Neutrophiltolymphocyte ratio as a novelpotential marker for
Transkript
Neutrophiltolymphocyte ratio as a novelpotential marker for
The Laryngoscope C 2013 The American Laryngological, V Rhinological and Otological Society, Inc. Neutrophil-to-Lymphocyte Ratio as a Novel-Potential Marker for Predicting Prognosis of Bell Palsy Abdulkadir Bucak; Sahin Ulu; Serdar Oruc; Fatih Yucedag, PhD; Mustafa Said Tekin, MD; Fatıma Karakaya, MD; Abdullah Aycicek Objectives/Hypothesis: Bell palsy can be defined as an idiopathic, acute, facial nerve palsy. Although the pathogenesis of Bell palsy is not fully understood, inflammation seems to play important role. Neutrophil-to-lymphocyte (NLR) ratio was defined as a novel potential marker to determine inflammation and it is routinely measured in peripheral blood. Our goal was to investigate the relationship between Bell palsy and inflammation by using NLR. Study Design: Retrospective study. Methods: The 54 patients who were followed up for Bell palsy for a period of 1 to 3 years, along with 45 age- and sexmatched controls, were included in the study. An automated blood cell counter was used for NLR measurements. All patients were treated with prednisone, 1 mg/kg per day with a progressive dose reduction. Patients were classified according to the House-Brackmann grading system at posttreatment period. Those with House-Brackmann grade I and grade II were regarded as satisfactory recovery; and those with House-Brackmann grade III to grade VI were regarded as nonsatisfactory recovery. Results: The mean NLR and neutrophil values in patients with Bell palsy were significantly higher than in the control group (P 5 0.001 and P < 0.001, respectively). In addition, NLR levels were higher in nonsatisfactory recovered patients compared with satisfactory recovered ones (P < 0.001). Conclusion: This is the first study investigating the relationship between NLR levels and Bell palsy and its prognosis. Our result suggest that while evaluating Bell palsy patients, NLR might be taken into account as a novel potential marker to predict the patients’ prognosis. Key Words: Facial nerve, Bell palsy, prognosis, inflammatory marker, neutrophil, neutrophil-to-lymphocyte ratio. Level of Evidence: 3b. Laryngoscope, 124:1678–1681, 2014 INTRODUCTION The pathogenesis of Bell palsy is not fully understood; however, inflammation and viral infections seem to play an important role.1,2 Inflammatory reaction compresses the facial nerve in the fallopian canal, particularly in the labyrinthine segment.3 Because it is difficult to predict a prognosis in the early stage of the disease, a variety of clinical tests have been introduced. Electrophysiological tests are in use as the main prognostic test for facial nerve paralysis. These tests include electroneuronography (ENoG), nerve excitability test, electromyography (EMG), blink reflex, and the stapedial muscle reflex. Among these, ENoG and EMG usefulness for predicting the prognosis has been proven.4–6 However, most of these tests must take place From the Department of Otolaryngology (A.B., S.U., F.Y., M.S.T., A.A.); and Department of Neurology (S.O., F.K.), Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar, Turkey. Editor’s Note: This Manuscript was accepted for publication November 26, 2013. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Abdulkadir Bucak, Assist. Professor, Department of Otolaryngology, Afyon Kocatepe University, Faculty of Medicine, Ali Cetinkaya Kampusu Tıp Fakultesi Izmir Karayolu 8.km 03200, Afyonkarahisar, Turkey. E-mail: abdulkadirbucak@yahoo.com DOI: 10.1002/lary.24551 Laryngoscope 124: July 2014 1678 during a specific time period; thus, they are not suitable for practical use. White blood cell (WBC) count and its subtypes are known as classic inflammatory markers, especially in cardiovascular diseases.7 Neutrophil-to-lymphocyte ratio (NLR) has been defined as a novel potential marker to determine inflammation and can be measured routinely in peripheral blood without any cost. Also, in recent studies NLR has been introduced as a potential marker to determine inflammation in cardiac and noncardiac disorders.8–12 To our knowledge, NLR values in Bell palsy and role in the prognosis of this disease have not been investigated. Based on this background, we aimed to investigate the relationship between Bell palsy and inflammation by using NLR, which is a new method that is measured