgery the total recurrence was detected in 6 patients (25%) in the first group and in 2 patents (8.3%) in the second group of patients. After one year of follow-up the total number of recurrences in the first group was 10 patients (41.6%) compared with only 3 patients (12.5%) in the second group of patients. (Table II demonstrate the follow-up results up to one year). These results show a

statically significant reduction in the number of recurrences of nasal polyps after one year in the second group in comparison with the first group. Even in patients with recurrence, there were important differences between the two groups. The polyps’ size, number and speed of growth were smaller in Group II patients which resulted in better nasal airways and more satisfaction from operation in comparison with patients with recurrence in Group I. It has been noted, also, that preoperative steroids decrease the edema of nasal mucosa and shrink the size of nasal polyps which greatly facilitates the access and makes the operation easier without increasing the risk of postoperative bleeding as expected (two patients in each group). No major complications were reported in both groups of patients. Minor complications included periorbital fat exposure (four patients in the first group and three patients in the second group) and postoperative bleeding (two patients in each group) without significant differences between the two groups. There was no increase of the usual side effects of prolonged use of intranasal steroid sprays such as headache, epistaxis, pharyngitis, nasal irritation and dryness more than it is stated in the drug’s leaflet and were managed accordingly.

Discussion

This study emphasizes the role of preoperative short course of oral steroids followed by postoperative topical nasal steroid sprays on decreasing the recurrence of nasal polyps after endoscopic nasal polypectomy. It is well known that both medical and traditional surgical treatment methods of nasal polyps have high rates of recurrence, so many patients with nasal polyps require multiple surgical procedures. Based on many articles reviewed, intranasal corticosteroids appear to be

safe and the benefits of their use outweigh their potential risks in appropriate patients.(20,21) Many studies have been conductedto assess the effect of oral steroid and intranasal steroid in the

treatment of sinonasal polyposis. For example, Lildholdt et al. studied the efficacy of topical corticosteroid powder (budesonide) for nasal polyps in 129 patients and showed

success in 82% of actively treated patients as opposed to about 43% in the placebo group.(22) Bross-Soriano et al. in their study

on 162 patients concluded that the use of topical intranasal steroid (fluticasone propionate) after endoscopic resection of sinonasal polyps is not only effective in reducing recurrence (14% compared to 44.4% in control group), but also it is a safe and reliable and does not increase the prevalence of infection.(1) Kang et al. reported that high-dose topical corticosteroid therapy is more effective than lowdose topical

therapy in preventing recurrent nasal polyps (7.1% opposed to 44%).(10) Gulati et al. found that only patients who stoppedusing postoperative nasal sprays (10%) developed recurrence

three months after surgery.(23) The results of the previous studies strongly support the results of our study and emphasize the importance of corticosteroid use to decrease the incidence of recurrent nasal polyps.

Conclusions

Administration of preoperative short course of oral steroids followed by postoperative topical nasal steroid sprays is safe and reliable for preventing recurrence of nasal polyps after endoscopic nasal polypectomy.

References1. Bross-Soriano D, Arrieta-Gomez J, Prado- Calleros H.

Infections after endoscopic polypectomy using nasal steroids.

Otolaryngol Head Neck Surg 2004; 130: 319-322.

2. Diamantopoulos I, Jones N, Lowe L. All nasal polyps need histological examination: an audit based appraisal of clinical practice. The Journal of Laryngology and Otology 2000; 114: 755-759.

3. Hissaria P, Smith W, Wormalled P, Taylor J, et al. Short course of systemic corticosteroids in sinonasal polyposis: A double-blind, randomized, placebo-controlled trial with evaluation of outcome measures. J Allergy Clin Immunol 2006; 118: 128- 133.

4. Settipane GA. Epidemiology of nasal polyps. Allergy Asthma Proc 1996; 17: 231-236.

5. Assanasen P, Naclerio R. Medical and surgical management o f nasal polyps. Current Opinion in Otolaryngology & Head and Neck Surgery 2001; 9:27-36.

6. Settipane GA, Chafee FH. Nasal polyps in asthma and rhinitis: a review of 6,037 patients. J Allergy Clin Immunol 1977; 59:17-21.

