Etiopathogenesis of nasal polyps.
Laryngologists estimate polyposis on the grounds of rhinoscopy with 4 degree scale, proposed in 1993 by Johansen :
0[degrees] polyps are not recognized 1[degrees] mild polyposis (small polyps which do not reach upper edge of lower nasal concha) 2[degrees] moderate polyposis (moderate polyps localized between upper and lower edge of lower nasal concha leading to the significant impairment of nasal cavity permeability) 3[degrees] severe polyposis (leads to total occlusion of the air flow, at this part of nasal cavity)
Laryngologists divide nasal polyps into several types:
* polyps without the co-existence of chronic disorders of the respiratory system,
* those without the co-existent asthma and intolerance for non-steroidal anti-inflammatory drugs,
* with local or general immunological insufficiencies [4,5].
It has to be mentioned that macroscopic image of all types of nasal polyps is similar. They are soft, pink or pearl white outgrowths, usually connected with nasal mucosa by flaccid crus (Fig. 1 and 2) [5, 6]. However, histological image reveals significant differences, in particular cases (Fig. 3). It shows that nasal polyp is covered with respiratory epithelium placed on the thickened basement membrane. The mucosa of the nasal polyp is thin. In colloid inside of the polyp, we may observe very few small vessels, seromucous glands and cellular infiltrations. In the majority of nasal polyps, eosinophilic granulocytes (eosinophiles) are present [7-9]. Eosinophilic polyps constitute 70-90% of all nasal polyps [8, 9]. Less common are neutrophilic polyps with the infiltration of neutrophil granulocytes [8, 10].
A histopathological examination of nasal polyps reveals many differences. The image of nasal polyps includes edemic, glandular and fibrous (also called mixed) forms . Edemic forms are the majority of nasal polyps (50-60% of all cases). In such a type of the rhinal polyp's connective tissue, edema is visible along with few mixed glands covered with unaffected mucosa. Glandular form of the nasal polyps is next, according to the frequency of occurrence (27-30%). Glandular nasal polyp consists of connective tissue with edema placed centrally; large cysts and glands are visible. Mixed form of nasal polyps has its core built from fibrous connective tissue. In the core of the mixed nasal polyp, large number of infiltrations is observed (monocytes and macrophages). Such type is recognized only in 10-13% of all polypoid lesions .
Because of the variety of nasal polyps, the choice of proper treatment is very difficult. Only eosinophilic polyps respond to the topical treatment with glucocorticosteroids [8,11-13]. Neutrophilic polyps usually require inhalations with antibiotics . Unfortunately, regardless to the type of changes, pharmacological treatment only delays the growth of nasal polyps. The long-term relief and slower regrowth may only be achieved by extensive polypectomy [11,15,16]. Difficulties in the nasal polyps' treatment are due to the lack of consensus among physicians regarding etiopathogenesis of nasal polyps.
Etiopathogenesis of nasal polyps
Physicians agree that nasal polyps are a consequence of damage in the epithelium of the nasal mucosa. Injuries of the epithelium may be caused by bacterial or viral infection as well as prolonged inhalation of irritating substances. Damaged mucosa always tends to heal the injury through the migration of the epithelium from the edge of the damage to its inside. In some cases, a regeneration of the nasal epithelium is insufficient. A regeneration of nasal epithelium releasing cytokines, which activate inflammatory cells, may lead to the formation of nasal polyps (Fig. 4) .
Different etiopathogenetic theories of nasal polyps' formation have been published.
Polyposis as an allergic disease.
