Rhinology, 40, 173-178, 2002

Clinical factors influencing the eosinophil

infiltration of nasal polyps*
R. Jankowski1, F. Bouchoua1, L. Coffinet1, J.M. Vignaud2

1
Department of Otorhinolaryngology, Henri Poincaré University, CHU - Central Hospital, Nancy, France
2
Department of Anatomopathology, CHU - Central Hospital, Nancy, France

SUMMARY Aims and methods: our study, based on a retrospective chart analysis, was aimed 1) to
describe the varying degree of eosinophil infiltration in a series of 263 adult patients operat-
ed on diffuse and bilateral nasal polyposis (NPS) after failure of medical treatment, in 15
cystic fibrosis patients with bilateral nasal polyps, and in 31 patients with chronic sinusitis
without polyps (18 bilateral, 13 unilateral) 2) to search for clinical factors that might influ-
ence the degree of eosinophil infiltration. Eosinophil infiltration was expressed semi-quanta-
tivily as a percentage of inflammatory cells.
Results: our study confirms that eosinophil infiltration is a striking feature of nasal polypo-
sis. All patients with chronic sinusitis showed less than 10% eosinophils (mean ± SEM = 2
± 2 %) whereas 88% of patients with NPS showed more than 10% eosinophils (50 ± 2 %).
Cystic fibrosis lied in between with 40% of patients showing more than 10% eosinophils. In
idiopathic bilateral NPS the number of eosinophils was increased in patients with asthma
(58 ± 3%) and even more in Widal’s triad (75 ± 4 %). Atopic patients did not have more
eosinophils (52 ± 5%). Patients treated with systemic steroids within two months before
surgery showed decreased eosinophil infiltration (22 ± 3 % vs 50 ± 2 for treated versus
untreated ) whereas patients treated with topical steroids did not (47 ± 2 %).
Conclusions: thus, a link might exist between clinical presentation and eosinophil infiltra-
tion. Chronic sinusitis and nasal polyps are probably not the same disease. Eosinophils
appear as a link between nasal polyps, asthma and aspirin intolerance. Atopic status does
not modify eosinophil infiltration of nasal polyps. Systemic steroids appear significantly
more effective to reduce the eosinophil infiltrate than topical steroids in our selected group of
operated patients.

Key words: nasal polyps, eosinophils, asthma, aspirin intolerance, cystic fibrosis, chronic
sinusitis, steroids

INTRODUCTION In childhood nasal polyposis is a common manifestation of

Nasal polyps originate from the respiratory mucosa covering cystic fibrosis. In adulthood, nasal polyposis can occur either
the complex anatomy of the ethmoidal bones. Histologically, as an isolated disease or as a disease associated with asthma
nasal polyps are characterised by stromal oedema and inflam- (Jankowski, 1997). Nasal polyposis, asthma, and aspirin sensi-
matory cell infiltration, with a moderate - to - high infiltration tivity when present in one patient form the “aspirin triad”
of eosinophils (Jankowski et al., 1989; Stoop et al., 1989; (Widal’s triad in Europe, Samter’s triad in USA). Despite the
Bachert et al., 2000). The aims of our study were 1) to evaluate presence of eosinophils, the causal relationship between nasal
the degree of eosinophil infiltration in a series of 263 adult polyposis and allergy remains doubtful (Keith et al., 1997).
patients with diffuse bilateral nasal polyposis, 15 cystic fibrosis Nasal polyps have been described as neutrophilic in cystic
patients with nasal polyps, and 31 patients with chronic sinusi- fibrosis (Otsuka et al., 1987). In patients with the aspirin triad a
tis without polyps and 2) to search for clinical factors that marked infiltration with eosinophils seems always to be found
might influence the degree of eosinophil infiltration. (Ogino et al., 1986). The first question is whether or not the
degree of eosinophil infiltration could be related to the clinical
presentation of nasal polyposis.

* Received for publication: April 30, 2002; accepted: July 25, 2002
174 Jankowski et al.