7. Alatas N, Baba F, San I, Kurcer Z. Nasal polyp diseases in allergic and non-allergic patients and steroid therapy.

Otolaryngology-Head and Neck Surgery 2006; 135: 236-42.

J. Dhaka National Med. Coll. Hos. 2011; 17 (02): 40-43

8. Alobid I, Benitez P, Pujols L, et al. Sever nasal polyposis and its impact on quality of life. The effect of a short course of nasal steroids followed by long-term intranasal steroid treatment. Rhinology 2006; 44: 8-13.

9. Ozdemir R, Yorulmaz A, Kutlu R, et al. Loss of nocturnal decline of blood pressure in patients with nasal polyposis. Blood Pressure 1999; 8:165-171.

10. Bachert C, Hormann K, Mosges R, et al. An update on the diagnosis and treatment of sinusitis and nasal polyposis. Allergy 2003; 58:176-191.

11. Jacquelynne P, Steven M, Bernard A. Nasal congestion: a review of its etiology, evaluation, and treatment. ENT-Ear, Nose & Throat Journal 2000; 79(9):690-702.

12. More D. Overview of nasal polyps. About.com [internet]; [cited 2008 June 27]. Available from: http://www.nap.edu/books/0309074029/html/.

13. Alobid I, Benitez P, Bernal- Sprekelsen M, et al. Nasal polyposis and its impact on quality of life: comparison between the effects of medical and surgical treatments. Allergy 2005; 60:452-458.

14. Larsen L, Tos M. Origin and structure of nasal polyps in nasal polyposis: an inflammatory disease and its treatment. Copenhagen: Munksgaad 1997; 17-30.

15. Meltzer O, Orgel A, BackhausW, et al. Intranasal flunisolide sprays as an adjunct to oral antibiotic therapy for sinusitis. J Allergy Clin Immunol 1993; 92: 812-823.

16. Desrosiers M, Hussain A, Frenkiel S, et al. Intranasal corticosteroid use is associated with lower rates of bacteria recovery in chronic rhinosinusitis. Otolaryngol Head Neck Surg 2007; 136: 605-609.

17. Kang G, Yoon B, Jung J, et al. The effect of highdose topical corticosteroid therapy on prevention of JOURNAL OF THE

ROYAL MEDICAL SERVICES Vol. 17 No. 4 December 2010 60 recurrent nasal polyps after revision endoscopic sinus surgery. Am J Rhinol 2008; 22:497- 501.

18. Lin P, Lin H, Chang H, et al. Effects of Functional Endoscopic Sinus Surgery on Intraocular Pressure. Arch Otolaryngol Head Neck Surg 2007; 133:865-869.

19. Cumberworth L, Sudderick M, Mackay S. Major complications of functional endoscopic surgery. Clin Otolaryngol Allied Sc 1994; 19(3): 248-253.

20. Penttila M, Poulsen P, Hollingworth K, Holmstrom M.

Dose-related efficacy and tolerability of fluticasone propionate nasal drops 400 μg once daily and twice daily in the treatment of bilateral nasal polyposis : a placebo-controlled randomized study in adult patients. Clinical and Experimental Allergy

2000; 30: 94-102.

21. Sheth K. Evaluating the safety of intranasal steroids in the treatment of allergic rhinitis. Allergy, Asthma, and Clinical Immunology 2008; 4 (3): 125-129.

22. Lildholdt T, Rundcrantz H, Lindqvist N. Efficacy of topical corticosteroid powder for nasal polyps: a double-blind, placebo-controlled study of budesonide. Clinical Otolaryngology 2007; 20: 26- 30.