The allergic theory about nasal polyps has been presented in 1970s [17, 18]. It also appears in reports from 2011 . Supporters of allergic theory claim that mucosa derived from the polyps of their patients revealed features of an allergic inflammation. An edema and eosinophil granulocytes dominated in the polypoid mucosa. Supporters of allergic theory discovered in nasal polyps significant amounts of locally produced IgE . In the smear from the nasal mucosa, the decrease in the concentration of inflammatory cells (immunocytes) has been observed after the intranasal administration of specific antigen . The theory of allergic origin of nasal polyps has not been finally confirmed. The reason for doubts is connected with the fact that the percentage of patients with allergy and diagnosed nasal polyps was only 5% . The patients with allergic fungal rhinosinusitis (AFRS) are the exception. In AFRS, the frequency of occurrence of nasal polyps is more than 85%. Fungal fimbriae have been observed in the para nasal sinuses of healthy patients and those with sinusitis. They probably come with inhaled air. Many authors claim that allergic reaction on fungal fimbriae occurs only in some patients. Fungal antigens act similarly to the super antigenes and stimulate lymphocytes T to the production of the excessive number of cytokines, mainly interleukin 2 (Il-2). Cytokines produced by lymphocytes T provoke eosinophilic inflammations. However, there is no explanation for the excessive production of cytokines by lymphocytes T after reaction with fungal antigens [22-24]. It has to be mentioned that in patients with chronic sinusitis, reaction for fungal antigens is IgE-independent. Aforementioned facts deny the allergic theory of nasal polyp's formation.
Nasal polyps as a stage of a long-term development of non-allergic rhinitis with eosinophilic syndrome.
In 1980s, reports describing non-allergic rhinitis with the eosinophilic syndrome (NARES) appeared [25, 26]. Three stages may be differentiated in the non-allergic rhinitis. In the first-stage, eosinophiles migrate from the vessels to the nasal mucosa. In the second stage, they cumulate in the mucosa leading to the formation of nasal polyps in the third stage . The weak point of the theory of non-allergic rhinitis with eosinophilic syndrome is the fact that nasal polyps have been recognized only in 30-40% of patients with NARES .
Nasal polyps as a stage of chronic hyperplastic sinusitis development.
Some authors claim that formation of nasal polyps occurs during chronic hyperplastic sinusitis. Chronic hyperplastic sinusitis is accompanied by large local and peripheral eosinophilosis. Chronic hyperplastic sinusitis theory is confirmed by fact that in polyp's tissue, interleukin 5 (Il-5) has been observed enabling the migration of eosinophiles to the nasal and sinus mucosa. Additionally, Il-5 is responsible for bronchial asthma in patients with chronic hyperplastic sinusitis as II-5 leads to the accumulation of eosinophiles in pulmonary tissue .
Examples described above, regarding nasal polyps with eosinophilic infiltration, lead to the conclusion that polyps with neutrophils are not of allergic background and do not develop from eosinophilic inflammation.
Kim et al.  suggest that etiopathogenesis of eosinophilic nasal polyps may differ from etiopathogenesis of non-eosinophilic nasal polyps. They reported  that noneosinophilic polyps have a thinner basement membrane than eosinophilic ones. Non-eosinophilic nasal polyps contain more lymphocytes with the expression of chemokines receptors CCR 5 and CCR 3 responsible for decreasing the number of eosinophiles in the peripheral blood of patients with non-eosinophilic nasal polyps in comparison to the eosinophilic nasal polyps .
Nasal polyps as a stage of inflammatory-bioelectric changes development.
In 1994, Bernstein proposed the inflammatory-bioelectric theory of nasal polyp's formation . He claimed that inflammatory changes occurred as a result of turbulent air flow in the vicinity of the lateral wall of nasal cavity. Inflammations of the mucosa are exaggerated by bacterial and viral infections, which frequently bother allergic patients and those with other chronic insufficiencies of the respiratory system. Recurrent inflammatory states lead to the ulceration of mucosa and, as a consequence, to electrical changes in chloride and sodium membrane channels, according to the theory. Electrical changes in chloride and sodium membrane channels impair the secretion of chloride ions into the lumen of nasal cavity with simultaneous activation of sodium (and as a result, water) reabsorption to the inside of mucosal cells. Changes in the integrity of sodium and chloride channels lead to changes in mucus composition (it thickens) and in consequence, to difficulties in mucociliary transport. As a result of disturbances of ion channels, another portion of water penetrates interstitial tissue;--edema then occurs, and nasal polyps are formed. Other authors subsequently confirmed bioelectric theory, stating that the epithelium of nasal polyps has the capacity to extend reabsorption of [Na.sup.+] ions and loss of Clions in comparison to the unaltered epithelium of nasal concha .