Systemic or topical steroids are efficient treatment of nasal (The period of two months before surgery was chosen
polyposis (Lildholdt et al., 1997). Human eosinophils have glu- because this was the mean time between the patient’s visit
cocorticoid receptors (Peterson et al., 1981), and might be one at the clinic and admission at the hospital for surgery; the
of the main targets of corticosteroids. Their beneficial effect patient’s treatments were usually well recorded in the charts
may be due either to an inhibition of mediator release or to a between these two points in time).
reduction in the number of eosinophils. Thus we looked at the If and only if a clear answer to these questions was obtained,
consequences of topical and systemic steroid treatment on the the chart was selected (one missing answer was however
density of eosinophils present in nasal polyps. accepted in a few charts).

Our results, based on a retrospective chart analysis, indicate that Methods

clinical presentation and systemic steroids are factors influenc- Our study is based on a retrospective chart analysis. However,
ing the degree of eosinophil infiltration of nasal polyp tissue. the histopathological proceedings were performed in the same
Our results may help to design future studies or trials based on way for all patients of the study with constant criteria for a
histopathology, and to understand the pathophysiology of nasal semi-quantitative evaluation of the eosinophil population.
polyposis as well as the mechanisms of action of corticosteroids.
Haematoxylin-eosin counterstained slides from formaldehyde
PATIENTS AND METHODS fixed tissue specimens were scanned at low power to deter-
Patients mine the areas having the highest content in inflammatory
All patients’ charts for this retrospective study were selected cells. In each specimen, more than 1.000 cells were counted in
only if the histopathological report clearly described the these areas, in random fields, using a x 40 objective magnifica-
eosinophil population in a semi quantitative way. tion. The number of eosinophils divided by the total number
of inflammatory cells counted provided the percentage of
Two hundred and sixty three patients included in this study eosinophil content for each sample. The procedure was done
had idiopathic bilateral polyposis for which they were operated by two independent pathologists without knowledge of the
on. The diagnosis of nasal polyposis was based on rhinoscopic diagnosis or other clinical parameters. In case of disagreement
or endoscopic examination showing the presence of oedema- (the two counts differed by > 10 %) a consensus was reached
tous polyps in both nasal cavities. Idiopathic means that by reviewing the case at a multihead microscope.
patients did not have cystic fibrosis, primary ciliary diskinesia,
Young’s syndrome, fungal sinusitis or other specific syn- Statistics
dromes. Nasalisation was the surgical technique performed, i.e. Data are presented as the mean plus or minus the standard
an endonasal endoscopic complete ethmoidectomy with resec- error of the mean (SEM). The parametric t-test was applied for
tion of the middle turbinate and large opening of the frontal, comparison of means. Linear relationships between continu-
maxillary and sphenoid sinuses into the nose (Jankowski, 1995; ous parameters were measured by the correlation coefficient.
Jankowski et al, 1997).

Fifteen patients with cystic fibrosis and operated on diffuse

and bilateral nasal polyposis formed a group apart.

Thirty one patients operated on chronic sinusitis (functional eth-

moidectomy) served as a reference group (18 bilateral, 13 unilat-
eral). Chronic sinusitis was defined as chronic nasal or sinus dis-
comfort that could clearly be related to sinus CT-scan opacities;
surgery was only indicated after failure of medical treatment.

In addition to the histopathological report, each chart was

checked in order to find the following data:
- did the patient report asthma?
- did the patient report aspirin intolerance?
- did the patient report atopy (based on skin tests or multi-
RAST results)
- what was the treatment at admission at the hospital and
during the two months before surgery? Systemic steroids?
nasal topical steroids? treatment for asthma (inhaled topical Figure 1. Age distribution in our series of 263 idopathic nasal polyposis
steroids, ß2 mimetics, theophyllin,…)? other treatments? patients.
Eosinophil infiltration of nasal polyps 175

