Samter's Triad Research Articles

Aspirin-exacerbated respiratory disease: Prevalence, diagnosis, treatment, and considerations for the future.

Aspirin-exacerbated respiratory disease (AERD) is a late onset condition characterized by the Samter triad (aspirin sensitivity [as well as sensitivity to any nonselective cyclooxygenase inhibitor], nasal polyps, asthma) and additional features, including eosinophilic chronic rhinosinusitis, hypereosinophilia, anosmia, frequent absence of atopy, and, intolerance to ingestion of red wine and other alcoholic beverages. The diagnosis is rare, and, because of this, it is also often missed by physicians. However, it is highly overexpressed in patients with severe asthma (and severe chronic rhinosinusitis with nasal polyps), which makes its recognition essential. For this review, we considered mechanisms involved in the pathogenesis of this disease and discussed the clinical symptoms of AERD. We also discussed the role of aspirin desensitization in the treatment of AERD. Also, we considered medications (e.g, leukotriene modifiers) and surgical interventions that have a role in the treatment of AERD.

Outcomes of endoscopic ethmoidectomy performed on a day-case basis: a prospective bi-centric study.

Evaluation of endoscopic ethmoidectomy performed as a day-case in terms of security, quality, and satisfaction of the patient. This prospective observatory bi-centric study over 1year included 74 patients undergoing an ethmoidectomy respecting the eligibility criteria of ambulatory care. We recorded patients' demographic data, operative details, satisfaction, postoperative course, and follow-up results. Nasal symptoms were evaluated by SNOT-22 on preoperative appointment and postoperatively at D30. No non-absorbable nasal packing was used, eventually in the case of preoperative-bleeding absorbable gelatine packing. The postoperative follow-up took place at D1 by phone call and at D10 and D30 to assess complications, Visual Analogue Scale, and state of ethmoidal corridors by endoscopic exam. Patients benefited of bilateral ethmoidectomy in 82.4% cases associated with septoplasty in 42%. The majority (95%) was discharged on the same day. Only one patient had bleeding at D0 and was kept in standard hospitalization, such as three other patients for medical or organizational reasons not related to surgery. At D1, 23% described postoperative light bleeding but needed no revisit and pain was estimated at 1.3 (VAS). No readmission was observed, and no major complication was noted. SNOT-22 decreased successfully by 56%, statistically related to postoperative treatment of corticosteroids and in the case of Samter triad. 97% of patients were satisfied of the ambulatory care. These results suggest that within an experienced and dedicated day-case medical and paramedical team, ethmoidectomy can be safely performed on a day-case basis with high quality of taking care and satisfaction of patients.

Análisis y resultados de la cirugía endoscópica nasosinusal en rinosinusitis crónica con pólipos

Introduction and objectivesEndoscopic sinus surgery is currently the surgical procedure chosen in cases of sinonasal polyposis refractory to medical treatment. The aim of this study was to show our experience in managing such patients operated using endoscopic sinus surgery. MethodA retrospective study of 246 patients with chronic rhinosinusitis and nasal polyps who were operated by endoscopic surgery. We studied the characteristics of the population, symptoms, grade of affectation, complications and recurrences. ResultsThe most frequent comorbidity was asthma (34.6%) and its relationship with Samter's triad (16.3%). Grades 2 and 3 polyposis prevailed according to Lildholdt staging by nasofibroscopy, coinciding with the radiological preoperative staging. The microdebrider did not shorten surgical time but it lowered complications. Reducing the average stay with the use of absorbable haemostatic agents and their effectiveness in controlling hemostasis were statistically significant. We found 23.2% complications, with only one (.4%) being a major complication; the rest were minor complications, with synechiae as the most frequent (16.3%). ConclusionEndoscopic sinus surgery is a minimally invasive and safe technique. Absorbable haemostatic agents are an effective alternative to get complete and stable hemostasis, reducing mean hospital stay. Synechiae continue being the most frequent complication. The fact that many patients recurred but without complications speaks in favour of a natural evolution of the disease and not of the influence of technique.

The Role of Surgery in Management of Samter's Triad: A Systematic Review.