Bernstein's and Yankaskas's theory  has been developed in their further articles. They suggest that disorders in electrolytes transport in the epithelium of respiratory tract are responsible for the creation of nasal polyps. Bernstein and Yankaskas [31, 32] claim that the excessive fluid in polyps may be caused by impaired function of protein CFTR (Cystic Fibrosis Transmembrane Regulator) regulating the activity of sodium channels. Impaired CFTR protein is observed in patients with cystic fibrosis (CF) in which nasal polyps occur very frequently (over 50% of cases) . Cystic fibrosis is an inherited, autosomal recessive disorder carried by both parents who have mutated gene encoding CFTR protein. Carriers of CFTR gene do not reveal the symptoms of cystic fibrosis; however, there is lack of reports regarding the occurrence of nasal polyps in carriers of CFTR gene.
Abnormal regulation of the tissue hydration by impaired CFTR protein is connected with an increase of the number of open sodium channels on the surface of epithelium cells. Such increase on the surface of epithelium cells leads to water overflow, which causes edema of nasal polyp stroma. Furthermore, major basic protein (MBP) released by eosinophiles may be responsible for the absorption of sodium cations by the stroma. MBP decreases mucus secretion with a simultaneous increase of sodium absorption [32, 34]. Water retention in the extracellular matrix is caused by [Na.sup.+] - [K.sup.+] pump which actively pumps [Na.sup.+] out of cell and K+ into it against their electrochemical gradients. Sodium ions are extracellular cations, which bind water. The defective action of [Na.sup.+] - [K.sup.+] pump retains [Na.sup.+] in the cell instead of intercellular space . Thus, accumulation of [Na.sup.+] and water in the extracellular matrix of polypoid nasal mucosa cannot be explained by insufficiencies in [Na.sup.+] - [K.sup.+] pump activity.
Impaired water-mineral balance may be explained by the fact that predisposition to absorb sodium and chloride ions is more developed in the epithelium of a polyp than in the epithelium of unchanged nasal conchas . Main substances in intercellular space responsible for water binding are proteoglycans (proteins with long chains of chondroitin sulphate and heparan sulphate connected with polypeptide chain) and hyaluronic acid . Proteoglycans and hyaluronic acid have spatially concentrated anions of sulphate groups and large amount of hydrophilic -OH groups. Only some water molecules are bound with proteoglycans through hydrogen bridges with anions and -OH groups. In the extracellular matrix of nasal polyps, the majority of water molecules are located in hyaluronian heteropolysaccharide helix .
Tissue of nasal polyps produces cytokines, which increase formation and growth of immunological response cells . Chemokines direct cells of immunologic response to the centre of inflammation. Prostaglandins , as well as other mediators, are responsible for local changes. Inflammatory processes activate leukocytes (especially neutrophils) to accumulate in the center of inflammation [8, 11, 13, 15]. Accumulation of leukocytes may confirm the inflammatory background of nasal polyps. However, in polyps such symptoms as pain (dolor), redness (rubor) and increased body temperature (calor) are not observed. Only edema (tumor) and, frequently, impairment of functions (functio laesa) are noted. Occurrence of eosinophils or neutrophils in nasal polyps may be connected with disorganized mechanisms leading to the full-blown inflammation.