RESULTS
1. Study population
1.1 Idiopathic bilateral nasal polyposis patients (n = 263)
Two hundred and sixty three cases were selected among 412
consecutive patients operated between 1993 and 1998. Males
represented 60.5%. Mean age was 45 years (range: 8-77 years)
(Figure 1). The polyp size score according to Rouvier’s classifi-
cation was at the time of surgery:
- stage 1 (small polyps reaching the lower edge of the middle
turbinate) in 37 (14.1%) patients
- stage 2 (polyps extending between the lower edge of the
Figure 3. Histogram of the frequency distribution of eosinophils in
middle and the upper edge of the inferior turbinates) in 63 untreated nasal polyps.
(23.9%) patients
- stage 3 (large polyps extending below the upper edge of the
inferior turbinate) in 154 (58.5%) patients; polyp size was 1.2 cystic fibrosis patients (n = 15)
not described in 9 (3.4%) patients. The mean age was 14 years (range: 6-31 years). Males repre-
Hundred and twenty nine (48.3%) patients reported asthma. sented 57%. The polyp size score was stage 3 in all except one
Bronchial hyperresponsiveness to carbamylcholine was known patient (stage 1). Only one patient out of 15 was atopic. Only
in 7 (2.7%) patients without asthma attack but with suggesting two patients received topical nasal steroids at the time of
symptoms. No history of asthma was reported by 127 (49.05%) surgery. None was under systemic steroid therapy.
patients.
Aspirin sensitivity with clinical manifestations was reported by 1.3 chronic sinusitis patients (n = 25)
7 (2,7%) patients with isolated nasal polyposis and by 60 The mean age was 52 years (range: 15-76 years). Males repre-
(22.8%) patients with nasal polyps and asthma (Widal’s triad). sented 64.5 %. CT scan ethmopacities were found bilaterally in
No information was found in 31 (11.9%) charts. 18 patients, and unilaterally in 13. One patient reported mild
Atopy (positive skin or multiRAST-tests) was found in 100 asthma (no treatment). Five patients had bronchiectasies, and
(38%) patients. No data were available in 21 (8%) patients. two others chronic bronchitis. One patient reported aspirin
Patients under systemic steroids at admission to the hospital sensitivity. Atopy was found in 7 (28%) patients.
were 83 (31.5%). There were only 57 (21.7%) patients treated
with topical nasal steroids. Patients without systemic and/or 2. Eosinophil distribution in untreated nasal polyps (n = 123)
topical nasal steroids counted 123 (46.8%). In the asthma popu- A good correlation was observed between the left and the right
lation (n = 127), 72 patients (57%) had mild asthma without nostrils (r = 0,43, p < 0.0001) (Figure 2). As a consequence we
need for treatment at the time of surgery. report only the data of the left side in the following sections.
The histogram of the frequency distribution of eosinophils in
untreated nasal polyps is presented in Figure 3.

2.1 untreated nasal polyps: with (n = 50) versus without (n = 68)

asthma
The mean number of eosinophils was 44 ± 3% in patients
without asthma and 58 ± 3 % in nasal polyps of patients report-
ing asthma (p < 0.002).

2.2 untreated polyps with asthma: with aspirin sensitivity (n = 16)

versus without aspirin sensitivity (n = 34)
In patients with nasal polyps reporting asthma (n = 50), those
who also reported aspirin sensitivity (Widal’s triad) showed sig-
nificantly more eosinophils in their polyps (75 ± 4 %) than
those without aspirin sensitivity (51 ± 4 %) (p < 0.0002).

2.3 untreated nasal polyps: in atopic (n = 33) versus non atopic

patients (n =67)
No data about skin or multi-RAST tests were found in 23
Figure 2. Correlation between right and left: eosinophil infiltration in charts of our 123 patients with untreated polyps. No difference
nasal polyps, which clearly shows the symmetrical distribution of in the number of eosinophils was observed between atopic (52
eosinophils in nasal polyps. ± 5 %) and non atopic patients (51 ± 3 %).
176 Jankowski et al.