Aspirin-exacerbated respiratory disease (AERD) represents a severe form of chronic rhinosinusitis (CRS) characterized by nasal polyposis, bronchial asthma, and aspirin intolerance. This syndrome, known as Samter's triad, is more difficult to manage than routine CRS and poses a challenge to the treating clinician. We performed a systematic review of the literature to determine the role of endoscopic sinus surgery in patients with AERD who are on adjuvant medical therapies. PubMed, Embase, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Cochrane Technology Assessments, Cochrane Economic Evaluations, Cochrane Groups, and Clinicaltrials.gov. A systematic review of the literature was performed using the 2009 PRISMA guidelines. Studies with both preoperative and postoperative data for patients with AERD who underwent sinus surgery were considered appropriate for inclusion. Publications were written in English, included patients aged 18 years or older, and had a minimum follow-up of 3 months. Eighteen studies met criteria for inclusion in our review. The primary outcome was change in symptom profile as measured by sinonasal and asthma symptom scores. Most studies demonstrated improvement in sinus- and asthma-related symptoms and quality-of-life measures after endoscopic sinus surgery. This review, which did not exclude the use of concomitant medical therapy, suggests that surgery is beneficial in AERD management. Evidence demonstrates improvement in sinonasal and asthma symptom severity and frequency, radiographic and endoscopy scores, and quality of life after surgery.

Smell Decline as a good Predictor of Sinonasal Polyposis Recurrence after Endoscopic Surgery.

To evaluate the most sensitive symptom to predict early recurrence of nasal polyposis. Prospectivelongitudinal cohort study. Tertiaryuniversityreferral center with accredited otorhinolaryngology residency programs. In this prospective study, we evaluated 62 patients with diffuse nasal polyposis. All patients underwent functional endoscopic sinus surgery.Theauthor-devised questionnaire relating to the four major symptoms of chronic rhinosinusitis were answered by patients at the pre-operative visit and at 1, 3, 6, 12, and 24 months after surgery. Patients were followed up with serial endoscopic examinations, and a computed tomography (CT) scan was performed if indicated. All 62 patients (37 male, 25 female) completed the study. The mean age was 41.24 ± 12.47 years. All major symptoms showed significant improvement after surgery (P=0.000); however, the severity of symptoms gradually increased in patients with a recurrence of polyposis,but at different points in time(P= 0.008). Sense of smell was the first symptom to deteriorate in patients with relapse (mean, 6 months) followed by nasal secretion (12 months), obstruction and pain(24 months). Patients with asthma, Samter's triad, allergic fungal rhinosinusitis (AFRS) and allergic rhinitis showed symptoms of recurrence sooner than other patients (P<0.05). The most sensitive symptom for the early detection of recurrence of nasal polyposis is a decrease in the sense of smell. Nasal obstruction and facial pain were observed in the late stage of relapse when frank polyposis formation was established.

Effectiveness of leukotriene receptor antagonism in the postoperative management of chronic rhinosinusitis.

Montelukast is used in the treatment of allergic rhinitis and asthma. It has been used as adjuvant therapy in patients with chronic rhinosinusitis (CRS), but its effectiveness has not been evaluated. This study evaluates the efficacy of adjuvant leukotriene receptor antagonism in CRS and subtypes. Retrospective review of collected data at a tertiary-referral institution. We identified all patients who were prescribed montelukast postoperatively and had a lapse in therapy for at least 1 month (n = 50), so that the patients themselves serve as their own control group. Twenty-item Sino-Nasal Outcomes Test (SNOT-20) scores and Lund-Kennedy endoscopy scores were obtained for each patient. Scores were compared with and without montelukast using Wilcoxon signed rank test. The analysis was controlled for changes in other medications. Fifty-two therapy lapses were identified in 50 patients. Twenty-seven patients had eosinophilic CRS with polyps (eCRSwNP), 8 had Samter's triad (ST), and 15 had allergic fungal sinusitis (AFS). Overall mean follow-up was 46.5 months. Overall, SNOT-20 scores and endoscopy scores were significantly lower with montelukast (p < 0.005 for both). On subgroup analysis, SNOT-20 scores were significantly improved for patients with eCRSwNP and AFS (p < 0.001 and p = 0.001, respectively). Endoscopy scores were significantly improved for patients with eCRSwNP (p = 0.044). Outcomes approached, but did not reach, significance for patients with ST (p = 0.123 for SNOT-20 and p = 0.146 for endoscopy). There was also significant improvements in patients with asthma. The addition of montelukast as postoperative therapy may be beneficial for patients with eCRSwNP and AFS.