23. Gulati P, Raman W, Antariksh D. Efficacy of Functional Endoscopic Sinus Surgery in the treatment of Ethmoidal polyps. Internet Journal of Otorhinolaryngology 2007; 7(1): 150-157

Journal Reading

Efek Pemberian Steroid Peroral Jangka Pendek Sebelum Operasi

Diikuti dengan Pemberian Steroid Topikal Semprot pada Polip

Nasi Kambuhan Setelah Endoskopi Polipektomi

Tutor:

dr. Tris Sudyartono, Sp. THT-KL

dr. Santo Pranowo, Sp. THT-KL

dr. Agus Sudarwi, Sp. THT-KL

Disusun oleh:

Caroline (11-2013-083)

Lidya B.E Saptenno (11-2013-151)

Luqman Hakim MJ (11-2013-170)

Kepaniteraan Klinik Ilmu Penyakit Telinga Hidung Tenggorok

Fakultas Kedokteran Universitas Kristen Krida Wacana

Periode 09 Juni 2014 - 12 Juli 2014

Rumah Sakit Mardi Rahayu Kudus

6

Efek Pemberian Steroid Peroral Jangka Pendek Sebelum Operasi

Diikuti dengan Pemberian Steroid Topikal Semprot pada Polip

Nasi Kambuhan Setelah Endoskopi Polipektomi

Dr. Khaled Mahmud1, Prof.M.N.Faruque2, Dr.K.A3

1Assistant Professor, ENT, Dhaka National Medical College Hospital, 2Professor ENT, Dhaka National Medical

College Hospital. 3Registrat ENT, Dhaka National Medical College Hospital

Abstrak:

Objektif: Mengevaluasi efek pemberian steroid peroral jangka pendek sebelum operasi diikuti

dengan pemberian steroid topikal semprot pada polip nasi berulang setelah endoskopi

polipektomi.

Metode: Empat puluh delapan pasien dari kedua gender dengan gejala-gejala dan tanda-tanda

dari polip nasi yang termasuk dalam studi prospektif antara bulan Januari 2006 sampai

Desember 2009. Umur mereka antara 18-60 tahun. Sampel terbagi menjadi dua grup. Grup I

terdiri dari 24 pasien diterapi dengan endoskopi polipektomi tanpa terapi steroid peroral dan

lokal. Grup 2 terdiri dari 24 pasien yang juga diterapi dengan endoskopi polipektomi tetapi

sebelum operasi diberikan 60 mg prednisolon tablet perhari selama seminggu dan setelah

operasi mendapat steroid topikal (Mometasone Furoate suspensi) selama 3 bulan. Semua

pasien dipantau selama satu tahun. Kambuhnya polip nasi dinilai secara endoskopi pada

bulan ke-3, ke-6, dan ke-12 setelah operasi. Setiap terbentuknya polip nasi ukuran apapun

dianggap sebagai kekambuhan.

Hasil: 48 pasien (32 pria dan 16 wanita) dengan polip sinus nasi termasuk dalam studi ini.

Rasio pria dan wanita adalah 2:1. Umur pasien antara 18-60 tahun dengan nilai tengah umur

42 tahun. Tingkat kekambuhan pada bulan ke-3, ke-6, ke-12 setelah operasi untuk grup I

adalah 8,33% (2 pasien), 25% (6 pasien), dan 41,6 % (10 pasien), sementara tingkat

kekambuhan untuk Grup II 4,1% (1 pasien), 8,3% 2 pasien, dan 12,5% 3 pasien.

Kesimpulan: Pemberian steroid peroral jangka pendek sebelum operasi dengan diikuti

pemberian sterioid topikal semprot setelah operasi memberikan pengurangan yang signifikan

terhadap tingkat kekambuhan dari polip nasi setelah endoskopi polipektomi.

Kata kunci: Endoskopi polipektomi, Steroid lokal, Polip Nasi, Steroid Oral.

7

Pendahuluan

Polip nasi adalah pembengkakan jaringan lunak yang tumbuh di luar mukosa hidung dan

sinus paranasal.(1) Mereka memiliki karakter makroskopik halus, berkilau, permukaan merah

mudah atau keabu-abuan, dan secara mikroskopik terdiri dari stroma yang membengkak

ditutupi oleh sel epitel pernapasan dan metaplasia skuamosa.(2) Polip sinonasal merupakan

kelainan kronik dengan efek yang besar terhadap individu yang bersangkutan. Pilihan

penanganan polip sinonasal adalah terapi medis, bedah, atau kombinasi terapi medis dan

terapi bedah. Ini menjadi praktek umum untuk menggunakan kortikosteriod secara sistemik

dan topikal sebagai terapi pilihan pertama, diikuti dengan tindakan bedah untuk kasus

resisten dan berulang.(3) Prevalensi polip nasi pada populasi umum dari 1% sampai 5%.(4)