3. Eosinophil distribution in nasal polyps of patients treated

with systemic steroids (n = 83)
We found 83 charts in which the intake of systemic steroids
during the last 2 months before surgery was recorded either as
a short course or as a long-lasting treatment. The histogram of
the frequency distribution of eosinophils in these patients is
presented in Figure 4.
The mean number of eosinophils was 22 ± 3 % in these
patients, i.e. significantly lower than in nasal polyps of untreat-
ed patients (50 ± 2 %, n = 123) (p<0.0001).

Figure. 5. Histogram of the frequency distribution of eosinophils in

patients treated only with nasal steroids during the last two months
before surgery.

123). No difference in eosinophil infiltration due to topical

steroids was found in the subgroups of patients with isolated
polyposis (44 % versus 43 %) and of patients with polyposis and
asthma (50 % versus 41 %). In the Widal’s triad, patients treat-
ed with nasal steroids (n = 16) showed a slightly lower
eosinophil content (61 ± 6 %) than untreated patients (75 ± 4
%, n = 16) (p = 0.05).

Figure 4. Histogram of the frequency distribution of eosinophils in 5. Eosinophil distribution in nasal polyps of cystic fibrosis (n =
patients having taken systemic steroids during the last two months
15)
before surgery.
None of these 15 patients reported systemic steroid therapy
over the last two months before surgery; only two of them
3.1 isolated polyposis treated with systemic steroids (n = 28) versus were on topical steroids. The histogram of the frequency distri-
untreated (n = 68) bution of eosinophils in these patients is presented in Figure 6.
The mean number of eosinophils was approximately four The correlation between left and right side was very high (r2 =
times lower in the treated (13 ± 3 %) than in the untreated 0.98, p < 0.0001). The mean number of eosinophils was 5 ±
group (44 ± 3 %) (p < 0.0001). 1%.

3.2 nasal polyposis + asthma patients treated with systemic 6. Eosinophil distribution in a control group of chronic sinusi-
steroids (n = 23) versus untreated (n = 34). tis (n = 25)
In patients with nasal polyps reporting asthma and no aspirin None of these patients reported systemic steroid therapy dur-
sensitivity, the mean number of eosinophils was more than ing the last two months before surgery. Eighteen patients were
one half lower in the systemic steroid group (19 ± 5 %) than in operated on bilateral sinusitis and the histopathologic study
the untreated group (51 ± 4 %) (p < 0.0001). found a good correlation between the right and left sides (r2 =

3.3 widal’s triad patients treated with systemic steroids (n = 25)

versus untreated (n = 16)
The mean number of eosinophils is approximately one half
lower in the treated group (34 ± 5% versus 75 ± 4%) (p <
0.0001).

4. Eosinophil distribution in nasal polyps of patients treated

with topical steroids only (n = 55)
Among the 263 patients, 55 were only on topical steroids dur-
ing the two months before surgery. The histogram of the fre-
quency distribution of eosinophils in these patients is present-
ed in Figure 5. The percentage of eosinophils was very similar Figure. 6. Histogram of the frequency distribution of eosinophils in
in the treated (47 ± 2 %) and untreated groups (46 ± 2 %, n = polyps from patients with cystic fibrosis.
Eosinophil infiltration of nasal polyps 177

Nasal polyposis has been regarded as an allergic condition as

long as eosinophils were considered markers for allergy. Atopy is
rather better defined today according to skin or multi-RAST
tests. Our study confirms the results by Pawliczak et al. (1997),
who used an advanced morphometric image analysis system: the
density of eosinophils is similar in atopic and non atopic patients.