Critical link between glycogen synthase kinase 3β and forkhead box P3 in patients with chronic rhinosinusitis with nasal polyps

Critical link between glycogen synthase kinase 3β and forkhead box P3 in patients with chronic rhinosinusitis with nasal polyps

A 12½-year journey of a patient with Samter triad syndrome and sporadic omalizumab use

A 12½-year journey of a patient with Samter triad syndrome and sporadic omalizumab use

Prevalencia de intolerancia a salicilatos en pacientes con poliposis nasosinusal

Salicylates intolerance is related to alteration in the metabolism of arachidonic acid leading to increased leukotrienes. The condition may be manifested with respiratory, skin or systemic symptoms or associated with sinonasal polyposis. Salicylates are present in anti-inflammatory drugs, cosmetics products and food. To determine the prevalence of salicylates intolerance in patients with sinonasal polyposis presenting to Clinical Immunology and Allergy and Otolaryngology Service, CMN 20 Noviembre, Mexico City. An observational, descriptive, cross sectional study included patients with sinonasal polyposis. The sample size was 49 patients, and variables were compared using STATISTICA 8.0. The prevalence of sinonasal polyposis was 4% of the study group, predominantly in females; only 24% of the population had an ideal weight, the salicylates intolerance prevalence was 53%, and the Samter triad was 31%. Sinonasal polyposis has an inflammatory disease pattern. Its pathophysiology is not yet fully established and in this study was related to obesity and persistent sinusitis. The most feared complication recurrence is associated with salicylates intolerance. The study found a slight increase of recurrence in the group of intolerance, with no statistically significant difference, possibly related to the sample size.

Long-term outcomes following functional endoscopic sinus surgery in Samter's triad.

This study aimed to assess the long-term outcome of functional endoscopic sinus surgery for Samter's triad patients using an objective visual analogue scale and nasal endoscopy. Using a retrospective database, 33 Samter's triad patients who underwent functional endoscopic sinus surgery were evaluated pre- and post-operatively between 1987 and 2007 in Hospital of La Chaux-de-Fonds, Switzerland. A total of 33 patients participated in the study, and the mean follow-up period was 11.6 years (range 1.2-20 years). Patients were divided into two groups based on visual analogue scale scores of the five parameters with the greatest difference in intensity of symptoms between the beginning and end of follow up. Group 1 included patients with a mean visual analogue scale score of 6 and below at the end of follow up and group 2 included patients with a mean visual analogue scale score of more than 6. The only statistically significant difference noted between the two groups was the endonasal findings: stage III-IV polyposis was present in 1 out of 24 patients (4 per cent) in group 1 and in 5 out of 9 patients (56 per cent) in group 2. The results of our study indicate that functional endoscopic sinus surgery helps stabilise disease progression. Stage III-IV polyposis had a significant adverse effect on long-term outcome.

Omalizumab in the treatment of aspirin-exacerbated respiratory disease

Omalizumab in the treatment of aspirin-exacerbated respiratory disease

When do the risks of repeated courses of corticosteroids exceed the risks of surgery?

The management of chronic rhinosinusitis with nasal polyposis (CRSwNP) becomes unclear when patients require multiple courses of corticosteroids to maintain quality of life. Repeated courses of corticosteroids carry increased risks to patients. Although endoscopic sinus surgery (ESS) is an effective therapeutic modality, it also carries inherent risks. This study aims to identify the threshold at which the risks of repeated courses of corticosteroid exceed the risks of surgery. An evidence-based risk analysis was simulated using literature-reported complication rates, quality of life changes, and Medicare costs. Simulations were performed from the Medicare patient perspective, societal perspective, and the universal healthcare patient perspective. All 3 simulations demonstrate a breakeven threshold favoring surgery over medical therapy when patients require oral corticosteroids (OCS) more often than once every 2 years in CRSwNP, once per year in CRSwNP/asthma, or twice per year for Samter's triad patients. This represents the first rationalized evidence-based analysis for when surgery should be considered in place of repeated courses of oral corticosteroids. This threshold provides a guide for otolaryngologists to use when making clinical decisions with patients.

Centripetal endoscopic sinus surgery in chronic rhinosinusitis: a 6-year experience.

Despite technical advances in the tools designed to facilitate endoscopic nasosinusal surgery, the approach used, functional endoscopic sinus surgery, has not undergone major modifications since it was first described in the late 1980s. Centripetal endoscopic sinus surgery (CESS) is a new approach based on taking the medial wall of the orbit and the anterior cranial base as constant dissection landmarks. The aim of this study was to evaluate the long-term outcome of CESS in chronic rhinosinusitis (CRS) by measuring clinical and objective improvement, the need for revision surgery, and the complication rate. We reviewed 114 patients with CRS with or without polyps who underwent CESS at our center between May 2006 and December 2011. CRS was assessed using the Lund-Mackay staging system. The follow-up period ranged from 18 to 84 months (May 2013). Of 114 patients, 83 presented CRS with nasal polyposis, 12 had CRS without nasal polyposis, 17 had Samter's triad, and 2 had antrochoanal polyps. Postoperative evaluation of nasal obstruction and olfaction showed a significant and lasting improvement in these symptoms. Only four patients (3.5%) have required revision surgery, to date. CESS provided a lasting improvement in patients with CRS, by dramatically reducing the number of reinterventions. This approach is especially indicated in difficult cases, such as recurrent nasal polyposis and massive polyposis, because the dissection is based on constant borders and not influenced by previous surgery or disease extension.