Polip nasi biasanya bermanifestasi setelah usia 20 tahun. Rasio pria dan wanita adalah 2:1. (5)

Tujuh puluh satu persen pasien dengan polip nasi menderita asma bronkial(6), meskipun

mekanisme pembentukan polip nasi dan pertumbuhannya masih belum jelas dan peran alergi

masih kontroversial.(7) Polip nasi dapat disertai dengan gejala penyulit yang ditandai oleh

gangguan kualitas hidup, polip nasi juga dapat menyebabkan komplikasi orbital dan serebral

yang serius.(8) Gejala utama adalah hidung tersumbat, rhinorrhea, pilek, bersin, hiposmia, post

nasal drip dan kadang-kadang anosmia. Hypoxia, hiperkapnia, mengorok, gangguan tidur dan

suatu risiko hipertensi yang bertambah bisa terjadi pada pasien dengan poliposis nasal. (9)

Nasal polip dapat menyebabkan obstruksi sinus yang mengakibatkan sinusitis dan

perkembangan polip lebih lanjut. (5,10) Kortikosteroid mengurangi inflamasi dengan cara

mengurangi infiltrasi dari sel-sel inflamasi, terutama sel mast dan eosinofil. Kortikostreoid

mengurangi hiperaktivitas dan permeabilitas vaskuler pada mukosa hidung, dan

kortikosteroid juga bisa mengurangi pengaktifan kembali mediator dari sel mast. (10)

Pemakaian jangka pendek steroid oral pada sebelum operasi sangat memudahkan

pembedahan endoskopi sinus dengan cara mengurangi ukuran polip (12,13) Kambuhnya polip

hidung setelah pembedahan endoskopi sinus merupakan hasil dari reaksi inflamasi yang

hebat sewaktu periode penyembuhan mukosa.(14) Oleh karena itu, pemakaian steroid topikal

semprot setelah operasi diperuntukkan untuk menekan reaksi ini dan memungkinkan untuk

membangun struktur epitel normal dan pertahanan lokal.(15,16) Itu semua juga sering digunakan

untuk mengatasi gejala persisten sinonasal setelah operasi.(17) dan untuk mengurangi

pertumbuhan dari bakteri di rongga sinus setelah FESS (Functional Endoscopic Sinus

Surgery).(16) Sekarang FESS adalah salah satu prosedur yang sering dilakukan oleh

rhinologists.(18) Insiden serius komplikasi dari FESS telah dilaporkan 0,5% atau kurang.(19)

8

Komplikasi yang paling sering termasuk pendarahan, infeksi, cedera orbital, kebocoran

cerebrospinal, cedera duktus nasolakrimal, dan cedera karotis. Tujuan dari studi ini untuk

mengevaluasi keuntungan pemakaian oral steroid jangka pendek diikuti dengan steroid

topikal semprot hidung untuk menurunkan kekambuhan dari polip hidung setelah endoskopi

polipektomi hidung,

Metode

Studi prospektif ini telah dilakukan pada Ear, Nose, Throat (ENT) Department di Dhaka

national medical college & hospital dari Januari 2006 sampai Desember 2009. Empat puluh

delapan pasien semua gender dengan gejala dan tanda dari polip hidung telah masuk pada

studi ini. Range umur pasien dari 18-60 tahun (umur rata-rata 42 tahun). Pasien dibagi

menjadi dua kelompok:

Grup I terdiri dari 24 pasien dilakukan dengan polipektomi endokopi hidung tanpa steroid

oral sebelum operasi dan steroid lokal sehabis operasi.