routinely in complete blood count (CBC) tests without any cost. MATERIALS AND METHODS The present study was conducted in the Otorhinolaryngology and Neurology Clinics of Afyon Kocatepe University Faculty of Medicine Hospital between January 2010 and March 2013. The study protocol was approved by the ethics committee of Afyon Kocatepe University Faculty of Medicine and was conducted in accordance with the ethical principles described by the Declaration of Helsinki. A uniform consent was obtained from all the groups. The patient files were scanned; 54 patients who were followed up due to Bell palsy for a period of 1 to 3 years by otorhinolaryngology and neurology clinics and 45 Bucak et al.: Neutrophil-to-Lymphocyte for Prognosis of Bell Palsy TABLE I. The Characteristics and the Laboratory Data of the Groups. Mean Value Variables Patient Group Control Group P Value 43.11 6 18.12 48.33 6 5.65 NS 27 (50) 18 (40) NS Neutrophil 27 (50) 5.86 6 2.38 27 (60) 3.94 6 1.12 <0.001 Lymphocyte 2.51 6 1.38 2.27 6 0.56 NS NLR Monocyte 2.69 6 1.48 0.62 6 0.29 1.82 6 0.79 0.64 6 0.62 0.001 NS White blood cell 8.94 6 2.86 6.96 6 1.31 < 0.001 Age Gender (%) male female NLR 5 neutrophil-to-lymphocyte; NS 5 not significant. age-matched and sex-matched controls were included in the study. The patients were classified according to the HouseBrackmann grading system at pretreatment and posttreatment period. At posttreatment period, the patients with HouseBrackmann grade I and II were regarded as satisfactory recovery, and House-Brackmann grade III to grade VI were regarded as nonsatisfactory recovery. The 13 patients with nonsatisfactory recovery, despite minimum follow-up at 1 year, were invited to the hospital and an EMG test was carried out. The routine pretreatment CBC test of patients were recorded. Those patients who had any acute inflammation or infection, pneumonia, acute or chronic renal failure, chronic liver disease, chronic obstructive pulmonary disease, obstructive sleep apnea, connective tissue disease, inflammatory bowel disease, current smoking, or active otologic disease were excluded from the study. The patients were evaluated with gadoliniumenhanced MRI or CT with the intention to rule out additional otologic diseases. All the patients were treated with corticosteroids (at an initial dose of prednisone of 1 mg/kg/day), with a gradual dose reduction maintained for at least 2 weeks. Hematologic Analyses NLR was calculated as a simple ratio between the absolute neutrophil and the absolute lymphocyte counts. An automated blood cell counter was used for CBC measurements (Sysmex XT 2000i, Kobe, Japan). All samples were run in duplicate, and the mean values were used for statistical analysis. Fig. 1. The mean NLR values of the patients with Bell palsy and the control group. NLR 5 neutrophil-to-lymphocyte. [Color figure can be viewed in the online issue, which is available at www.laryngoscope. com.] Bell palsy was 27:27, whereas it was 18:27 for the control group. Age and sex distributions of the groups were both similar. All of the characteristics of the groups and the laboratory data are outlined in Table I. The mean neutrophil values of Bell palsy patients were 5.86 6 2.38 and 3.94 6 1.12 in the control group. The mean neutrophil values in patients with Bell palsy were significantly higher than in the control group (P <0.001). The mean lymphocyte values of Bell palsy patients were 2.51 6 1.38 and 2.27 6 0.56 in the control group. The difference was not statistically significant (P > 0.05). The mean NLR values were 2.69 6 1.48 in Bell palsy patients and 1.82 6 0.79 in the control group. The mean NLR values in patients with Bell palsy were significantly higher than in the control group (P 5 0.001) (Fig. 1). Statistical Analysis Continuous variables were presented as mean 6 SD, and categorical variables were expressed as percentage. KolmogorovSmirnov test was used to evaluate the distribution of variables; student’s t test was used for continuous variables for those with normal distribution; Mann-Whitney U test was used for continuous variables for those without normal distribution; and Chisquare test was used for categorical variables. Pearson correlation analysis was used to assess the relationships. P < 0.05 value was accepted as significant level. For statistical calculations, SPSS statistical software (SPSS for Windows, version 17.0; SPSS Inc., Chicago, IL) was used. RESULTS Mean age of the patients with Bell palsy and the control group was 43.11 6 18.12 and 48.33 6 5.65 years, respectively. Male-to-female ratio of the patients with Laryngoscope 124: July 2014 Fig. 2. The mean NLR values according to the recovery. NLR 5 neutrophil-to-lymphocyte. