Pattern of sensitivity to respiratory allergens in patients with sinonasal polyposis

Background & Aim: Sinonasal polyposis is the existence of a nontumoral mass inside the nose and paranasal sinuses which can lead to nasal obstruction and other annoying problems for the patient. Since the pathogenesis of this disease and the involved factors in severity of symptoms has remained unknown, the present study has proceeded to evaluate the Pattern of sensitivity to respiratory allergens in patients with sinonasal polyposis. Methods & Materials: This observational study was a descriptive cross sectional study evaluating 77 patients with sinonasal polyposis from May 2014 to April 2015. The demographic data, history of signs related to allergy in the patient and his/her family was collected and recorded. The concentrations of serum specific IgE were measured. Results: Seventy-seven patients with sinonasal polyposis including 25 women (32.5%) with average age of 42.48± 13.43 years and 52 men (67.5%) with average age of 43.40±13.57 years were evaluated. The present study showed that the result of allergen test was positive in 32 men (61.54%) and 20 women (80%). Also, the results showed that the allergen test was negative in 25 patients (32.47%), in 6 cases (7.79%) only one allergen was positive, the results of allergen test in 46 patients (59.74%), for at least two allergens were positive. The highest numbers of positive allergens in a patient was 28. The most allergen observed in patients included plane tree 23 (29.9%), Kochia 22 (28.6%), Alternaria alternaria 20 (26%), Pigweed 20 (26%). Conclusion: Our results indicate that there are correlations between aeroallergen and clinical signs in individuals with sinonasal polyposis, and the possibility of allergic background can be considered in encountering with such patients, although these cases need specific studies with larger sample sizes.


INTRODUCTION
Sinonasal polyposis is a chronic disorder which influences on life quality of suffering individuals, this disorder is a non-neoplastic inflammation of nose which finally leads to development of abnormal masses in nasal cavity and paranasal sinuses.Treatment of this disorder includes medical treatment, surgery, or combination of these two methods (1,2).Nasal obstruction is the most important sign of sinonasal polyposis which its severity is related to location and size of polyposis, retropharyngeal discharges, headache, anosmia, and coughing are other signs of this disorder (3).Studies have shown that the clinical complications are lower in patients with polyposis in smaller sizes (4,5).
This disease is more common between men comparing to women (ration 2 to 1), the average age of nasal polyposis incidence is third and fourth decades of life, although the exact prevalence of this disorder is unknown, but, according to epidemiological studies in various areas of world, it is between 2 to 15%, approximately half of patients with nasal polyposis have a positive family history (6)(7)(8).
The pathogenesis of sinonasal polyposis is not accurately determined, but the studies have suggested that different types of infections, immunologic factors, metabolic diseases, congenital diseases such as cystic fibrosis and also autonomic dysfunction are some leading factors of polyposis.From long times ago, the correlation between asthma and polyposis has been known (9)(10)(11).The aim of the present study was to evaluate pattern of sensitivity to respiratory allergens in patients with sinonasal polyposis.

METHODS & MATERIALS
This observational study was a descriptive cross sectional study evaluating 77 patients with sinonasal polyposis from May 2014 to April 2015 referring to Ahvaz Imam Hospital.The demographic data, sinonasal symptoms according to SNOT 22 Questionnaire and his/her family history was collected and recorded.The tests based on severity from asymptomatic to very severe (0 to 5+) in four seasons of spring, summer, autumn and winter were evaluated,

Determination of serum IgE level
For measurement of IgE specific to studied allergens, 5 mililiters venous blood was collected from the patient and after separation of serum, immediately the serums were frozen at -30 centigrade degree up to day of trial.Commercial kit of AlleisaScreen made by Germany was used according to the kit's guidelines in order to measurement of the amounts of IgE specific to aeroallergens.In this method, the amounts of specific IgE antibody was reported in IU/ml.In Iran, the mentioned standard trial (AllergyScreen® test using common allergens in the country) is Iranized with cooperation of allergiologists and immunologists in the country and Mediwiss company (Germany) (Table 1).

Inclusion and Exclusion Criteria
The inclusion criteria in the present study were confirmation of polyposis through evaluation of clinical signs and radiologic tests.Patients with cystic fibrosis, kartagener syndrome and fungal allergic sinusitis are excluded from the study.

Statistical Analysis
After coding, the collected data were analyzed using SPSS software version 18. Qui-square statistical test was used for evaluation of correlation between qualitative variables with each other, and for quantitative variables, t-independent test was used.The confidence ratio is 95% in all measurements and P<0.05 is considered significant.