Elevated total serum IgE in nonatopic patients with aspirin-exacerbated respiratory disease.

Aspirin-exacerbated respiratory disease (AERD), also known as Samter's triad, is characterized by asthma, recurrent nasal polyps, and by allergic-like reactions to aspirin and other nonsteroidal anti-inflammatory drugs, although it is not a true immunoglobulin E (IgE)-mediated allergy. Atopy, although common in patients with AERD, is not a characteristic of the disease. Recently, we have observed a subgroup of patients with AERD who have no history of atopy but have abnormally elevated total serum IgE, a phenomenon that has been observed in patients with asthma but has not been further explored. We sought to explore this phenomenon of elevated total serum IgE in the absence of atopy in a subset of patients with AERD. Patients were diagnosed with AERD with an oral aspirin challenge at the Brigham and Women's Hospital Allergy and Clinics. Atopy was defined as a positive test result to at least one of the common aeroallergens. Elevated total serum IgE was defined as IgE of >100 IU/mL. We present six patients with AERD and elevated total serum IgE in the absence of any clear atopy. Total serum IgE in these patients ranged from 110 to 1760 IU/mL. Mean blood eosinophil levels for these patients were not significantly different from those of the entire cohort of patients with AERD included in the study. In a subset of patients with AERD, we observed elevated total serum IgE even when atopy was not present. To better understand the disease, the cause and clinical relevance of this phenomenon deserves further exploration.

The Editor takes a closer look at some of this month's articles

The Editor takes a closer look at some of this month's articles

Aspirin desensitization for aspirin‐exacerbated respiratory disease (Samter's Triad): a systematic review of the literature

To critically review the current literature regarding aspirin desensitization treatment for nasal polyposis in patients with Aspirin-Exacerbated Respiratory Disease (AERD). Systematic review of the literature. All English literature published between January 1995 and February 2013 reporting specifically nasal outcomes following aspirin desensitization in AERD patients were eligible for inclusion. Exclusion criteria were non-investigative, non-human, and ex-vivo studies. Studies were categorized by level of evidence and evaluated for quality using the Downs and Black scale. A total of 614 citations were retrieved and eleven studies met the criteria for analysis. Outcome measurements included self-reported symptom scores, amount of corticosteroid use, rate of revision surgery, and quantitative measurements such as rhinomanometry. Overall, most studies reported a significant improvement in symptom scores, decrease in corticosteroid use, and decrease in revision surgery. A few studies showed promising results with quantitative outcomes. However, most studies were of Level 2 evidence with small samples sizes. Rates of adverse events ranged from 12.5% to 23%. Unlike traditional treatments for nasal polyposis, aspirin desensitization targets AERD etiology rather than phenotype and can be an effective therapeutic option. While the current literature shows encouraging results, additional studies are needed to better define clinical benefits.

Aspirin sensitivity does not compromise quality‐of‐life outcomes in patients with samter's triad

To demonstrate that quality-of-life outcomes after endoscopic sinus surgery are not compromised in patients with Samter's triad (asthma, nasal polyps, aspirin sensitivity) when compared to patients with eosinophilic chronic rhinosinusitis with nasal polyposis (eCRSwP) who are not aspirin sensitive. Retrospective review of prospectively collected data. Thirty-two patients with Samter's triad were identified from a prospectively collected patient database from 2003 to 2012. Preoperative and postoperative symptom and endoscopy scores were compared to those of 37 consecutive patients with eCRSwP who were not aspirin sensitive (control). Student t test and Fisher exact test were used to examine for differences between the two groups. Symptom scores were assessed using the 20-item Sino-Nasal Outcome Test (SNOT-20). Endoscopy findings were scored according to the Lund-Kennedy methodology. Samter's triad patients had significantly worse disease preoperatively when compared to the control group: SNOT-20 (31.1 vs. 22.1, P = .004), endoscopy score (10.9 vs. 7.6, P = .0005), and Lund-Mackay computed tomography score (18.9 vs. 13.9, P = .0001). Although postoperative endoscopy scores remained worse in the Samter's triad group, postoperative SNOT-20 scores were comparable to those of the control group at ≥ 3 years follow-up (22.8 vs. 17.3, P = .43). Although Samter's triad patients present with more severe disease and are more likely to undergo revision surgery, they have postoperative quality-of-life outcomes that are comparable to patients with eCRSwP who are not aspirin sensitive. This is the first study to utilize a disease-specific, validated outcomes instrument in comparing Samter's triad patients with aspirin-tolerant patients who have nasal polyposis and tissue eosinophilia.