Grup II terdiri dari 24 pasien dilakukan dengan polipektomi endoskopi hidung yang

mendapat tablet 60 mg prednisolon perhari sebelum operasi, dibagi menjadi 3 dosis (20mg x

3) untuk satu minggu dan steroid topikal semprot hidung (suspense Momethasone furoate)

setelah operasi dengan dosis 2x50 mcg pada setiap lubang hidung dua kali sehari (total dosis

sehari 400mcg) untuk 1 bulan. Lalu dikurangi menjadi 2x50 mcg pada setiap lubang 1x

sehari (total dosis harian 200mcg) untuk 2 bulan. Semua pasien telah dipantau minimal 1

tahun. Kekambuhan dari polip nasal dinilai secara endoskopi pada bulan ke 3,6 dan 12

setelah operasi. Jika ada bukti pembentukan polip hidung dengan berbagai ukuran

diperhitungkan sebagai kekambuhan. Semua pasien melewati pemeriksaan medis secara

menyeluruh termasuk endoskopi saluran pernapasan atas, X-ray dada, tes fungsi paru, CT

scan sinus coronal dan axial. Pasien dengan riwayat dari polip nasal, hipertensi, gangguan

lambung, diabetes melitus, kistik fibrosis, sinusistis alergi jamur, intoleransi aspirin, keratitis

herpes, glaukoma, gangguan psikiatri, osteoporosis lanjut dan tuberkulosis sebelumnya tidak

termasuk pada studi ini. Polipektomi endoskopi hidung telah dilakukan dengan anestesi

general dengan pendekatan standart anterior dan posterior. Balutan anterior hidung dilepas

pada hari berikutnya dan semua pasien dipulangkan dan diberi obat antibiotik oral selama 1

minggu.

9

Hasil

48 pasien (32 pria dan 16 wanita) dengan polyposis sinonasal dilibatkan pada studi ini.

Tabel I. Gejala dari polip nasal dalam persentase (N=48)

Jumlah Pasien %

Sumbatan hidung 40 83.3

Rhinorrhea 36 75

ISPA berulang 32 66.6

Bersin-bersin 30 62.5

Postnasal discharge 28 58.33

Sakit kepala 26 54.16

Hyposmia 18 37.5

Nyeri wajah 10 20.8

Tabel II. Persentase kekambuhan pada kedua kelompok

3 bulan 6 bulan 12 bulan

Pasien % Pasien % Pasien %

Kelompok 1 2 8.33 6 25 10 41.6

Kelompok 2 1 4.1 2 8.3 3 12.5

Rasio antara pria dan wanita adalah 2:1. Umur pasien berkisar antara 18 – 60 tahun dengan

rata-rata umur adalah 42 tahun. Sumbatan hidung adalah gejala yang paling umum terdapat

pada 40 pasien (83.3 %), diikuti dengan rhinorrhea pada 36 pasien (75%), serangan

berulang infeksi saluran pernafasan atas pada 32 pasien (66.6%), bersin-bersin pada 30 pasien

(62.5 %), postnasal drip pada 28 pasien (58.33 %), sakit kepala pada 26 pasien (54.16 %),

hyposmia pada 18 pasien (37.5 %) dan nyeri wajah pada 10 pasien (20.8 %) seperti yang

ditujukan pada tabel I. Dari 24 pasien pada kelompok I yang ditangani dengan endoskopi

polipektomi nasal tanpa penggunaan steroid pre dan post-operasi, kekambuhan ditemukan

pada 2 pasien (8.33%) setelah 3 bulan post-operasi dibandingkan hanya 1 pasien (4.1%) pada

kelompok kedua yang diberikan prednisolon oral pre-operasi dan steroid topikal semprot

hidung post-operasi (larutan nometasone furoate) dua kali sehari. Pasca 6 bulan pembedahan,

kekambuhan ditemukan pada 6 pasien (25%) pada kelompok pertama dan 2 pasien (8.3%)