The reason why patients with isolated nasal polyposis have sig-
nificantly less eosinophils in their polyps than patients with asth-
ma or the Widal’s triad is not clear. The number of eosinophils
in polyps of the Widal’s triad is almost twice the number found
in isolated nasal polyposis. (Please remember that isolated nasal
Figure. 7. Histogram of the frequency distribution of eosinophils in
polyposis means diffuse bilateral polyposis and does not mean a
patients with chronic sinusitis.
single polyp). Could this number reflect the severity of the dis-
ease ? This would argue again for the key role of eosinophils.
0.49, p = 0.0008). The histogram of the frequency distribution
of eosinophils in these patients is presented in Figure 7. All Steroids are well known to be effective treatment for nasal
these patients showed less than 10% eosinophils. The mean polyposis. Intranasal steroids are, by far, the best documented
percentage of eosinophils in chronic sinusitis was 2 ± 2 %. type of treatment for nasal polyposis. Their mechanisms of
action are not well understood. It has been shown mainly in
COMMENTS biopsy studies, that topical steroids reduce the total number of
Our study confirms that eosinophil infiltration is a striking fea- eosinophils (Sorensen et al., 1977; Klemi et al., 1997;
ture of nasal polyposis (Stopp et al., 1993; Bachert et al. 2000). Tingsgaard et al., 1999). Our results, surprisingly, show no evi-
In our control group of chronic sinusitis, all patients show less dence of significant eosinophil reduction after topical steroid
than 10% eosinophils. In our group of untreated idiopathic treatment. This might be explained in different ways: 1) our
nasal polyposis, 83% (103/123) patients show more than 20% patients were operated on their polyps because the efficacy of
eosinophils. The eosinophil infiltration of polyps associated topical steroids was not satisfactory (failure of topical steroids),
with cystic fibrosis seems to lie in between, with 40% of 2) our specimens for histologic examination came from surgi-
patients showing more than 10% eosinophils. cal removal of both superficial and deep polyps, the last ones
Polyps associated to cystic fibrosis have been described as neu- being probably not reached by the limited intranasal distribu-
trophilic (Sorensen et al., 1976). In the study by Rowe-Jones et tion of a spray. It has also been suggested that, besides a small
al. (1997), polyps from patients without cystic fibrosis contain reduction in total number of eosinophils, topical steroids could
more eosinophils (p < 0.001) whilst polyps from patients with mainly act by reducing eosinophils activation (Stopp et al.,
cystic fibrosis contain more neutrophils (p < 0.001) and plasma 1993; Kanai et al., 1994; Tingsgaard et al., 1999).
cells (p < 0.03). However, in our study eosinophils seem to be Systemic steroids are commonly used in the treatment of nasal
present in varying degrees in polyps from patients with and polyposis because their efficacy is obvious. However, investiga-
without cystic fibrosis. These data suggest that, both in non- tion of systemic steroids in polyposis has been remarkably
cystic fibrosis and in cystic fibrosis patients, eosinophils could insufficient. Oral steroids have, to our knowledge, not been
be key cells for understanding the pathophysiology of nasal compared with placebo in any polyposis study. Recently,
polyposis (Jankowski, 1996; Bachert et al., 2000). The higher Bachert et al. (2000) have suggested that oral corticoid treat-
number of neutrophils frequently observed in cystic fibrosis ment may lead to the shrinkage of nasal polyps by down regu-
could actually be the result of chronic bacterial infection, lation of the eosinophilic inflammation and reduction of the
which is not usual in idiopathic nasal polyposis. extravasation and deposition of albumin. Interestingly, our
results indicate that systemic steroids appear remarkably effica-
Approximately 20% (20/123) of our untreated idiopathic nasal cious to reduce the eosinophil content of polyp tissue. The
polyps show less than 20% eosinophils. One major explanation content in eosinophils is lowered by approximately 3/4 in iso-
of low eosinophilia could be associated bacterial infection, a lated polyposis, 2/3 in polyposis + asthma, and 1/2 in Widal’s
factor we did not systematically record during surgery. Others triad. A short course of systemic steroids has been shown to be
explanations are however possible: depletion of eosinophils as effective as polypectomy with a snare (Lildholdt, 1997).
because nasal polyposis disease has come to a non-active phase Thus the efficacy of both treatment could result from the same
of its evolution, heterogeneity in the tissue distribution of mechanism, i.e. a significant reduction in eosinophil content.
eosinophils, etc… It might also be that non-eosinophilic polyps
represent a different species of nasal polyps with a different The reasons why eosinophils accumulate into nasal polyp tis-
clinical behaviour, as suggested by Stammberger (1997). sue are unknown, but the hypothesis by Otsuka et al (Otsuka
178 Jankowski et al.

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