Samter's triad in childhood: a warning for those prescribing NSAIDs

Aspirin-exacerbated respiratory disease (AERD) has been recognized in adults with chronic asthma. Samter's triad is a subset of AERD where adult patients develop nasal polyps, asthma, and sensitivity to aspirin. This condition is thought not to occur before the third decade of life. We report a 13-year-old boy with nasal polyps who suffered a life-threatening exacerbation of asthma during a graded aspirin challenge. Resuscitation required positive pressure ventilation and inotropic support. Our observations confirm that classical Samter's triad can occur in children. We suggest that graded aspirin challenges in children are undertaken in a facility with equipment and staff trained for resuscitation. Consideration should be given to this rare complication when prescribing nonsteroidal anti-inflammatory drugs in the perioperative period. Suspicion of this condition merits referral to an immunologist for desensitization to aspirin.

Budesonide nasal irrigations in the postoperative management of chronic rhinosinusitis

Nasal steroids play an important role in the postoperative management of patients with chronic rhinosinusitis (CRS). However, commercially available nasal steroid sprays may not deliver adequate amounts of medication to the entire postoperative sinus cavity. The off-label use of budesonide nasal irrigation (BNI) theoretically solves this problem by delivering concentrated steroid solution through a high-pressure, high-volume system. Several studies have attested to the safety of BNI, but there are very few reports of its efficacy. This is a retrospective review of prospectively-collected data. We identified 60 patients who were prescribed BNI postoperatively, but had a lapse in therapy for 1 month or longer. The 20-item Sinonasal Outcomes Test (SNOT-20) and Lund-Kennedy endoscopy scores while the patients were using BNI were compared with scores from the same patients while they were not using BNI. Student paired t test was used for statistical analysis. Thirty patients had eosinophilic chronic rhinosinusitis (eCRS) with polyps (eCRSwNP), 13 had allergic fungal sinusitis (AFS), 13 had Samter's triad (ST), and 4 had eosinophilic chronic rhinosinusitis without polyps (eCRSsNP). Mean follow-up time was 25 months (range, 2-89 months). Overall, SNOT-20 scores were significantly lower with BNI (p < 0.05). On subgroup analysis, SNOT-20 scores were significantly improved with BNI for patients with eCRS and Samter's triad (p = 0.04, 0.03). Endoscopy scores were significantly improved only in the eCRS group (p = 0.02). The addition of BNI is beneficial in the postoperative management of patients with CRS.

Eicosanoid imbalance correlates in vitro with the pattern of clinical symptoms of Samter's triad

Hypersensitivity to non-steroidal anti-inflammatory drugs (NSAIDs) is often associated with chronic rhinosinusitis (CRS), nasal polyps (CRSwNP) and asthma, together known as Samter's triad. The disease is characterised by eicosanoid imbalance. In our study, we determined clinical and laboratory parameters in respect of three groups of patients: 1) CRSwNP, 2) CRSwNP and asthma (CRSwNP-A), and 3) CRSwNP with asthma and NSAID-triggered hypersensitivity (CRSwNP-AA). Our main goal was to improve the characterisation of the stages of development in Samter's triad, pointing to the homogeneous or heterogeneous course of disease. Forty-three patients (10 CRSwNP, 14 CRSwNP-A, 19 CRSwNP-AA) and 10 control subjects were included in the study. Nasal assessment using the CRS visual analogue score, endoscopy- and computer tomography scores, allergy tests, analysis of sinus surgeries, asthma severity and in vitro functional eicosanoid tests (FET) with peripheral blood leucocytes were performed. The scores reflecting CRS symptoms such as nasal congestion, nasal discharge and smell impairment differed between the patients groups reflecting the severity of disease (CRSwNP-AA > CRSwNP-A > CRSwNP). Eicosanoid imbalance correlated with nasal congestion, nasal discharge and loss of smell. The data presented support the hypothesis of the continuous development of NSAID-triggered hypersensitivity, culminating in Samter's triad.