Demographic Characteristics of Patients
In the present study, 77 patients with sinonasal polyposis including 25 women (32.5%) with average age of 42.48± 13.43 years and 52 men (67.5%) with average age of 43.40±13.57years were evaluated.The ratio of men to women in this study was 2.08 to 1.There was no significant difference between male and female patients for age.The patients were categorized into two age range of <40 & ≥ 40 years, on the other hand, 20 patients (25.97%) were positive for asthma and 35 patients (45.46%) had a positive family history and none of them were positive for consumption of NSAIDs sensitivity (Figure 1).

The Status of Allergens in Evaluated Patients
In the present study, the patients with sinonasal polyposis were evaluated for the presence or absence of respiratory allergens.The results showed that the most frequent observed allergen in patients were: plane tree 23 (29.9%),Kochia 22(28.6%),Alternaria alternaria 20 (26%), pigweed 20 (26%).On the other hand, the results of Duck, Hen, Artemisisa, Ambrosia, Goose and Xanthium allergens were positive in none of the patients (Table 2).

IgE Specific Concentration
The mean specific IgE related to respiratory allergens of patients showed that the most amount of this specific antibody were Kochia, Pigweed, Sycamore mix, alternaria alternaria, respectively (Table 3).

The Results of Allergen Test According to Age and Gender
The present study showed that the results of allergen test was positive in 32 men (61.54%) and 20 women (80%), also the positive results in age categorization of 40 years old were higher than age categorization younger than 40 years old (Table 4).

The Abundance of Allergens
The results showed that the allergen tests were negative in 25 patients (32.47%), in 6 cases (7.79%)only one allergen was positive, the results of allergen test in 46 patients (59.74%) was positive for at least two allergens.The most number of positive allergens in a patient was 28 instances (Figure 2).

The Results Related to Evaluated Allergens
In the present study, 49 different allergens were evaluated in various categories including mites, molds, epithelium and feather of animals, cockroach, trees, weeds and grasses.The most frequent evaluated allergens were weeds, trees, grasses and …, respectively (Figure 3).

The Correlation of Allergens and Clinical Signs
The results showed that there is no significance correlation between clinical signs with age (P=0.390,r=0.640) and gender (P=0.662,r=0.293) of patients.The mean of SNOT in patients was 45.33 ± 25.11, on the other hand the results showed that there was an overall significant correlation in facing with molds (P=0.008,r=0.711), cockroach (P=0.009,r=0.816), tree (P=0.028,r=0.673), weeds (P=0.028,r=0.693), grasses (P=0.001,r=0.752), but there was no significant correlation between clinical signs and mites (P=0.217,r=0.666).The correlation between allergens and clinical signs are separated shown in Table 5.The current study has shown Cynodon, Rye grass and Kentucky are the most common allergen in the Grasses group.This prevalence ordering is same as the results of Liam et al. in Malaysia and Assarezadegan although the level of prevalence is in contrast with the last (17,22).
Our study has indicated no correlation between clinical sign and allergen test among 59 patients (76.62%) however 18 patients (23.38%) have been found with some level of correlation between clinical signs and allergen level.In the positive group, Grasses cases were most positive cases and then Weeds, Trees, and Mites respectively.Gosepath et al. have determined DNA of some fungus as Alternaria Alternaria in the polyp of patients (23), als Sabirov et al. have indicated the meaningful correlation among pathology of nasal polyps (18) that consistent with our results.Correlation between allergen agents and nasal polyp is considered as a controversial issue.As a temple, Castillo et al. have shown that skin test was significantly higher in patients with nasal polyp than healthy individuals also they have introduced Dermatophagoides pteronyssinus, Dermatophagoides farina and Olea Europaea as the most important polyp-associated allergen (24) also Asero et al. in two different studies have indicated the correlation between polyp and fungal allergen (25).In contrast, Erbek et al. have claimed that there is not any correlation between allergen agents and polyp size also clinical sings and the disease recurrence (26), in addition Bonfils et al. have supported the idea that allergen are not causative agents for nasal polyp (27).

CONCLUSION
Our results show that some degree of correlation between aeroallergens and clinical signs in patients with sinusoidal polyposis.This type of correlation can be useful in clinical aspect for patient with allergic background although further investigations are needed for confirmation of such correlation.

Figure 1 :
Figure 1: The percentage of evaluated patients based on age categorization

Figure 2 :
Figure 2: The abundance of evaluated allergens for age and gender

Figure 3 :
Figure 3: Different types of evaluated allergens for age of patients

Table 2 :
The status of studies allergens in patients

Table 3 :
The specific concentration of IgE of evaluated antigens

Table 4 :
The results of allergen test in patients according to age and gender