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.] Bucak et al.: Neutrophil-to-Lymphocyte for Prognosis of Bell Palsy 1679 Patients were evaluated according to the response to the treatment and were divided into two groups: satisfactory recovery and nonsatisfactory recovery. The mean NLR values were 3.41 6 1.76 in the nonsatisfactory recovered group and 2.46 6 1.32 in the satisfactory recovered group. NLR levels were higher in the nonsatisfactory recovered group compared with the satisfactory recovered group (P < 0.05) (Fig. 2). DISCUSSION Bell palsy is defined as a sudden paralysis/paresis of all muscles on one side of the face; dry eye; pain around the ear; altered sense of taste; hypersensitivity to sounds; or decreased tearing that is not associated with any other cranial neuropathy, ear, cerebellopontine, or brainstem disease.13 Approximately one in 65 people may experience such a condition in their lifespan. However, the exact etiopathogenesis of the Bell palsy is still unclear. Microcirculatory failure and infectious, genetic, immunologic, and inflammatory causes have been hypothesized.2,14 The studies proposed that cell-mediated immunologic responses may be of importance in the pathogenesis of this disease. The measuring of the serum samples of the patients with Bell palsy shows that the IL-6, IL-8, and TNF-a levels were significantly higher in the Bell palsy than in the control.2,13 In another study, the patients with Bell palsy had a significantly lower percentage of B cells and T helper/ inducer subsets levels than did the controls. Patients were evaluated according to clinical presentation and divided into two groups. The patients with severe impairment had significantly lower percentages of both B cells and T helper/inducer subsets, whereas the patients with mild to moderate impairment had only decreased percentages of B cells subsets.1 WBC and its subtypes were found as inflammatory markers in cardiovascular diseases. NLR was defined as a novel-potential marker to determine inflammation in cardiac and noncardiac disorders.8–11,15 NLR can be easily calculated as the neutrophils-to-lymphocytes ratio in the peripheral blood. NLR is practical, inexpensive, and also valuable as high-cost inflammatory markers including IL-6, IL-1b, IL-8, and TNF-a.12 NLR has been found to be an important index for predicting adverse clinical outcomes and a reliable marker in oncology16–19; cardiology (acute coronary syndromes, heart failure, and coronary revascularization procedures)8,9,20–22; end-stage renal disease; and inflammatory diseases such as Alzheimer, ulcerative colitis and appendicitis.12,23–25 In our study, NLR levels were significantly higher in patients with Bell palsy than the in control group, indicating the presence of inflammation. In addition, neutrophil and values were higher than in the control group. Also, when the patients were compared according to the recovery, NLR levels were higher in patients with nonsatisfactory recovery, which may be explained by the higher inflammatory situation in the nonsatisfactory recovered patients. This result may help clinicians as a practical and reliable indicator for Bell palsy patients in terms of treating and predicting the prognosis. Laryngoscope 124: July 2014 1680 Limitations of Our Study Because this was a single-center study in one locality, our study group was small. CONCLUSION To our knowledge, this is the first study investigating the relationship between NLR levels and Bell palsy and its prognosis. Our results suggest that while evaluating Bell palsy patients, NLR might be taken into account as a novel potential marker to predict the patients’ prognosis. Also, because this area of research is a novel field, more prospective multicenter controlled studies with larger series are needed to demonstrate the possibility of a future test that could be used as an estimator for prognosis. Acknowledgement The authors would like to thank Dr. Mehmet Yaman and Dr. M. Sena Ulu for their contribution to this project. BIBLIOGRAPHY 1. Tekgul H, Polat M, Serdaroglu G, et al. 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