In almost every case of intense inflammation, it can be observed the increase of glycoconjugates catabolism in lysosomes , Chojnowska et al. [41, 42] recently reported a decrease of glycoconjugates metabolism in tissue of a rhinal polyp. Chojnowska et al. [41, 42] found lower concentrations and lower specific activities of lysosomal exoglycosidases in nasal polyps in comparison to hypertrophic lower nasal conchas [41,42]. Decrease of catabolism of glycoconjugates' oligosaccharide chains in polyps suggests that polyposis is not entirely an inflammatory lesion. Results of Chojnowska et al. [41, 42] may support the inflammatory-bacterial theory of nasal polyps' formation [29, 30].
Steinke et al.  believe that eosinophilosis observed in the majority of nasal polyps case is connected with the activity of cytokines: Il-3, Il-4, Il-5, Il-13 and CSF released by activated lymphocytes Th2. Rostkowska-Nadolska  claims that the most important in eosinophil's activation is the Il-4 which intensifies the migration of neutrophils to the area of chronic inflammation, inhibits their apoptosis  and increases the proliferation of fibroblasts and their mediators. Bachert  and Fan  prove that Interlukin 5 (Il-5) is crucial for migration, activation and inhibition of eosinophils in tissue. Their arguments are connected with the fact that eosinophilic granulocytes have specific receptors for Interleukin 5.
Chronic inflammation of the nasal mucosa with polyps may lead to disturbances in its immunological response. It may be assumed that nasal polyps are formed due to impaired immunological mechanisms. Hypothesis of impaired immunological mechanisms has been confirmed by Lee et al.  who claim that expression of 114 genes in nasal polyps is significantly different than in healthy tissue. Some of those genes have a significantly higher expression. They are connected with:
* Cells differentiation,
* Cellular adhesion,
* Immunological response proteins,
* Extracellular matrix modification,
* Growth factors regulating cell cycle
* Immunological response proteins
According to Lee et al. , some genes revealed decreased expression in nasal polyps in comparison to control group. In the nasal polyps, genes with decreased expression are coding proteins responsible for:
* Cell communication,
* Calcium binding,
* Proteins synthesis,
* Cytoskeleton synthesis.
Metzler et al.  claim that inflammatory state is the background for polyps' formation. Albumins cumulate in the subepithelial layer (in the form of cyst). It may be assumed that this effect is followed by the bioelectric changes leading to further accumulation of fluid in the extracellular matrix.
After analysis of expression of cytokines 4,13 and 19 in epithelium of nasal polyps, Rostkowska-Nadolska  came to a conclusion, that pathological changes in polyps regard rather stroma than epithelium. In nasal mucosa with polyps, edema of cells is not observed which leads to a conclusion that pathogenetic implications connected with cellular edema may be ignored .
Nasal polyps as a neoplastic proliferation.
In 2003, Fritz proposed the neoplastic theory of nasal polyps' formation. The background for neoplastic theory was the discovery of mammoglobin (glycoprotein with molecular weight 10 kD) in epithelial cells of polyps. Mammoglobin is a receptor for steroids binding which modulate inflammatory processes. Mammoglobin presence in the epithelium of polyps may explain positive influence of locally administered glucocortycoids on delaying postoperative regrowth of nasal polyps [4, 50, 51]. The presence of mammoglobin in some neoplasms (e.g. breast cancer) confirms the neoplastic theory of nasal polyps' formation. Mammoglobin is observed in lymphatic tissue of lymph nodes to which neoplasms (e.g. breast cancer) metastasize [52 ,53].
In nasal polyps, gene determining the expression of glutathione transferase has also been detected. Glutathione transferase gene is assumed as a risk factor for bladder cancer . It is also observed in other neoplasms, e.g., lungs, ovaries and prostate . Neoplastic theory of nasal polyps was supported by de Castro  who reported that chemotherapeutic agent, Mitomycine C, administered locally, gives good results in nasal polyp's treatment.