10

pada pasien kelompok kedua. Follow up setelah setahun dari jumlah total kekambuhan pada

kelompok pertama adalah 10 pasien (41.6%) dibandingkan hanya 3 pasien (12.5%) pada

pasien kelompok kedua. (Tabel II menunjukan hasil follow up selama setahun). Hasil ini

menunjukan perbedaan statistik yang signifikan dalam jumlah kekambuhan polip nasal

setelah satu tahun, pada kelompok kedua dibandingkan dengan kelompok pertama. Bahkan

pada pasien yang terjadi kekambuhan terdapat perbedaan yang penting diantara kedua

kelompok. Ukuran, jumlah, dan kecepatan pertumbuhan polip nasal lebih kecil pada pasien

kelompok kedua yang memberikan hasil aliran udara nasal yang lebih baik, dan kepuasan

dari operasi yang lebih dibandingkan dengan pasien yang mengalami kekambuhan pada

kelompok pertama. Juga didapatkan, penggunaan steroid pre-operasi menurunkan edema

mukosa hidung dan mengecilkan ukuran polip hidung dimana memberikan akses yang lebih

baik dan membuat operasi jauh lebih mudah tanpa meningkatkan risiko perdarahan post-

operatif (2 pasien pada masing-masing kelompok). Tidak ada komplikasi mayor yang

dilaporkan pada kedua kelompok pasien. Timbul komplikasi minor seperti tampak lemak

periorbital ( 4 pasien pada kelompok pertama dan 3 pasien pada kelompok kedua) dan

perdarahan post-operasi (2 pasien pada masing-masing kelompok) tanpa perbedaan signifikan

diantara kedua kelompok. Tidak terdapat peningkatan efek samping yang tidak biasa dari

penggunaan steroid semprot didalam hidung yang berkepanjangan seperti sakit kepala,

epistaksis, faringitis, iritasi hidung dan kekeringan, melebihi yang telah tercantum pada

leaflet obat dan penggunaan secara umum.

Pembahasan

Penelitian ini menekankan peran pre-operasi steroid oral jangka pendek yang diikuti dengan

steroid topikal semprot hidung post-operasi, terhadap penurunan kambuhnya polip nasi

setelah endoskopi nasal polipektomi. Hal ini juga diketahui bahwa kedua metode terapi bedah

medis dan tradisional polip nasi memiliki tingkat kekambuhan yang tinggi, begitu banyak

pasien dengan polip nasi memerlukan prosedur bedah yang berkelanjutan. Berdasarkan

banyak artikel terakhir, kortikosteroid intranasal tampaknya aman dan manfaat penggunaan

kortikosteroid lebih besar dibandingkan potensi risikonya pada pasien yang cocok. Banyak

penelitian telah dilakukan untuk menilai efek dari steroid oral dan steroid intranasal dalam

pengobatan poliposis sinonasal. Misalnya, Lildholdt et al. mempelajari khasiat bubuk

kortikosteroid topikal (budesonide) untuk polip nasi pada 129 pasien dan menunjukkan

keberhasilan pada 82 % pasien yang aktif diterapi dibandingkan dengan sekitar 43 % pada

kelompok plasebo Bross - Soriano et al. dalam studi mereka pada 162 pasien disimpulkan

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bahwa penggunaan steroid topikal intranasal (flutikason propionat) setelah reseksi

endoskopik polip sinonasal tidak hanya efektif dalam mengurangi kekambuhan (14 %

dibandingkan dengan 44,4 % pada kelompok kontrol), tetapi juga aman dan terpercaya dan

tidak meningkatkan prevalensi infeksi. Kang et al. dilaporkan bahwa dosis tinggi terapi

kortikosteroid topikal lebih efektif daripada terapi topikal dosis rendah dalam mencegah polip

nasi berulang (7,1 % dibandingkan dengan 44 %). Gulati et al. menemukan bahwa hanya

pasien yang berhenti menggunakan semprot nasal pasca operasi (10%) meningkatkan

kekambuhan tiga bulan setelah operasi. Hasil penelitian sebelumnya sangat mendukung hasil

penelitian kami dan menekankan pentingnya penggunaan kortikosteroid untuk mengurangi

kejadian polip nasi berulang.

Kesimpulan

Pelaksanaan pre-operasi steroid oral jangka pendek diikuti dengan steroid topikal semprot

hidung post-operasi adalah aman dan dapat diandalkan untuk mencegah kekambuhan polip

hidung setelah endoskopi nasal polipektomi.

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