One of the many factors accelerating neoplasm development are free radicals. Antioxidant barrier consists of enzymes and substrates, which remove free radicals. Olszewski et al.  assessed the antioxidant barrier in the serum and biopsy tissues of patients with nasal polyps. They reported significant decreases in iron, copper and zinc levels in the biopsy specimens as well as iron and copper levels in serum of patients with nasal polyps, in comparison to the control group. According to another report of the same authors , decreased level of magnesium and zinc was observed in the biopsy tissues of patients with precancerous conditions in the larynx, in comparison to the healthy tissues. According to the fact that disorders in the antioxidant barrier derive from, among others, hormonal disorders, it should be considered whether nasal polyps, observed the most commonly in men, have a hormonal background.
Several reports on the activity of lysosomal exoglycosidases support the neoplastic theory of polyps' etiopathogenesis. Bosmann and Kim [58, 59] reported a lower activity of N-acetyl-beta-hexosaminidase (HEX) in colon cancer, in comparison to healthy tissue. Kim described also tendency of the activity of [beta]-galactosidase, [beta]-N-acetylgalactosaminidase, [alpha]-mannosidase and [alpha]-N-acetylgalactosaminidase in colon cancers to decrease in comparison to normal colon tissue . Chojnowska et al.  reported significant decrease in the activity of several lysosomal exoglycosidases in nasal polyps' tissue in comparison to the activity of lysosomal exoglycosidases in hypertrophic lower nasal conchas. Borzym-Kluczyk et al.  reported that the activity of lysosomal exoglycosidases in the tissue of renal cancer was lower than in healthy renal tissue [41, 60].
However, in neoplastic tissues of:
* brain [40, 61],
* pancreas ,
* larynx [40, 61],
* large intestine 
significant increase in the activity of lysosomal exoglycosidases has been reported.
In conclusion, it has to be stated that review of available literature does not confirm the inflammatory theory of nasal polyp's formation. Neoplastic theory seems to be more possible. However, the strongest support has the bioelectric theory which may help to design strategy for further research on etiopathogenesis of nasal polyps focused on glycoconjugates, especially proteoglycans of connective tissue as structural elements responsible for water binding. The most probable is that the etiopathogenesis of nasal polyps is not homogeneous and nasal polyps' formation is influenced by many coexisting mechanisms .
Conflicts of interest
The authors declared no conflicts of interest.
The authors are grateful to Dr. Boguslaw Lazarczyk of the Bialystok Province Hospital for disclosing nasal polyps' pictures.
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Chojnowska S. (1) *, Kepka A. (2), Waszkiewicz N. (3), Kolodziejczyk ZP. (4), Konarzewska-Duchnowska E. (5), Oscilowicz K. (4), Cabaj-Wiater I. (6), Sowizdraniuk J. (7), Dzieciol J. (8), Ladny JR. (5), Zwierz K. (4), Szajda SD. (5)
(1) Medical Institute, College of Computer Science & Business Administration in Lomza, Poland
(2) Department of Biochemistry and Experimental Medicine, The Children's Memorial Health Institute in Warsaw, Poland
(3) Department of Psychiatry, Medical University of Bialystok, Poland
(4) Medical College of the Universal Education Society, Lomza, Poland
(5) Department of Emergency Medicine and Disasters, Medical University of Bialystok, Poland
(6) District Hospital of Garwolin, Poland
(7) Emergency Service of Krakow, Poland
(8) Department of Human Anatomy, Medical University of Bialystok, Poland
* Corresponding author:
Medical Institute, College of Computer Science & Business Administration in Lomza
14 Akademicka street, 18-400 Lomza, Poland
Tel.: +48 86 2155485
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|Author:||Chojnowska, S.; Kepka, A.; Waszkiewicz, N.; Kolodziejczyk, Z.P.; Konarzewska-Duchnowska, E.; Oscilow|
|Publication:||Progress in Health Sciences|
|Date:||Dec 1, 2013|
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